Most of us know someone who has “a bad back”. Research tells us up to 70% of people will experience back pain at some stage during their lives. But what about when a child or teenager complains of musculoskeletal pain such as back or neck pain?
The most common type of musculoskeletal pain is spinal (back or neck pain), and many more adolescents complain of pain than is commonly recognised. Between one-third and half of all adolescents aged 13 and over report back pain about every month or more often. In fact, the prevalence of these conditions rises so sharply in early adolescence the rates approach adult levels by 18 years.
It’s becoming increasingly clear so-called non-specific “musculoskeletal conditions”, the leading causes of disability worldwide, are significant health issues in children. By non-specific conditions we mean pain that cannot be attributed to a defined and diagnosable anatomical cause. In adults, these conditions are recognised as complex disease states that have biological, psychological and socio-environmental underpinning.
Aren’t they just growing pains?
In the absence of an identifiable injury such as a sprain or fracture, we often disregard childhood and adolescent spinal and musculoskeletal pain. A common belief is that pain in kids will just go away or be forgotten when life takes over.
However, for a significant proportion of adolescents, non-specific pain has extensive impacts on health and quality of life. For example, in a study in Western Australia, about 20% of 17-year-olds reported either missing school, seeking health care, taking medication, interference with normal activities, or interference with physical/sporting activities due to back pain.
Worryingly, there is evidence persistent pain symptoms in adolescence predict chronic pain problems in adulthood.
The blame for pain in kids is often directed at school bags, computer and small-screen device usage, posture, or other biomechanical targets. It is also sometimes believed (permanent) damage is being done to the spine, with lifelong consequences.
However, there is little evidence this is true. Studies show socioeconomic, lifestyle, cognitive and psychological factors are just as strongly, or even more strongly, related to pain, particularly chronic pain, as physical factors.
These societal beliefs about physical causes of pain may be not only incorrect, but detrimental if they cause worry about the spine being fragile and discourage children from physical activity.
Back pain and health
Health issues such as excess weight and obesity, diabetes, substance use and poor mental health among children are causes for concern, and the targets of national public health campaigns.
Recent evidence has shown these general risk factors for poor health and chronic disease cluster in children with spinal pain. At this point, it is not possible to say whether pain precedes poorer general health or vice-versa. Relationships between them are likely to be complex.
However, given the high rates of musculoskeletal pain across the population, and in particular in kids with other health risks, a case can be made for considering the influence of pain in the effectiveness of lifestyle-related public health campaigns. For instance, pain could be an important barrier to participation in physical activity.
Addressing health behavioural risk factors, such as inactivity, weight gain, diet and even substance use, when treating young patients with pain is likely to be important. This will be important whether these behavioural risks are (partially) responsible for the pain itself or develop in response to painful symptoms.
Unfortunately, to date we don’t really understand the complex interaction between painful events, the growing body and broader health influences, and other social or environmental influences from family, health care providers and schooling. In particular, we know very little about what brings on the initial episodes of painful conditions and whether this underpins the link with future chronic pain.
Given wide recognition that early life events are critical in shaping health as people grow older, understanding the context of common painful conditions in early life is critical to inform future health.
Overdiagnosis and overtreatment
It is important we provide effective treatment to those at risk of developing persistent pain. It is also important we don’t create medical problems out of transient aches and pains. We definitely don’t want to be sending every child who complains of back or neck pain off for diagnostic tests and intensive treatments. A problem currently is we don’t have sufficient quality evidence to enable us to decide who we should be concerned about, and who can be reassured and sent on their way.
While we don’t have good evidence about what specific treatments are effective for childhood and adolescent spinal pain, it is possible to engage the community in better conversation about what causes “non-specific” musculoskeletal conditions.
The role of social influences needs closer examination, and pain must be considered within the broader context of chronic disease and long-term health risk factors. A shift away from the narrow and outdated focus on school bags, posture and damaged spines is a must. Efforts to update the narrative around pain are as important for children as for adults.