Prevention in low back pain in schoolchildren.

What is the evidence?

Greet Cardon, Federico Balagué

Greet Cardon, PhD (corresponding author)

Department of Movement and Sports Sciences - Ghent University -

Watersportlaan 2 - B-9000 Gent - Belgium - Tel. 0032.9.264.91.42. - Fax. 0032.9.264.64.84.

greet.cardon@UGent.be

F. Balagué, MD

Department of Rheumatology - Physical Medicine and Rehabilitation

Hopital Cantonal - CH-1708 Fribourg - Switzerland

balaguef@hopcantfr.ch

Acknowledgement.

The support of the European Commission, through COST Action B 13 is acknowledged.

Summary

Given the high prevalence rates of back pain, as early as in childhood, there has been a call for early preventive interventions. To determine which interventions are used to prevent back problems in schoolchildren as well as what the evidence is for their utility, the literature was searched to locate all investigations that were using subjects under the age of 18, not seeking treatment, and specifically designed as an intervention for the prevention in low back pain (LBP). Additionally a literature search was performed for modifiable risk factors for LBP in schoolchildren. The literature update search was performed within the scope of the “COST Action B13” of the European Commission, approved for the development of European guidelines for the management of LBP. It was concluded that intervention studies in schoolchildren focusing on back pain prevention are promising but too limited to formulate evidence based guidelines. On the other hand, since the literature shows that back pain reports in schoolchildren are mainly associated with psychosocial factors, the scope for the prevention in LBP in schoolchildren may be limited. However, schoolchildren are receptive to back care related knowledge and postural habits, which may play a preventive role for back pain in adulthood. Further studies with a follow-up into adulthood are needed to evaluate long term effect of early interventions and the possible detrimental effect of spinal loading at young age.

Introduction

Low back pain (LBP) was traditionally reported to be uncommon in children.

Moreover, it was believed that this symptom was almost always due to a serious underlying illness. During the last decades, an increasingly large number of surveys have demonstrated that non-specific LBP in schoolchildren is much more frequent than thought in the past.

Different approaches have been used to prevent LBP in schoolchildren. A majority of these studies could be grouped under the label “education” because the interventions consisted of a variable number of hours of education with or without associated exercises. Some authors had a very limited target, such as lifting technique, while others aimed at reducing LBP and its consequences. It has been demonstrated that different interventions successfully improved specific back care related knowledge and / or skills. However, this is not synonymous with prevention in LBP. There have also been attempts to prevent LBP by modifications of the “school furniture”, however any high quality study to test the possible protective effect of furniture could not be located. A third approach could be focusing on “modifiable risk factors” (e.g.: smoking).

However, since primary causative mechanisms for common LBP remain largely undetermined, considering risk factor modification as prevention, without evidence of influence on LBP outcomes, needs caution.

To increase consistency in the management of non-specific LBP across countries in Europe, the European Commission Research Directorate General approved a program for the development of European guidelines for the management of LBP, called “COST Action B13”. The COST program of the European Commission stimulates and co-ordinates European collaboration in the field of scientific and technical research with the aim to establish networks of researchers across Europe. Typically, COST Actions have several Working Groups (WG). Specifically within the COST B13 action, WG 1 focuses on the diagnosis and treatment of acute LBP, WG 2 on the diagnosis and treatment of chronic LBP, WG 3 on the prevention in LBP composed of 3 subgroups aiming respectively at the general population, the workforce and schoolchildren and WG 4 on pelvic pain. Since the searches of WG 3 focus not only on effects of preventive interventions on back pain prevalence but also on effects on back pain related consequences, the searches evaluate the prevention “in” LBP and not only “of” LBP. The present review paper is the result of a literature search performed for the COST B13 action by a subgroup of WG 3 members, focusing on the prevention in LBP in schoolchildren.

Methods

Due to the limited number of studies, evaluating the effects of a preventive intervention in schoolchildren, it was decided by WG 3 to include a search for modifiable risk factors for LBP in schoolchildren. An electronic search on Pub Med for articles published since 1995 was performed by two independent researchers. Non-English manuscripts without an English abstract were not considered for inclusion. The database research was supplemented by citation tracking, personal databases and expert knowledge. Both researchers independently reviewed the studies and excluded manuscripts limited to specific back pain and non-modifiable risk-factors, like age, gender, anthropometrics, parental educational level and demographic factors. Also studies with only epidemiologic data, studies not focusing on back pain or possible consequences of back pain and studies without data for children under the age of 18 were excluded for the present review.

Results

Intervention studies.

In schoolchildren, only 5 intervention studies, including the evaluation of back pain or the consequences of back pain, could be located in the literature since 1995. Balagué et al., Mendez et al., Cardon et al., Feingold and Jacobs and Storr-Paulsen all evaluated a school based intervention program consisting of a variable number of hours education. In the study of Balagué et al. Swedish Back School was implemented by a rheumatologist to 55 primary school teachers during 2 sessions of 90 minutes plus an annual 2 hours session. Back School was then administered by the primary school teachers over a 3-year period.

Effects of the program were evaluated through a pre-post intervention survey.

The post intervention survey included 1715 elementary schoolchildren.

The program implementation resulted in an overall reduction in prevalence of LBP during the 3-year period analysed. Recollection of participation in the prevention program was associated with increased self-reported LBP but with significantly decreased utilization of medical care. A shortcoming of the study was the non-randomised design and the fact that the population of schoolchildren at the beginning and at the end of the study was partially different.

Therefore results can not be generalized.

Cardon et al., evaluated the effects of a 6 hours back education program, implemented by a physical therapist in 347 9 to 11-year-old schoolchildren. A controlled pre-post design with a 1-year follow-up was used. Following the program resulted in better use of back care principles and in decreased selfreported back- and neck pain prevalence. However, the quasi-experimental design requires cautious interpretation of the study results. A third intervention study was performed by Mendez et al., evaluating a postural hygiene program, consisting of 11 sessions: 3 devoted to physiotherapy exercises and 8 to behaviour intervention. As in the study of Cardon et al., a quasi-experimental design was used with a 12-month follow-up assessment. The postural hygiene program was applied to 106 9-year-old schoolchildren. The intervention group showed increased back related knowledge and improved general postural habits. In addition, making use of a placebo group, it was shown that programs involving practice and motivating strategies impart health knowledge and habits more efficiently than those restricted to the mere transmission of information.

In an independent health check conducted by the local school health services 4 years after completion of the postural hygiene program, the intervention group required less medical treatment for LBP (p= 0.07), reflecting a slight trend of LBP prevention among participants. However the value of the follow-up evaluation can be questioned.

In the study of Feingold and Jacobs, evaluating an educational intervention focusing on back pack wearing posture, it was concluded that postures had not significantly improved after the intervention, while a decrease of pain was reported. However, the experimental group consisted of only 9 children and a decrease in back pain was reported by only 2 participants. As a result findings can not be generalized. In contrast to the above mentioned studies, the educational intervention, evaluated by Storr-Paulsen did not have any effect on back pain of the pupils. The intervention, evaluated in approximately 250 children, was developed to increase body-consciousness and consisted of information on ergonomics, change of posture and the advantages of physical activity among the teachers. According to the authors the lack of effect might be explained by the relative short time of implementation and unexpected practical problems at the school, where the intervention was implemented.

While it can be concluded that the majority of the results of the intervention studies are promising there is no evidence that LBP in schoolchildren can be prevented by an educational intervention program. Moreover, the large differences between the evaluated programs make comparison and the formulation of guidelines difficult and it needs to be taken into account that the reviewed studies have several limitations.

Studies on risk factors

The review of the risk factors can be summarised as follows: Lifestyle factors

• Obesity / overweight: there is no evidence for or against recommending weight control as a preventive action for LBP in schoolchildren

• Smoking: there is no evidence that anti-smoking campaigns will have a preventive effect in LBP at school-age • Eating habits: there is insufficient evidence to recommend for or against modification of eating habits as a preventive measure for LBP in schoolchildren.

• Alcohol intake: there is no evidence for or against recommending modification of alcohol intake as a preventive measure for LBP in schoolchildren

• Sports/physical inactivity: there is no evidence that doing sports or being physically active have a preventive effect on LBP in schoolchildren/ insufficient evidence to recommend a general limitation of involvement in competitive sports participation as a preventive measure for LBP in schoolchildren

• Sedentary activities: there is insufficient evidence to recommend for or against modified sitting postures as a preventive action for LBP in schoolchildren / there is no evidence that decreasing sedentary activities will have a preventive effect on LBP in schoolchildren • Work: there is insufficient evidence to recommend modification of working as a preventive measure for LBP in schoolchildren Physical factors • Physical fitness: there is no evidence that being fitter has a preventive effect on LBP in schoolchildren

• Mobility / flexibility: there is insufficient evidence to recommend for or against modification of mobility and flexibility of muscles and joints as a preventive action for LBP

• Muscle strength: there is insufficient evidence to recommend for or against muscle strengthening as a preventive action for LBP in schoolchildren.

School-related factors

• Schoolbags: there is no consistent scientific evidence for or against recommending a clear limit to the weight of school bags (or for avoiding use of schoolbags), changing the type of schoolbags or the method of carrying the school bag as primary measures for reducing LBP in schoolchildren.

• School furniture: there is insufficient evidence to recommend for or against modified school furniture as a preventive measure for LBP in schoolchildren Psychosocial factors: there is moderate evidence that psychosocial factors are associated with reports of BP in school children / there is no evidence that modification of psychological factors may have a preventive effect on LBP in schoolchildren.

It can be concluded that the role of most factors still remains controversial.

Moreover there is no evidence for a possible preventive effect in LBP in school children by modifying these factors.

Discussion

While epidemiology and risk-factors of back pain at young age have extensively been described, studies evaluating the effects of interventions to prevent LBP or the consequences of LBP in schoolchildren are still sparse. As a result the aim to formulate evidence based guidelines for the prevention in LBP in schoolchildren could not be accomplished. However, the conclusions of the present literature search may give guidance for further development and evaluation of preventive interventions in schoolchildren.

Primary prevention programs have been part of the schools curriculum for years in areas such as dental hygiene, cardiovascular disease and teen pregnancy.

Advantages of health education in elementary school systems are the possibility of giving prolonged feedback and the large percentage of the population that can be reached. According to Johnson, schools hold enormous potential for helping students develop the knowledge and skill they need to be healthy. In the same line, it was shown in the literature that educational interventions designed to prevent LBP, resulted in improved back care related knowledge or skills. Additionally, 4 of the 5 evaluated interventions found a positive effect on back pain or on the consequences on back pain, like medical consumption [3, 49] in schoolchildren. While it can be concluded that the results of the intervention studies are promising, differences between the interventions, the lack of the evaluation of long term effects and the limitations of the studies require a cautious interpretation and do not allow the formulation of evidence based guidelines for the prevention in LBP in schoolchildren. Moreover there is insufficient information present to be able to specify precisely what may be the most effective components of the interventions.

Although in order to provide evidence for relevant prevention strategies, intervention studies deserve priority, evaluating the modifiable risk factors of the incidence of back pain and of the consequences of back pain in schoolchildren is important for the development of preventive interventions. However, many studies carried out to investigate risk factors have the major disadvantage of being cross-sectional. For this reason it is not always possible to distinguish etiologic from prognostic factors. Moreover, according to the present literature review the role of most factors still remains controversial, namely BMI, mobility and flexibility, muscular strength, physical activity, physical fitness and sports participation, back pack related factors, sitting posture and sedentary activity, and smoking. As a result there is no evidence for a possible preventive effect in LBP pain in schoolchildren by modifying these factors. On the other hand, the present literature review gives moderate evidence that psychosocial factors are associated with reports of back pain and related consequences in schoolchildren. Furthermore according to Power et al. poor emotional adjustment between the ages of 7 and 16 years was significantly associated with LBP at age 33 years. However, it can be questioned if psychosocial risk factors are modifiable in schoolchildren and more study is necessary to differentiate between the various psychosocial risk factors. Also for working during leisure time the findings in the literature are consistent. However the limited number of studies and the possible confounding effect of muscle fatigue do not justify including this factor in prevention guidance.

Since we can conclude from the literature that back pain reports in schoolchildren are mainly associated with psychosocial factors and since it is shown in the literature that LBP in the young is mostly benign and self-limiting, it can be argued that there is limited scope for prevention in LBP in schoolchildren.

Furthermore, an aggregation of symptoms retrieved by questioning children can be misleading and the definition of boundaries between pain as an experience as opposed to pain as a sign of “a medically significant” disease is sometimes difficult. Children are in a general learning process, including expression of pain in an adequate and acceptable fashion, both socially and culturally.

Therefore, it may be time to look at what pain, aches, disability and “disease” mean to schoolchildren themselves, and not to simply apply adult definitions to assess children and LBP [6].

While the scope for prevention in LBP in schoolchildren is limited, further study is necessary to evaluate whether improving back care knowledge and postural habits at young age have a preventive effect on LBP at adult age. If young people learn good lifestyle habits early, then perhaps the burden for LBP can be lessened. Therefore, in the future it seems necessary to learn from adult risk factors and to evaluate in which degree the risk for adult LBP can be altered by early interventions. Further study with a follow-up into adulthood is also needed to evaluate whether or not the physical cumulative load experience on the lumbar spine during adolescence contributes to the adult cumulative lifetimes load.

However, while it can be argued that the need for long term studies is pressing, the multifactorial character of back pain in adults may make it unrealistic to show a possible preventive effect of early interventions or risk factor modification in childhood and, as a result, it may be necessary to rely on positive effects on adult risk factors.

While it can be concluded that there are several arguments to justify back education in schoolchildren, Burton et al. argued that the risk exists that early back education results in increased fear-avoidance beliefs about physical activity and reinforces an erroneous belief that there is something seriously amiss.

However in a study of Cardon et al. it was found that pupils, who followed back education, did not have higher fear-avoidance beliefs than controls.

Furthermore misconceptions about back pain, which are shown to be widespread in adults and play a role in the development of long-term disability, may be prevented by carefully selected and presented health promotion programs in children, with the merit of demedicalizing LBP. For the development of these programs it is necessary to learn from studies evaluating the implementation of back education through the school system and from positive experiences reported in other fields.

It can be concluded that medicalizing back pain in schoolchildren needs to be avoided, while longitudinal studies, evaluating the possible positive effects of preventive programs and risk factor modifications at young age, are advocated.

Main references

1. Balagué F, Nordin M, Dutoit G, Waldburger M (1996) Primary prevention, education, and low back pain among school children. Bull Hosp Jt Dis 55:130-134.

2. Balagué F, Troussier B, Salminen JJ (1999) Non-specific low back pain in children and adolescents: risk factors. Eur Spine J 8:429-438.

3. Cardon G, De Bourdeaudhuij I ,De Clercq D (2001) Back care education in elementary school: a pilot study investigating the complementary role of the class teacher. Patient Educ Couns 45:219-226.

4. European Commission COST B 13 Management Committee (2002) European guidelines for the management of low back pain. (www.backpaineurope.org).

5. Feingold AJ, Jacobs K (2002) The effect of education on backpack wearing and posture in a middle school population. Work 18: 287-294.

6. Mendez FJ, Gomez-Conesa A (2001) Postural hygiene program to prevent low back pain. Spine 26:1280-1286.

7. Storr-Paulsen A (2002) The body-consciousness in school – a back pain school. Ugeskr laeger 165:37-41.