Spinal pain in Danish school children - how often and how long? The CHAMPS Study-DK

The prevalence of chronic pain in children and adolescents: a systematic review update and meta-analysis

ABSTRACT

Chronic pain, defined as persistent or recurring pain or pain lasting longer than 3 months, is a common childhood problem. The objective of this study was to conduct an updated systematic review and meta-analysis on the prevalence of chronic pain (ie, overall, headache, abdominal pain, back pain, musculoskeletal pain, multisite/general pain, and other) in children and adolescents. EMBASE, PubMed, CINAHL, and PsycINFO were searched for publications between January 1, 2009, and June 30, 2023. Studies reporting population-based estimates of chronic nondisease related pain prevalence in children or adolescents (age ≤ 19 years) were included. Two independent reviewers screened articles based on a priori protocol. One hundred nineteen studies with a total of 1,043,878 children (52.0% female, mean age 13.4 years [SD 2.4]) were included. Seventy different countries were represented, with the highest number of data points of prevalence estimates coming from Finland and Germany (n = 19 each, 4.3%). The overall prevalence of chronic pain in children and adolescents was 20.8%, with the highest prevalence for headache and musculoskeletal pain (25.7%). Overall, and for all types of pain except for back pain and musculoskeletal pain, there were significant differences in the prevalence between boys and girls, with girls having a higher prevalence of pain. There was high heterogeneity (I 2 99.9%). Overall risk of bias was low to moderate. In summary, approximately 1 in 5 children and adolescents experience chronic pain and prevalence varies by pain type; for most types, there is higher pain prevalence among girls than among boys. Findings echo and expand upon the systematic review conducted in 2011.

Musculoskeletal pain in 13-year-old children: the generation R study

ABSTRACT

Musculoskeletal (MSK) pain is a common reason for consultation in general practice and frequently reported in children and adolescents. This study examined the prevalence of MSK pain in 13-year-old children and assessed associations with physical and psychosocial factors. Data from the Generation R Study, a population-based birth cohort, was used. Prevalence and characteristics of MSK pain were assessed, using a pain mannequin, at 13 years of age (N = 3062). Demographics and data on physical activity, sedentary behaviors, previous reported MSK pain, and behavioral problems were extracted from questionnaires. The body mass index (BMI) SD-score was calculated from objectively measured weight and height. A prevalence of 23.3% was found for MSK pain in children of which 87.2% persisted for more than 3 months (ie, chronic), 45.5% experienced pain daily. More physically active children and children with a higher BMI reported MSK pain more frequently compared with non-MSK pain and no pain. The knee was the most often reported location. Children with MSK pain were more likely to have reported MSK pain at 6 years. Multivariable analyses showed significant associations for male sex (OR 0.74, 95% CI 0.56-0.98), high maternal educational (OR 0.69, 95% CI 0.49-0.96), higher BMI (OR 1.19, 95% CI 1.05-1.35), being physically active (OR 1.41, 95% CI 1.03-1.91), and behavioral problems (OR 1.85, 95% CI 1.33-2.59) with the presence of MSK pain. The chronic nature of MSK pain in combination with the relatively high prevalence of MSK pain in this study shows that MSK pain is already an important problem at a young age.

Rehabilitation of back pain in the pediatric population: a mixed studies systematic review

BACKGROUND

A significant proportion of children and adolescents experience back pain. However, a comprehensive systematic review on the effectiveness of rehabilitation interventions is lacking.

OBJECTIVES

To evaluate benefits and harms of rehabilitation interventions for non-specific low back pain (LBP) or thoracic spine pain in the pediatric population.

METHODS

Seven bibliographic electronic databases were searched from inception to June 16, 2023. Moreover, reference lists of relevant studies and systematic reviews, three targeted websites, and the WHO International Clinical Trials Registry Platform were searched. Paired reviewers independently conducted screening, assessed risk of bias, and extracted data related to study characteristics, methodology, subjects, and results. Certainty of evidence was evaluated based on the GRADE approach.

RESULTS

We screened 8461 citations and 307 full-text articles. Ten quantitative studies (i.e., 8 RCTs, 2 non-randomized clinical trials) and one qualitative study were included. With very low to moderate certainty evidence, in adolescents with LBP, spinal manipulation (1-2 sessions/week over 12 weeks, 1 RCT) plus exercise may be associated with a greater likelihood of experiencing clinically important pain reduction versus exercise alone; and group-based exercise over 8 weeks (2 RCTs and 1 non-randomized trial) may reduce pain intensity. The qualitative study found information provided via education/advice and compliance of treatment were related to effective treatment. No economic studies or studies examining thoracic spine pain were identified.

CONCLUSIONS

Spinal manipulation and group-based exercise may be beneficial in reducing LBP intensity in adolescents. Education should be provided as part of a care program. The overall evidence is sparse. Methodologically rigorous studies are needed.

TRIAL REGISTRATION

CRD42019135009 (PROSPERO).

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.

Development of the Young Disability Questionnaire (spine) for children with spinal pain: field testing in Danish school children

OBJECTIVE

The objective of this study was to finalise the development of the Young Disability Questionnaire (YDQ-spine) to measure the consequences of neck, midback and low back pain, relevant for schoolchildren aged 9-12 years.

DESIGN

A cross-sectional field test of the YDQ-spine was carried out.

SETTING

Danish primary schools.

PARTICIPANTS

Children aged 9-12 years from all Danish schools were invited to complete the questionnaire.

METHODS

Eight hundred and seventy-three schools were invited to participate. Consenting schools received information material, instructions and a link to an electronic version of the prefinal YDQ-spine. Local teachers distributed the electronic YDQ-spine to children aged 9-12 years. Descriptive statistics and item characteristics were carried out. Item reduction was performed using partial interitem correlations (scrutinising correlations>0.3) and factor analyses (items loading>0.3 were retained) to eliminate redundant items and to obtain insight into the structure of the questionnaire.

RESULTS

A total of 768 children from 20 schools answered of the questionnaire and 280 fulfilled the inclusion criteria of having back and/or neck pain (36%). Multisite pain was reported by 38%. Partial interitem correlations and factor analyses resulted in elimination of four items which were considered redundant leaving 24 items in the final YDQ-spine with an optional section on what matters most to the child. The factor analyses showed a two-factor structure with a physical component (13 items) and a psychosocial component (10 items) in addition to one standalone item (sleep).

CONCLUSION

The YDQ-spine is a novel questionnaire with satisfactory content validity measuring physical and psychosocial components (including sleep disturbances) of spinal pain in children aged 9-12 years. It also offers an optional section on what matters most to the child allowing targeted care in clinical practice.

Chiropractic pediatric patient management and interdisciplinary collaboration: a descriptive cross-sectional study of chiropractors in Quebec

BACKGROUND

Worldwide, many patients, including minors, seek chiropractic care. The purpose of this study was to investigate the practice characteristics of chiropractors who treat pediatric patients in Quebec, Canada.

METHODS

We conducted a web-based cross-sectional survey of all licensed chiropractors working in Quebec (Canada). Data were collected using an adapted questionnaire. Descriptive statistics were produced for all the variables collected.

RESULTS

Among our 245 participants (response rate: 21%), 63% were women, and half defined themselves as general musculoskeletal (MSK) health care practitioners. Nearly all participants reported seeing 0-5 new pediatric patients/week, and the most common pediatric age group was 6-12 years old (57%). Pediatric patients were most commonly referred by family members and "word of mouth". The respondents most frequently indicated that they strongly agreed with statements affirming their confidence in their own diagnostic capacities regarding MSK disorders with respect to all age groups as well as non-MSK disorders with regard to young teens. They reported a moderate level of agreement with similar statements concerning the diagnosis of non-MSK disorders in newborns, preschoolers, and children. Chiropractors rarely referred their pediatric patients to a nurse/family doctor or a pediatrician. When presented with potential pediatric red flags, the respondents commonly indicated that they would refer the patient to a physician in an emergency situation or for comanagement.

CONCLUSION

Chiropractors in Quebec are confident in their diagnoses of pediatric MSK conditions and refer patients to physicians in the rare event of a worrisome presentation. However, some chiropractors may have expectations that are unsupported by evidence regarding the diagnosis and management of non-MSK complaints.

Exceeding 2-h sedentary time per day is not associated with moderate to severe spinal pain in 11- to 13-year-olds: a cross-sectional analysis

Neck, mid-back and low back pain, collectively known as spinal pain, become more common with increasing age across childhood and adolescence. A common belief among the general community is that sedentary time, including screen time, in adolescents is associated with spinal pain. We aimed to investigate whether exceeding 2-h of sedentary time per day is associated with moderate to severe spinal pain in a sample of Danish adolescents aged 11-13 years. We performed a cross-sectional analysis of the SPACE study baseline data (2010). Adolescents self-reported their spinal pain (outcome) via the Young Spine Questionnaire and duration of engagement in sedentary behaviours (exposure). We provide estimates of associations as odds ratios with 95% confidence intervals, stratified by age and sex. The sample comprised 1,303 adolescents (48.7% female, mean age 12.5 years, range 10.9-14.3 years). Approximately 9 out of 10 adolescents exceeded 2-h sedentary time on weekdays outside of school (88.9%) and weekend days (89.9%). Close to one-quarter, 23.3% (95%CI: 21.0-25.6), of participants experienced moderate to severe spinal pain. We found no association between exceeding 2-h sedentary time per day and experiencing moderate to severe spinal pain; odds ratios ranged from 0.34 (95%CI: 0.04-3.20) to 4.65 (95%CI: 0.26-82.44).Conclusion: We found no association between exceeding 2- or 5-h of sedentary time per day and moderate to severe spinal pain in this sample of 11-13-year-old Danish adolescents. Our cross-sectional analysis does not consider the longitudinal or complex sequences of events necessary to address predictive or causal questions. What is Known: • Up to a third of adolescents experience moderate to severe spinal pain, predisposing them to chronic spinal pain in adulthood. • Frequent and excessive sedentary time is associated with poor overall health in adolescents; there is conflicting evidence to suggest whether it is also related to spinal pain. What is New: • We found no association between sedentary time and moderate to severe spinal pain in 11- to 13-year-old Danes.

Factors associated with back pain in children aged 6 to 12 years of age, an eight months prospective study

Associated factors of back pain (BP) development before puberty and its persistence are poorly documented. We investigated the association and possible temporality between prior BP history (PBPH), muscular endurance (ME), aerobic capacity (AC), sport activity variables (SAV) and BP in children aged 6 to 12. We collected baseline characteristics (demographics, PBPH, ME, AC and SAV) of children from three primary schools in Canada. Parents replied to weekly text messages regarding their children BP status over an 8-month period. Logistic regression models were adjusted for potential confounders. Data from 242 children (46% female; 8.6 ± 1.7 years) were included. Over the 8-month survey BP prevalence was 48.1%, while the cumulative incidence was 31.9%. The occurrence of at least one BP event was associated with PBPH [OR (IC 95%) = 6.33 (2.35-17.04)] and high AC [2.89 (1.21-6.90)]. High AC was also associated with the development of a first BP episode [2.78 (1.09-7.07)], but ME and SAV were not. BP appears to be relatively common before puberty. BP history seems to be strongly associated with BP recurrence in children. Aerobic capacity is associated with first BP episode development.

Reducing the Weight of Spinal Pain in Children and Adolescents

Spinal pain in adults is a significant burden, from an individual and societal perspective. According to epidemiologic data, spinal pain is commonly found in children and adolescents, where evidence emerging over the past decade has demonstrated that spinal pain in adults can, in many cases, be traced back to childhood or adolescence. Nevertheless, very little focus has been on how to best manage spinal pain in younger age groups. The purpose of this article is to put the focus on spinal pain in children and adolescents and highlight how and where these problems emerge and how they are commonly dealt with. We will draw on findings from the relevant literature from adults to highlight potential common pathways that can be used in the management of spinal pain in children and adolescents. The overall focus is on how healthcare professionals can best support children and adolescents and their caregivers in making sense of spinal pain (when present) and support them in the self-management of the condition.

Pediatric back pain-Diagnostic algorithm

BACKGROUND

Back pain in the pediatric population is common. History and a thorough physical examination and a systematic work-up approach are key components to guide the physician in evaluating the possible causes of pain and providing appropriate treatment.

OBJECTIVE

The main aim of this review was to develop an algorithmic approach to assist physicians in the assessment of pediatric back pain. A comprehensive review of prevalence, differential diagnoses and proper management of pediatric back pain are also presented.

MATERIAL AND METHODS

An extensive literature search was performed in PubMed to gather articles on the prevalence, risk factors, diagnostic tools, differential diagnoses and appropriate management of pediatric back pain.

RESULTS

Available literature revealed that pediatric back pain is a common complaint. Although most cases are non-specific and self-limiting, there is a wide differential that should be considered including inflammatory, neoplastic, infectious and mechanical causes. Sedentary lifestyle, obesity and vigorous physical activity have been shown to increase the likelihood of developing back pain. We proposed an algorithm to guide the physician's decision about the next step in the diagnostic process.

CONCLUSION

A well-defined strategy in the diagnostic process is needed in approaching children/adolescents with back pain. This would have the benefit of minimizing costs, unnecessary tests and child/family anxiety as well as increasing the likelihood of early diagnosis and proper treatment.

Motor performance and back pain in children and adolescents: A systematic review

BACKGROUND AND OBJECTIVE

Motor performance during childhood and adolescence is recognized as a relevant determinant of present and future health, but its effects on back pain (BP) remain unclear. In this systematic review, we aimed to identify the association between motor performance and BP in children and adolescents.

DATABASES AND DATA TREATMENT

A literature search was performed in the MEDLINE, Scopus, Embase, SPORTDiscus and CINAHL databases. We included cross-sectional, cohort, case-control and controlled clinical trials (data from control groups). The inclusion criteria were as follows: (a) participants aged 6-19 years; (b) assessment motor performance components; (c) assessment of BP and (d) reported measures of association. The risk of bias was assessed by the Downs and Black instrument and the quality of evidence by the grading of recommendations, assessment, development and evaluation (GRADE).

RESULTS

A total of 2360 articles were identified, 25 of which were included in our systematic review. Of the 25 studies, 19 were evaluated as having a low risk of bias. GRADE indicated that 20 studies presented low or very low quality. Most of the studies evaluated flexibility (n = 16), muscle endurance (n = 18) and muscle strength (n = 9). Aerobic capacity, balance and speed were also examined in some studies (n < 5). Overall, motor performance (flexibility, muscle endurance, muscle strength, aerobic capacity, balance and speed) was not associated with BP. Most of the results were inconsistent because of the lack of studies, risk of bias and low quality of evidence. Only trunk extensor muscle endurance was associated with decreased BP with moderate quality of the supporting evidence. Prospective studies with a low risk of bias are warranted to further clarify this relationship in childhood and adolescence and findings may support more targeted and effective health promotion interventions.

SIGNIFICANCE

This systematic review shows that motor performance (flexibility, muscle endurance, muscle strength, aerobic capacity, balance and speed) was not associated with BP in children and adolescents. Most of the results were inconsistent because of the lack of studies, risk of bias and low quality of evidence. Only trunk extensor muscle endurance was associated with decreased BP with moderate quality of supporting evidence.

Prognosis and transition of multi-site pain during the course of 5 years: Results of knee pain and function from a prospective cohort study among 756 adolescents

INTRODUCTION

Multi-site pain has not been investigated among adolescents suffering from knee pain. This study aimed to examine the trajectory of pain in adolescents with knee-pain, to determine if multi-site pain in adolescents together with other established prognostic factors (frequency of pain, sex, sports participation, Health Related Quality of Life (HRQoL)) was associated with five-year prognosis of knee-pain and function.

METHODS

This prospective cohort study included 504 adolescents with knee pain and 252 controls. At five-year follow-up, participants responded to an questionnaire which documented prescence and severity of knee pain and co-occurring pain.

RESULTS

At follow-up, 358 (71.0%) of those with knee-pain at baseline, and 182 (72.2%) controls responded. Female sex, low HRQoL, daily pain, and multi-site pain were associated with an increased odds of knee pain after 5 years (odds ratio: 1.41-3.37). Baseline multi-site pain was not associated with problems running at follow-up, whereas higher sports participation at baseline was associated with less problems running at follow-up (odd ratio 0.49). Among those with knee-pain at inclusion, the number of pain sites increased from a median of 2 (IQR 1-3) to 4 (IQR 2-6) at follow-up (P<0.05). Those with multi-site pain at follow-up score significantly worse in self-reported knee function, compared to those with one pain site only.

CONCLUSION

This study identified a set of factors that appeared to be associated with an increased risk of knee pain at five years follow up. Research is needed to understand and help direct treatment of adolescents with multi-site pain.

Prognostic factors for adolescent knee pain: an individual participant data meta-analysis of 1281 patients

ABSTRACT

Adolescent knee pain has a propensity for chronicity, impacting physical activity and health into adulthood. The aim of this study is to investigate prognostic factors in adolescents with knee pain using individual participant data (IPD) meta-analysis. Studies were identified through a systematic search and a collaborative group. We included IPD from prospective studies of adolescents (age 10-19 years) with nontraumatic knee pain (13 studies and 1516 adolescents with 1281 unique participants). Primary outcomes were pain intensity and function (Knee Injury and Osteoarthritis Outcome Score "Sport/Rec" subscale). Primary endpoint was 12 months. Risk of bias was appraised with Quality in Prognosis Studies tool. Harmonised IPD was analysed by multilevel modelling. Fifty-one percent reported knee pain after 12-months. Lower baseline pain frequency was associated with lower pain intensity at 12 months ("less than weekly"; 12 (95% confidence interval [CI] 7-17) and "monthly"; 15 (95% CI 9-22) points lower on a 100-point pain scale, compared with "almost daily pain"). Other factors most strongly associated with 1-year pain prognosis were lower quality of life (30, 95% CI 19-42 points per unit change in the EQ5D index score), female sex (8 points, 95% CI 4-12 higher compared with males), and bilateral pain (7, 95% CI 1-13 points higher pain). Similar factors were associated with function. Body mass index, pain sensitivity, and knee strength were not associated with prognosis of pain or function. Adolescent knee pain is associated with clinically relevant long-term pain and functional deficits. Self-reported characteristics may help identify those at risk of poor prognosis.

The Young Disability Questionnaire-Spine: item development, pilot testing and conceptualisation of a questionnaire to measure consequences of spinal pain in children

OBJECTIVE

The objective of the present study was to develop a questionnaire to measure the consequences of neck, midback and low back pain, relevant for schoolchildren aged 9-12 years.

DESIGN

The development of the questionnaire was carried out in three phases: (1) generation of items, (2) pilot testing and (3) conceptualisation.

SETTING

Danish primary schools.

PARTICIPANTS

Children aged 9-12 years from a local school were invited for completion of questionnaires and subsequent interviews.

METHODS

In phase 1 an extensive literature search identified items from existing questionnaires measuring musculoskeletal disability in children. These were added to items from a previously conducted qualitative study and constituted the basis for the new questionnaire. In phase 2 two consecutive pilot tests were performed to test for comprehension and feasibility of the questionnaire. Phase 3 consisted of a categorisation of the newly developed items according to the WHO's International Classification of Functioning, Disability and Health (ICF).

RESULTS

The combination of the previously conducted qualitative study and the literature review resulted in an item pool of 35 items. Through the process of item formulation and pilot testing, these were reduced to 28 items in the final questionnaire, which represented all categories in the ICF model. The qualitative study identified codes giving relative weight to four important domains. These were not included in any of the existing questionnaires but were added to the new questionnaire.

CONCLUSIONS

We developed the first version of a questionnaire to measure the consequences of back or neck pain in children. The process showed the importance of combining research methods, each adding important contributions to the final product. Subsequent work will finalise the questionnaire, allowing various options for use of the questionnaire.

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.

Cross-Cultural Adaptation and Reliability of the Back Pain and Body Posture Evaluation Instrument (BackPEI) to the Spanish Adolescent Population

The prevalence of back pain (BP) among children and adolescents has increased over recent years. Some authors advocate promoting back-health education in the school setting. It is therefore important to adopt a uniform suite of assessment instruments to measure the various constructs. The present study aimed to perform a cultural adaptation of a validated measurement instrument (BackPEI), beginning with a translation and cultural adaptation phase, followed by a second phase to test reliability using a test-retest design. The translation and cross-cultural adaptation were performed based on the guidelines. Reliability was tested by applying the questionnaire to 224 secondary school students, at two different times with a 7-day interval between the tests. In general, the Spanish version presented adequate agreement for questions 1-20, with only question 9 achieving a low Kappa range of 0.312 (-0.152-0.189). The question about pain intensity did not show differences between the test means (4.72 ± 2.33) and re-test (4.58 ± 2.37) (p = 0.333), and the responses for these two tests obtained a high correlation (ICC = 0.951 (0.928-0.966); p = 0.0001). Psychometric testing indicated that the Spanish version of the BackPEI is well-adapted and reliable, based on the test-retest design, providing similar results to the original Brazilian version.

Rehabilitative management of back pain in children: protocol for a mixed studies systematic review

INTRODUCTION

Little is known about effective, efficient and acceptable management of back pain in children. A comprehensive and updated evidence synthesis can help to inform clinical practice.

OBJECTIVE

To inform clinical practice, we aim to conduct a systematic review of the literature and synthesise the evidence regarding effective, cost-effective and safe rehabilitation interventions for children with back pain to improve their functioning and other health outcomes.

METHODS AND ANALYSIS

We will search MEDLINE, Embase, PsycINFO, CINAHL, the Index to Chiropractic Literature, the Cochrane Controlled Register of Trials and EconLit for primary studies published from inception in all languages. We will include quantitative studies (randomised controlled trials, cohort and case-control studies), qualitative studies, mixed-methods studies and full economic evaluations. To augment our search of the bibliographic electronic databases, we will search reference lists of included studies and relevant systematic reviews, the WHO International Clinical Trials Registry Platform and consult with content experts. We will assess the risk of bias using appropriate critical appraisal tools. We will extract data about study and participant characteristics, intervention type and comparators, context and setting, outcomes, themes and methodological quality assessment. We will use a sequential approach at the review level to integrate data from the quantitative, qualitative and economic evidence syntheses.

ETHICS AND DISSEMINATION

Ethics approval is not required. We will disseminate findings through activities, including (1) presentations in national and international conferences; (2) meetings with national and international decision makers; (3) publications in peer-reviewed journals and (4) posts on organisational websites and social media.

PROSPERO REGISTRATION NUMBER

CRD42019135009.

The Prevalence of Abnormalities in the Pediatric Spine on MRI: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

The aim of this study was to provide an overview of the prevalence of reported musculoskeletal abnormalities on magnetic resonance imaging (MRI) of the pediatric spine.

SUMMARY OF BACKGROUND DATA

Back pain is a common complaint and significant health issue, already in children. Several studies have investigated musculoskeletal abnormalities of the pediatric spine as possible cause of low back pain (LBP). However, it is not clear which abnormalities are the most prevalent among children.

METHODS

A systematic literature search on the prevalence of musculoskeletal spinal abnormalities on MRI in children was conducted in the Embase, Medline Ovid, and Cochrane CENTRAL databases. Risk of bias (RoB) was assessed using a checklist based on the Downs and Black checklist. General information on study and patient characteristics and the prevalence of spinal abnormalities were extracted from the studies. Prevalence data were presented in three subgroups: nonathletes without LBP, participants with LBP, and athletes. Prevalence data of the most reported abnormalities were pooled using random-effects proportion meta-analysis. The study protocol was prospectively registered in PROSPERO (CRD42017080543).

RESULTS

The search resulted in 16,783 articles, of which 31 articles (2373 participants) were included in this systematic review. Two-thirds of the studies had a low RoB. The pooled prevalence in nonathletes without LBP, participants with LBP, and athletes without LBP was respectively 22%, 44%, and 22% for disc degeneration, 1%, 38%, and 13% for herniated discs, 5%, 22%, and 11% for endplate changes, and 0%, 30%, and 6% for pars fractures.

CONCLUSION

Disc degeneration, herniated discs, endplate changes, and spondylolysis are the most reported spinal abnormalities on MRI in children in literature. Spinal abnormalities seen in adults are already prevalent in children with LBP, with the highest prevalence for disc degeneration and herniated discs.

LEVEL OF EVIDENCE

2.

Motor performance and back pain in children and adolescents: a systematic review and meta-analysis protocol

BACKGROUND

The relationship between motor performance and back pain in children and adolescents remains unclear. This article describes the protocol for a systematic review to summarize the knowledge about the association between motor performance, such as agility, flexibility, balance, strength, muscle endurance, and cardiorespiratory fitness, and back pain. Thus, our aim is to identify the influence of motor performance on back pain among children and adolescents.

METHODS

Two independent researchers will search MEDLINE, Scopus, Embase, SPORTDiscus, and CINAHL databases, with no period or language restrictions. We will include cross-sectional, cohort, case-control, and controlled clinical trial studies based on the following criteria: (a) participants from 6 to 19 years of age, (b) assessment of motor performance, (c) assessment of back pain, and (d) report measures of associations between motor performance and back pain. Study quality and risk of bias will be assessed using an adapted version of the Downs and Black instrument. Grading of Recommendations, Assessment, Development, and Evaluations will be used to assess the strength of the body of evidence. Meta-analyses of association measures will be performed for each type of motor performance, separately for different study types. The results will be reported using forest to show the pooled effect of findings and funnel plots to assess precision of the data. If studies are not homogeneous, results from the meta-analyses will not be reported. Associations will then be synthesized descriptively using a pragmatic approach.

DISCUSSION

This systematic review will provide critical insights into the association between motor performance and back pain among children and adolescents; this information may help support clinical practice guidelines as well as public health programs.

ETHICS AND DISSEMINATION

Protocol was written according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA).

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020178496.

Musculoskeletal pain distribution in 1,000 Danish schoolchildren aged 8-16 years

Background

Knowledge about the occurrence and distribution of musculoskeletal problems in early life is needed. The objectives were to group children aged 8 to 16 according to their distribution of pain in the spine, lower- and upper extremity, determine the proportion of children in each subgroup, and describe these in relation to sex, age, number- and length of episodes with pain.

Method

Data on musculoskeletal pain from about 1,000 Danish schoolchildren was collected over 3 school years (2011 to 2014) using weekly mobile phone text message responses from parents, indicating whether their child had pain in the spine, lower extremity and/or upper extremity. Result are presented for each school year individually.

Results

When pain was defined as at least 1 week with pain during a school year, Danish schoolchildren could be divided into three almost equally large groups for all three school years: Around 30% reporting no pain, around 40% reporting pain in one region, and around 30% reporting pain in two or three regions. Most commonly children experienced pain from the lower extremities (~ 60%), followed by the spine (~ 30%) and the upper extremities (~ 23%). Twice as many girls reported pain in all three sites compared to boys (10% vs. 5%) with no other statistically significant sex or age differences observed. When pain was defined as at least 3 weeks with pain during a schoolyear, 40% reported pain with similar patterns to those for the more lenient pain definition of 1 week.

Conclusion

Danish schoolchildren often experienced pain at more than one pain site during a schoolyear, and a significantly larger proportion of girls than boys reported pain in all three regions. This could indicate that, at least in some instances, the musculoskeletal system should be regarded as one entity, both for clinical and research purposes.

Potential treatment effect modifiers for manipulative therapy for children complaining of spinal pain.Secondary analyses of a randomised controlled trial

Background

In children, spinal pain is transitory for most, but up to 20% experience recurrent and bothersome complaints. It is generally acknowledged that interventions may be more effective for subgroups of those affected with low back pain. In this secondary analysis of data from a randomized clinical trial, we tested whether five indicators of a potential increased need for treatment might act as effect modifiers for manipulative therapy in the treatment of spinal pain in children. We hypothesized that the most severely affected children would benefit more from manipulative therapy.

Method

This study was a secondary analysis of data from a randomised controlled trial comparing advice, exercises and soft tissue treatment with and without the addition of manipulative therapy in 238 Danish school children aged 9-15 years complaining of spinal pain. A text message system (SMS) and clinical examinations were used for data collection (February 2012 to April 2014).Five pre-specified potential effect modifiers were explored: Number of weeks with spinal pain 6 months prior to inclusion, number of weeks with co-occurring musculoskeletal pain 6 months prior to inclusion, expectations of the clinical course, pain intensity, and quality of life.Outcomes were number of recurrences of spinal pain, number of weeks with pain, length of episodes, global perceived effect, and change in pain intensity. To explore potential effect modification, various types of regression models were used depending on the type of outcome, including interaction tests.

Results

We found that children with long duration of spinal pain or co-occurring musculoskeletal pain prior to inclusion as well as low quality of life at baseline tended to benefit from manipulative therapy over non-manipulative therapy, whereas the opposite was seen for children reporting high intensity of pain. However, most results were statistically insignificant.

Conclusions

This secondary analysis indicates that children more effected by certain baseline characteristics, but not pain intensity, have a greater chance to benefit from treatment that include manipulative therapy. However, these analyses were both secondary and underpowered, and therefore merely exploratory. The results underline the need for a careful choice of inclusion criteria in future investigations of manipulative therapy in children.

Trial registration

NCT01504698; results.

Talking to Teens about Pain: A Modified Delphi Study of Adolescent Pain Science Education

Background: Persistent pain is a prevalent condition that negatively influences physical, emotional, social and family functioning in adolescents. Pain science education is a promising therapy for adults, yet to be thoroughly investigated for persistent pain in adolescents. There is a need to develop suitable curricula for adolescent pain science education.

Methods: An interdisciplinary meeting of 12 clinicians and researchers was held during March 2018 in Adelaide, South Australia. An a priori objective of the meeting was to identify and gain consensus on key learning objectives for adolescent pain science education using a modified-Delphi process.

Results and Conclusion: Consensus was reached via a modified Delphi process for seven learning objectives to form the foundation of a curriculum: 1) Pain is a protector; 2) The pain system can become overprotective; 3) Pain is a brain output; 4) Pain is not an accurate marker of tissue state; 5) There are many potential contributors to anyone’s pain; 6) We are all bioplastic and; 7) Pain education is treatment. Recommendations are made for promising areas for future research in adolescent pain science education.

Back pain, mental health and substance use are associated in adolescents

BACKGROUND

During adolescence, prevalence of pain and health risk factors such as smoking, alcohol use and poor mental health all rise sharply. The aim of this study was to describe the relationship between back pain and health risk factors in adolescents.

METHODS

Cross-sectional data from the Healthy Schools Healthy Futures study, and the Australian Child Wellbeing Project was used, mean age: 14-15 years. Children were stratified according to back pain frequency. Within each strata, the proportion of children that reported drinking alcohol or smoking or that experienced feelings of anxiety or depression was reported. Test-for-trend analyses assessed whether increasing frequency of pain was associated with health risk factors.

RESULTS

Data was collected from ~2500 and 3900 children. Larger proportions of children smoked or drank alcohol within each strata of increasing pain frequency. The trend with anxiety and depression was less clear, although there was a marked difference between the children that reported no pain, and pain more frequently.

CONCLUSION

Two large, independent samples show adolescents that experience back pain more frequently are also more likely to smoke, drink alcohol and report feelings of anxiety and depression. Pain appears to be part of the picture of general health risk in adolescents.

Spinal pain is prospectively associated with cardiovascular risk factors in girls but not boys (CHAMPS study-DK)

PURPOSE

To examine the prospective associations between spinal pain exposures and risk factors for cardiovascular disease in children and explore the mediating role of health-related physical activity.

METHODS

Students were recruited from ten public primary schools. Each week from November 2008 to October 2010, parents reported spinal pain occurrences in their children via text messaging. Clustered cardiovascular risk was estimated with a composite score comprising fasting serum triglycerides, homeostasis assessment model-estimated insulin resistance (HOMA-IR), total to high-density lipoprotein cholesterol ratio, and systolic blood pressure. Additional outcomes were fasting serum insulin and glucose concentrations and body mass index categories. Associations were explored with multilevel mixed regression models and reported with beta coefficients (β) and percent difference scores. All models were adjusted for potential confounders.

RESULTS

Data from 1022 children (53% female) with mean ± SD age of 8.4 ± 1.4 years were included. Girls with spinal pain had greater clustered cardiovascular risk (β [95% CI]; percent difference [95% CI] = .41 [.02-.80]; 3.3% [.2-6.4%]) than those without spinal pain. Similar outcomes were observed for log insulin (percent difference [95% CI] = 3.4% [.6-6.2%]) and log HOMA-IR = (percent difference [95% CI] = 3.8% [.4-7.3%]). Remaining associations between spinal pain and cardiovascular risk in girls were nonsignificant. There were no associations between spinal pain and cardiovascular risk in boys. Moderate-to-vigorous-intensity physical activity did not appear to mediate this relationship.

CONCLUSION

These findings suggest a potentially important link between spinal pain and cardiovascular risk in girls that may be independent of health-related physical activity. These slides can be retrieved under Electronic Supplementary Material.

Associations between number of pain sites and sleep, sports participation, and quality of life: a cross-sectional survey of 1021 youth from the Midwestern United States

BACKGROUND

Musculoskeletal pain in youth is common but little is known about the influence of the number of pain sites on pain characteristics. The objective of this study was to compare pain characteristics, quality of life, sleep, sport participation between adolescents without pain, those with single site pain, and those with multi-site pain and investigate the relationship between pain duration and number of pain sites.

METHODS

An online survey was sent via email to 7177 possible middle- and high-school students. The students completed a survey containing questions about their pain (including location, duration, intensity, frequency), health-related quality of life, sleep quantity and quality, and sports participation. Quantitative variables were analysed with one-way ANOVAs or t-tests and qualitative variables were analysed with Pearson Chi-squared tests. Relationships were investigated with a Pearson Correlation.

RESULTS

Of the respondents (n = 1021), 52.9% reported no pain, 17.2% reported pain in a single-site, and 29.9% reported pain in multiple sites. Those with multi-site pain reported significantly lower quality of life than both pain-free youth (p < 0.001) and those with single-site pain (p < 0.001); those with single-site pain had lower quality of life than pain-free youth (p < 0.001). Those with pain reported worse sleep than those without pain (P < 0.05). No differences in sport participation were found (p > 0.10). Those with multi-site pain reported greater intensity (p = 0.005) and duration (p < 0.001) than those with single-site pain. A positive, moderate, and significant correlation (r = 0.437, p < 0.001) was found between the pain duration and number of pain sites.

CONCLUSIONS

A large percentage of youth experience regular pain that affects their self-reported quality of life and sleep, with greater effects in those with multi-site pain.

The natural course of low back pain from childhood to young adulthood - a systematic review

Background

Taking the natural course of recurrent and fluctuating low back pain (LBP) seen in longitudinal studies of adults into consideration, the aetiology and development of LBP in children and adolescents also needs to be reflected in a long-term course. Therefore, a systematic critical literature review was undertaken to assess the natural course of LBP in the general population from childhood through adolescence to young adulthood.

Methods

A systematic literature search was conducted in MEDLINE, EMBASE, CINAHL and PsycINFO with synonyms of search terms for 1) low back pain; 2) natural course; 3) cohort study and 4) children. Records in English, German, French, Danish, Swedish, and Norwegian were included. To assess the methodological quality of the studies, the NIH quality assessment checklist for cohort studies was adapted and risk of bias was assessed on a study level. Two authors independently reviewed selected studies, assessed quality, and extracted data. A synthesis of results in relation to the natural course of LBP was created.

Results

Totally, 3373 records were identified, eight articles were included for quality assessment, and finally, four studies of good to fair quality were included for synthesis of results. Indication of three common patterns of LBP were identified across studies and labelled as 1) ´children and adolescents with no LBP or low probability of LBP´ (49 to 53%), 2) ´children and adolescents with fluctuation of LBP´ (16 to 37%) and 3) ´children and adolescents with repeated reporting of LBP´ (< 1 to 10%).

Conclusion

Although methodological heterogeneity, mainly due to different age ranges, an indication of a natural course of LBP was seen across studies. The majority of children and adolescents repeatedly reporting no or low probability of LBP. With recall periods between one week to three months and sampling rates ranging from one to four years, a very low rate repeatedly reported LBP, and approximately one-fifth to one-third of children and adolescents had fluctuating reports of LBP. A need of future research of LBP trajectories with short reporting period lengths and narrower sampling windows in a long-term perspective is emphasized in order to study childhood influences on the development of LBP throughout life.

Utilization of Chiropractic Care in US Children and Adolescents: A Cross-Sectional Study of the 2012 National Health Interview Survey

OBJECTIVE

The purpose of this study was to describe the prevalence of chiropractic utilization and examine sociodemographic characteristics associated with utilization in a representative sample of US children and adolescents aged 4 to 17 years.

METHODS

Data are from 9734 respondents to the 2012 National Health Interview Survey. Age, sex, race/ethnicity, geography, family income, parental educational attainment, and other health care providers served as exposure variables. Chiropractic utilization in the past 12 months (yes/no) was the targeted outcome. Weighted crude and adjusted logistic regression models, controlling for relevant covariates, were performed.

RESULTS

The 12-month prevalence of chiropractic utilization in US children was 3.0% (95% confidence interval: 2.6%-3.6%). The adjusted odds (95% confidence interval) of chiropractic utilization were higher among 11- to 17-year-olds (2.02 [1.41-2.90]) (vs 4- to10-year-olds), Midwest residents (2.45 [1.36-4.44]) (vs Northeast), families with incomes ≥$100000 (3.25 [1.87-5.66]) (vs <$35000), and those that visited other Complementary and Integrative Health (also known as Complementary and Alternative Medicine) practitioners (11.26 [7.19-17.64]). Blacks and Asians had lower adjusted odds of chiropractic utilization compared with whites (0.17 [0.06-0.47] and 0.17 [0.07-0.43], respectively). Sex, parental education, and having an orthodox medical personal physician were not associated with utilization.

CONCLUSION

Although overall prevalence was low, sociodemographic characteristics of child and adolescent users of chiropractic care were identified. Age, race/ethnicity, region of residence, family income, and utilization of other Complementary and Integrative Health services were associated with chiropractic utilization, after adjusting for sociodemographic covariates.

Conservative care with or without manipulative therapy in the management of back and/or neck pain in Danish children aged 9-15: a randomised controlled trial nested in a school-based cohort

BACKGROUND

A substantial number of children experience spinal pain, that is, back and/or neck pain. Today, no 'gold-standard' treatment for spinal pain in children exists, but manipulative therapy is increasingly being used in spite of a lack of evidence of its effectiveness. This study investigates the effectiveness of adding manipulative therapy to other conservative care for spinal pain in a school-based cohort of Danish children aged 9-15 years.

METHODS AND FINDINGS

The design was a two-arm pragmatic randomised controlled trial, nested in a longitudinal open cohort study in Danish public schools. 238 children from 13 public schools were randomised individually from February 2012 to April 2014. A text message system and clinical examinations were used for data collection. Interventions included either (1) advice, exercises and soft-tissue treatment or (2) advice, exercises and soft-tissue treatment plus manipulative therapy. The primary outcome was number of recurrences of spinal pain. Secondary outcomes were duration of spinal pain, change in pain intensity and Global Perceived Effect.We found no significant difference between groups in the primary outcome (control group median 1 (IQR 1-3) and intervention group 2 (IQR 0-4), p=0.07). Children in the group receiving manipulative therapy reported a higher Global Perceived Effect: OR 2.22, (95% CI 1.19 to 4.15). No adverse events were reported. Main limitations are the potential discrepancy between parental and child reporting and that the study population may not be comparable to a normal care-seeking population.

CONCLUSIONS

Adding manipulative therapy to other conservative care in school children with spinal pain did not result in fewer recurrent episodes. The choice of treatment-if any-for spinal pain in children therefore relies on personal preferences, and could include conservative care with and without manipulative therapy. Participants in this trial may differ from a normal care-seeking population.

TRIAL REGISTRATION NUMBER

NCT01504698; Results.

Chiropractic in Global Health and wellbeing: a white paper describing the public health agenda of the World Federation of Chiropractic

The World Federation of Chiropractic supports the involvement of chiropractors in public health initiatives, particularly as it relates to musculoskeletal health. Three topics within public health have been identified that call for a renewed professional focus. These include healthy ageing; opioid misuse; and women's, children's, and adolescents' health. The World Federation of Chiropractic aims to enable chiropractors to proactively participate in health promotion and prevention activities in these areas, through information dissemination and coordinated partnerships. Importantly, this work will align the chiropractic profession with the priorities of the World Health Organization. Successful engagement will support the role of chiropractors as valued partners within the broader healthcare system and contribute to the health and wellbeing of the communities they serve.

Risk factors of non-specific spinal pain in childhood

PURPOSE

Non-specific spinal pain can occur at all ages and current evidence suggests that pediatric non-specific spinal pain is predictive for adult spinal conditions. A 5-year long, prospective cohort study was conducted to identify the lifestyle and environmental factors leading to non-specific spinal pain in childhood.

MATERIALS AND METHODS

Data were collected from school children aged 7-16 years, who were randomly selected from three different geographic regions in Hungary. The risk factors were measured with a newly developed patient-reported questionnaire (PRQ). The quality of the instrument was assessed by the reliability with the test-retest method. Test (N = 952) and validity (N = 897) datasets were randomly formed. Risk factors were identified with uni- and multivariate logistic regression models and the predictive performance of the final model was evaluated using the receiver operating characteristic (ROC) method.

RESULTS

The final model was built up by seven risk factors for spinal pain for days; age > 12 years, learning or watching TV for more than 2 h/day, uncomfortable school-desk, sleeping problems, general discomfort and positive familiar medical history (χ² = 101.07; df = 8; p < 0.001). The probabilistic performance was confirmed with ROC analysis on the test and validation cohorts (AUC = 0.76; 0.71). A simplified risk scoring system showed increasing possibility for non-specific spinal pain depending on the number of the identified risk factors (χ² = 65.0; df = 4; p < 0.001).

CONCLUSION

Seven significant risk factors of non-specific spinal pain in childhood were identified using the new, easy to use and reliable PRQ which makes it possible to stratify the children according to their individual risk. These slides can be retrieved under Electronic Supplementary Material.

Does lower extremity pain precede spinal pain? A longitudinal study

The main objective was to investigate whether children aged 9-15 years at baseline were more likely to experience an incident event of spinal pain after experiencing lower extremity pain. Children's musculoskeletal pain was monitored by weekly mobile phone text message responses from parents, indicating whether the child had spinal pain, lower extremity pain, or upper extremity pain the preceding week. Data were analyzed using mixed effect logistic regression models and cox regression models. The association between an incident event of spinal pain and LE pain the preceding weeks increased with increasing observation period and was statistically significant for 12 and 20 weeks (OR = 1.34 (95% CI 1.05 to 1.70) and OR = 1.39 (95% CI 1.11 to 1.75), respectively). We found that the likelihood increased in children with more frequent or longer duration of lower extremity pain. The reversed relationship was investigated as well, and we also found a positive association between spinal pain and a subsequent incidence event of lower extremity pain, but less pronounced.Conclusion: Children were more likely to experience an incident event of spinal pain after experiencing lower extremity pain. The likelihood increased in children with more frequent or longer duration of lower extremity pain. What is Known: • Both spinal pain and lower extremity pain often start early in life and is common already in adolescence. What is New: • Children were more likely to experience an incident event of spinal pain after experiencing LE pain. • The likelihood increased in children with more frequent or longer duration of LE pain.

Musculoskeletal extremity pain in Danish school children - how often and for how long? The CHAMPS study-DK

Background

Musculoskeletal pain is common in childhood and adolescence, and may be long-lasting and recurrent. Musculoskeletal problems tend to follow adolescents into adulthood, and therefore it is important to design better prevention strategies and early effective treatment. To this end, we need in-depth knowledge about the epidemiology of musculoskeletal extremity problems in this age group, and therefore, the aim of this study was to determine the prevalence, frequency and course of musculoskeletal pain in the upper and lower extremities in a cohort of Danish school children aged 8–14 years at baseline.

Methods

This was a prospective 3-year school-based cohort study, with information about musculoskeletal pain collected in two ways. Parents answered weekly mobile phone text messages about the presence or absence of musculoskeletal pain in their children, and a clinical consultation was performed in a subset of the children.

Results

We found that approximately half the children had lower extremity pain every study year. This pain lasted on average for 8 weeks out of a study year, and the children had on average two and a half episodes per study year. Approximately one quarter of the children had upper extremity pain every study year that lasted on average 3 weeks during a study year, with one and a half episodes being the average. In general, there were more non-traumatic pain episodes compared with traumatic episodes in the lower extremities, whereas the opposite was true in the upper extremities. The most common anatomical pain sites were ‘knee’ and ‘ankle/ft’.

Conclusion

Lower extremity pain among children and adolescents is common, recurrent and most often of non-traumatic origin. Upper extremity pain is less common, with fewer and shorter episodes, and usually with a traumatic onset. Girls more frequently reported upper extremity pain, whereas there was no sex-related difference in the lower extremities. The most frequently reported locations were ‘knee’ and ‘ankle/ft’.

Electronic supplementary material

The online version of this article (10.1186/s12891-017-1859-8) contains supplementary material, which is available to authorized users.

Prevalence and incidence of musculoskeletal extremity complaints in children and adolescents. A systematic review

BACKGROUND

It is difficult to gain an overview of musculoskeletal extremity complaints in childhood although this is essential to develop evidence-based prevention and treatment strategies. The objectives of this systematic review were therefore to describe the prevalence and incidence of musculoskeletal extremity complaints in children and adolescents in both general and clinical populations in relation to age, anatomical site and mode of onset.

METHODS

MEDLINE and EMBASE were electronically searched; risk of bias was assessed; and data extraction was individually performed by two authors.

RESULTS

In total, 19 general population studies and three clinical population studies were included with children aged 0-19 years. For most of the analyses, a division between younger children aged 0-12 years, and older children aged 10-19 years was used. Lower extremity complaints were more common than upper extremity complaints regardless of age and type of population, with the most frequent pain site changing from ankle/foot in the youngest to knee in the oldest. There were about twice as many non-traumatic as traumatic complaints in the lower extremities, whereas the opposite relationship was found for the upper extremities in the general population studies. There were relatively more lower extremity complaints in the general population studies than in the clinical population studies. The review showed no pattern of differences in reporting between studies of high and low risk of bias.

CONCLUSIONS

This review shows that musculoskeletal complaints are more frequent in the lower extremities than in the upper extremities in childhood, and there are indications of a large amount of non-traumatic low intensity complaints in the population that do not reach threshold for consultation. A meta-analysis, or even a simple overall description of prevalence and incidence of musculoskeletal extremity complaints in children and adolescents was not feasible, due to a large variety in the studies, primarily related to outcome measurements.