Low back pain in children

Low back pain (LBP) is prevalent in children and its incidence continues to rise into adolescence, highlighting a need for early prevention. A systematic review of the incidence and prevalence of LBP in this study identified a noticeable increase in the prevalence of LBP between the ages of 12 to 15 years. There is a recognised association between the presence of LBP in childhood and the development of LBP in adults, and we know the risk of LBP is greater for people with a history of LBP than for those without. This indicates a need for primary prevention of the first episode of LBP. Strategies for the prevention of LBP require knowledge of the risk factors for LBP. A number of risk factors were identified in a systematic review in this study, but none of the nine significant risk factors identified were validated in independent studies. The review was confounded by method variations in included studies: a) a large variation in the methods used to measure risk factors made direct comparison difficult; b) definitions of risk factors varied; c) definitions of LBP varied making sensible pooling of data difficult; d) the methods used to collect and analyse data limited meaningful interpretation; and e) the long periods involved in the recall of events questions the accuracy of the reports. It is also difficult to determine at what point the presence of a risk factor becomes a problem or which risk factors are inter-related. The method issues found in this review concur with reports of method confounders in previous reviews of LBP studies. The constraints of predictive studies and the many covariates indicate that the measurement of predictors may be futile and a focus on intervention could be more useful in the search for strategies for preventing LBP. The evidence for specific interventions for LBP prevention in children is sparse. However, given the evidence of the benefits of exercise as a preventative measure for reoccurrence of LBP in adults, exercise for the prevention of LBP in children justified investigation. A randomised controlled trial (RCT) of daily exercise and education in children revealed that children participating in the exercise and back-awareness education program reported significantly fewer episodes of LBP and fewer lifetime first episodes of LBP than those who received only education. The reduction in LBP episodes could not be attributed solely to the specific spine exercises: it is possible that drawing attention to the spine by emphasizing awareness and regular movement in the back had beneficial effects. Further exercise intervention studies are needed as the RCT indicates that exercise has the potential to influence good back health in children. Adherence to exercise is a frequently reported problem with exercise-intervention studies. The RCT was designed to facilitate adherence. An observational study embedded in the RCT investigated adherence of children to the exercise program and the factors that have the potential to influence adherence. Exercise adherence declined through the nine months of the study despite a range of strategies designed to encourage it. This concurs with longer term studies of exercise adherence in adults and children. Innovative strategies need to be implemented if children are to develop new habits. This possibly requires the integration of spine exercises into sports regimens, and the use of modern technology to capture and maintain the attention of children over longer periods to facilitate the development of habits with the potential to improve spine health. Researching children in schools presented many challenges. The logistical issues and design features of the RCT are reported, and the strategies required in the planning of this type of study are reviewed. The research in this study indicated an appropriate time for the implementation of prevention strategies in children. The back awareness program investigated in this thesis showed promise for an effect on future LBP. School-based back awareness programs in some format require further development. This thesis uses a combination of published, accepted and prepared papers supplemented by a framework of chapters providing supporting work and knowledge.