Is Back Pain a Normal Part of Growing Up?

An article on the prevalence of pediatric lower back pain appeared in the January 2009 issue of Archives of Pediatric and Adolescent Medicine. Dr. Mark Lopes, the GCSS Research Chair, responded with a letter to the editor. The response was rejected. Was it rejected because of the D.C. behind his name? We will never know. Below is the abstract and Dr. Lopes’ letter.

Pellise F, Balagué F, Rajmil L, Cedraschi C, et al. Prevalence of Low Back Pain and Its Effect on Health-Related Quality of Life in Adolescents. Archives of Pediatric and Adolescent Medicine January 2009; 163(1):65-71.

ABSTRACT: Objectives: To assess the prevalence of low back pain (LBP) in adolescents and the clinical features of LBP in 2 European countries and to evaluate the effect of LBP on health-related quality of life (HRQOL) using standardized validated generic and disease-specific instruments.

Design: Cross-sectional study. Setting: Secondary schools of Barcelona, Spain, and Fribourg, France. Participants: Representative sample of adolescents from the 2 cities. Intervention: Selected adolescents completed a questionnaire including a generic HRQOL (KIDSCREEN-52) and 2 LBPspecific instruments. Main Outcome Measures: Results of KIDSCREEN-52, the Roland-Morris Disability Questionnaire, and the Hanover Functional Ability Questionnaire. Results: A total of 1470 adolescents (52.6% male)  with a mean (SD) age of 15.05 (1.17) years completed the questionnaires (response rate, 85.1%). Low back pain was reported by 587 adolescents (39.8%): isolated LBP in 250 (42.6%), LBP plus other pain in 271 (46.2%), LBP plus whole-body pain in 50 (8.5%), and unclassified LBP in 16 (2.7%). Five hundred adolescents (34.7%) reported on pain, and 369 (25.6%) reported other pain without LBP. In those with LBP plus whole-body pain, the percentage of adolescent girls was higher (62%; P<.001) and LBP was most severe. All KIDSCREEN scores in the group with LBP plus wholebody pain were significantly lower than in the other groups (effect size, 0.52- 1.24). No differences were found between the groups who reported isolated pain, no pain, or other pain with no LBP. On the LBP-specific instruments, adolescents who reported LBP plus other pain had significantly poorer scores (P<.001) compared with those with isolated LBP but better scores (P<.001) than those with LBP plus whole-body pain.

Conclusion: Low back pain in adolescents is a prevalent symptom with overall low associated disability and little effect on health-related quality of life. A subset of adolescents in whom LBP is associated with whole-body pain report significant impairment and deserve more attention.

DR. MARK LOPES’ RESPONSE: Low Back Pain in Adolescents:
Normal or Early Sign of Progressive Condition? The article “Prevalence of Low Back Pain and Its Effect on Health-Related Quality of Life in Adolescents” by Pellise’ et al. concluded that low back pain in adolescents is common, but only small percentage of adolescents suffered effects on quality of life (HRQOL) and 2 LBP specific instruments. The authors stated “9 of 10 adolescents reporting LBP can be considered healthy,” and that diagnosing or treating these “otherwise healthy” adolescents for LBP should be discouraged because psychosocial factors play a role in adolescent LBP.

Medscape Medical News reported that lead author, Dr. Pellise,’ stated that these findings suggest “pain is a normal life experience in adolescence. If a patient has low back pain for 1 or 2 days a week with no other symptoms, there is really no reason to pursue further investigations or even change their lifestyle, such as recommending a different schoolbag.”

Just because a condition is frequent and doesn’t impact the score of questionnaires, should not lead to an opinion that the condition is therefore normal. The authors’ conclusions reach beyond the study’s actual findings and run counterintuitive to prior studies. Citing the authors’ own references for substantiation, there is a “link between low back pain in adolescence and chronic LBP in adulthood”; “the strongest predictor of future LBP is a history of symptoms”; LBP “onset early in life is predictive of chronicity.”

The study provides useful data; however, the over-reaching conclusions evidently result from a preconception that is likely flawed. One of the authors’ pre-study perspectives was that “Differentiating disease from a common life experience on the basis of the effect on HRQOL should help to avert unnecessary treatment in otherwise healthy adolescents.” I believe that this preconception may have led to the potentially misleading opinions. One could be physiologically unhealthy without significant effect on HRQOL. Many common disorders are symptomatically silent. The soft data instruments used are tested for certain characteristics, but are not sufficient indicators to call an individual “otherwise healthy.”

Psychological factors are important in adolescents, but that doesn’t mean psychological factors cause low back pain. The author’s concern in this regard is warranted, however, should we be more concerned with the psychosocial effect of diagnosis and treatment than we are with developing positive, proactive approaches to managing these individuals, working to help prevent possible progression of this common disorder that often leads to impairment later in life? Should we wait until the symptoms affect quality of life to act?

Editor’s Note: So much appeared to have been ignored or assumed in this study. How many of the incidences of LBP due to trauma, occurred spontaneously, or were due to a progression over time. How many had ignored the pain and continued activities and considered themselves not disabled when they truly were, as they might have been compensating for the problem or took medication and/or otherwise ignored it. The majority (more than 50%) had to recall injuries that occurred months or years before filling out the questionnaires. Too many assumptions were made, and too many confounders were ignored in this study.