ABSTRACT

Introduction

Musculoskeletal (MSK) pain in children and adolescents is responsible for substantial personal impacts and societal costs, but it has not been intensively or systematically researched. This means our understanding of these conditions is limited, and healthcare professionals have little empirical evidence to underpin their clinical practice. In this article we summarise the state of the evidence concerning MSK pain in children and adolescents, and offer suggestions for future research.

Results

Rates of self-reported MSK pain in adolescents are similar to those in adult populations and they are typically higher in teenage girls than boys. Epidemiological research has identified conditions such as back and neck pain as major causes of disability in adolescents, and in up to a quarter of cases there are impacts on school or physical activities. A range of physical, psychological and social factors have been shown to be associated with MSK pain report, but the strength and direction of these relationships are unclear. There are few validated instruments available to quantify the nature and severity of MSK pain in children, but some show promise. Several national surveys have shown that adolescents with MSK pain commonly seek care and use medications for their condition. Some studies have revealed a link between MSK pain in adolescents and chronic pain in adults.

Conclusion

Musculoskeletal pain conditions are often recurrent in nature, occurring throughout the life-course. Attempts to understand these conditions at a time close to their initial onset may offer a better chance of developing effective prevention and treatment strategies.

Keywords:
children; adolescents; musculoskeletal pain; burden; epidemiology

Bullet points

• •

  The prevalence of MSK pain approaches adult levels by the end of adolescence.

• •

  Persistent adolescent MSK pain is a risk factor for chronic pain in adulthood.

• •

  MSK pain has substantial impacts in up to 1/4 of cases.

• •

  The relationship of other adverse health risk factors and MSK pain is unclear.

• •

  There is little research to inform clinical management of childhood MSK pain.

Background

Research by the World Health Organisation has brought the enormous global burden of musculoskeletal (MSK) pain into focus. Low back pain (LBP), neck pain and other musculoskeletal disorders were ranked numbers 1, 4 and 10 respectively, among all health conditions for years lived with disability. These conditions were also identified as the main drivers of the increase in years lived with disability over the past 20 years¹1 Vos T, Barber RM, Bell B, Bertozzi-Villa A, Biryukov S, Bolliger I, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;386(9995):743-800. PMid:26063472.. Although the epidemiology, burden and treatment of MSK pain in adults has been the subject of considerable research efforts, the same is not true for children. The dearth of clinical research relevant to children and adolescents has been highlighted by several authors²2 Cohen E, Uleryk E, Jasuja M, Parkin PC. An absence of pediatric randomized controlled trials in general medical journals, 1985-2004. J Clin Epidemiol. 2007;60(2):118-23. http://dx.doi.org/10.1016/j.jclinepi.2006.03.015. PMid:17208117.
http://dx.doi.org/10.1016/j.jclinepi.200...

3 Eccleston C, Malleson P. Managing chronic pain in children and adolescents. BMJ. 2003;326(7404):1408-9. http://dx.doi.org/10.1136/bmj.326.7404.1408. PMid:12829527.
http://dx.doi.org/10.1136/bmj.326.7404.1...

4 McBeth J, Jones K. Epidemiology of chronic musculoskeletal pain. Best Pract Res Clin Rheumatol. 2007;21(3):403-25. http://dx.doi.org/10.1016/j.berh.2007.03.003. PMid:17602991.
http://dx.doi.org/10.1016/j.berh.2007.03... ^-55 Michaleff ZA, Kamper SJ, Maher CG, Evans R, Broderick C, Henschke N. Low-back pain in children and adolescents: a systematic review and meta-analysis evaluating the effectiveness of conservative interventions. Eur Spine J. 2014;23(10):2046-58. http://dx.doi.org/10.1007/s00586-014-3461-1. PMid:25070788.
http://dx.doi.org/10.1007/s00586-014-346... . The purpose of this paper is to outline the current state of understanding with respect to MSK pain in people under the age of 18 years.

The lack of research into MSK pain in children is of concern for a number of reasons. There is emerging evidence that children, especially adolescents who report persistent pain, are at increased risk of chronic pain as adults⁶6 Brattberg G. Do pain problems in young school children persist into early adulthood? A 13-year follow-up. Eur J Pain. 2004;8(3):187-99. http://dx.doi.org/10.1016/j.ejpain.2003.08.001. PMid:15109969.
http://dx.doi.org/10.1016/j.ejpain.2003....

7 Hestbaek L, LeBoeuf-Yde C, Kyvik K, Manniche C. The course of low back pain from adolescence to adulthood: eight-year follow-up of 9600 twins. Spine. 2006;31(4):468-72. http://dx.doi.org/10.1097/01.brs.0000199958.04073.d9. PMid:16481960.
http://dx.doi.org/10.1097/01.brs.0000199... ^-88 Jones GT, Silman AJ, Power C, Macfarlane GJ. Are common symptoms in childhood associated with chronic widespread body pain in adulthood? Results from the 1958 British Birth Cohort Study. Arthritis Rheum. 2007;56(5):1669-75. http://dx.doi.org/10.1002/art.22587. PMid:17469161.
http://dx.doi.org/10.1002/art.22587... . This is important since adults with persistent pain endure the bulk of the individual and societal burden of painful conditions⁹9 Gore M, Sadosky A, Stacey BR, Tai KS, Leslie D. The burden of chronic low back pain: clinical comorbidities, treatment patterns, and health care costs in usual care settings. Spine (Phila Pa 1976). 2012;37(11):E668-77. http://dx.doi.org/10.1097/BRS.0b013e318241e5de. PMid:22146287.
http://dx.doi.org/10.1097/BRS.0b013e3182... . Further, many MSK conditions follow a long-term pattern of recurring exacerbations and remissions, with the most consistent predictor of a new episode being experience of a previous episode¹⁰10 Taylor JB, Goode AP, George SZ, Cook CE. Incidence and risk factors for first-time incident low back pain: a systematic review and meta-analysis. Spine J. 2014;14(10):20. http://dx.doi.org/10.1016/j.spinee.2014.01.026. PMid:24462537.
http://dx.doi.org/10.1016/j.spinee.2014.... . Given that the rise in prevalence of MSK conditions occurs in adolescence, it may be necessary to investigate the condition in this stage of life (or earlier) to identify the initial onset. Understanding factors surrounding the initial onset offers the best chance of developing successful treatments, and is fundamental to any efforts at primary prevention. Finally, clinicians who care for children with MSK conditions have little research evidence to inform their clinical decisions, since clinical practice guidelines, such as those for the treatment of LBP, either specifically exclude children or base their recommendations on adult research¹¹11 Koes BW, van Tulder MW, Lin C, Macedo LG, McAuley J, Maher C. An updated overview of clinical guidelines for the managementof non-specific low back pain in primary care al. Eur Spine J. 2010;19(12):2075-94. http://dx.doi.org/10.1007/s00586-010-1502-y. PMid:20602122.
http://dx.doi.org/10.1007/s00586-010-150... .

There is a question regarding the extent to which research conducted in adults can be generalised to children. Pain, in particular chronic pain is currently conceptualised within a biopsychosocial model¹². Thus the experience of pain is influenced by physical factors e.g. anatomical pathology and physiological process; psychological factors e.g. mood, cognitions and beliefs; and social factors e.g. relationships, social environment and culture. In each of these domains there are important differences between children and adults. Childhood and adolescence is a time of growth of the MSK system with changes in structural properties, biomechanics and motor control before the system stabilises in adulthood. Similarly, substantial cognitive and emotional development occurs during this time and hormonal changes regulate mood and emotions differently to adulthood. Finally, social relationships, expectations and environments experienced by children are distinct from those of adults¹³13 Clinch J, Eccleston C. Chronic musculoskeletal pain in children: assessment and management. Rheumatol. 2009;48(5):466-74. http://dx.doi.org/10.1093/rheumatology/kep001. PMid:19202161.
http://dx.doi.org/10.1093/rheumatology/k... . These differences provide good reasons to consider that the pain experience may be different.

Providing direction to those responsible for the care of children with MSK conditions will be a key function of research efforts in the area. Balancing the competing needs of early identification and appropriate management of those who need care, and reassurance and avoidance of ‘medicalization’ of transient aches and pains is a difficult task. Yet it is critical; over-investigation and over-treatment of MSK pain results in a large burden on overloaded healthcare systems, and can also negatively impact individual patient outcomes¹⁴14 Chou R, Qaseem A, Owens DK, Shekelle P. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011;154(3):181-9. http://dx.doi.org/10.7326/0003-4819-154-3-201102010-00008. PMid:21282698.
http://dx.doi.org/10.7326/0003-4819-154-... .

For the purposes of this review we focus on regional pain conditions e.g. non-specific neck or back pain, joint pain including hip, knee, shoulder and elbow pain. We do not discuss pain associated with congenital or systemic diseases, such as hip dysplasia, juvenile arthritis or scoliosis. We also exclude pain resulting from frank injuries e.g. anterior cruciate ligament rupture, ankle sprain, fractures and pain following surgical interventions. We collected evidence mainly from systematic reviews that describe the epidemiology, risk and prognostic factors, burden, and treatment of MSK pain in people under 18 years old. Where possible we have looked to studies published since 2000. To supplement the systematic reviews we included data from well-conducted cohort studies and surveys.

Incidence and prevalence

Numerous cohorts and surveys have included questions about MSK pain, and have estimated the prevalence of conditions in children and adolescents. Unfortunately, methodological features and reporting methods make synthesis of the estimates difficult. Along with case definitions, there is heterogeneity with respect to the prevalence period; where possible we report 1-month prevalence to facilitate comparison. A further source of heterogeneity is due to different aged children included in the various studies.

A recent, comprehensive systematic review investigating the prevalence of LBP in all age groups noted that prevalence during adolescence approached that in the adult years¹⁵15 Hoy D, Bain C, Williams G, March L, Brooks P, Blyth F, et al. A systematic review of the global prevalence of low back pain. Arthritis Rheum. 2012;64(6):2028-37. http://dx.doi.org/10.1002/art.34347. PMid:22231424.
http://dx.doi.org/10.1002/art.34347... . Notwithstanding these methodological and population inconsistencies, approximately one third of adolescents report MSK pain on a monthly basis. Estimates from recent reviews and large, well-conducted cohort studies are presented in Figure 1 ¹⁵15 Hoy D, Bain C, Williams G, March L, Brooks P, Blyth F, et al. A systematic review of the global prevalence of low back pain. Arthritis Rheum. 2012;64(6):2028-37. http://dx.doi.org/10.1002/art.34347. PMid:22231424.
http://dx.doi.org/10.1002/art.34347...

16 Jeffries LJ, Milanese S, Grimmer-Somers KA. Epidemiology of adolescent spinal pain: a systematic overview of the research literature. Spine (Phila Pa 1976). 2007;32(23):2630-7. http://dx.doi.org/10.1097/BRS.0b013e318158d70b. PMid:17978666.
http://dx.doi.org/10.1097/BRS.0b013e3181...

17 Evans AM, Scutter SD. Prevalence of “growing pains” in youg chidlren. J Pediatr. 2004;145(2):255-8. PMid:15289780.

18 Hakala P, Rimpelä A, Salminen JJ, Virtanen SM, Rimpela M. Back, neck, and shoulder pain in Finnish adolescents: national cross sectional surveys. BMJ. 2002;325(7367):743. http://dx.doi.org/10.1136/bmj.325.7367.743. PMid:12364301.
http://dx.doi.org/10.1136/bmj.325.7367.7...

19 Calvo-Muñoz I, Gómez-Conesa A, Sánchez-Meca J. Prevalence of low back pain in children and adolescents: a meta-analysis. BMC Pediatr. 2013;13(1):14. http://dx.doi.org/10.1186/1471-2431-13-14. PMid:23351394.
http://dx.doi.org/10.1186/1471-2431-13-1...

20 Zapata AL, Moraes AJP, Leone C, Doria-Filho U, Silva CA. Pain and musculoskeletal pain syndromes in adolescents. J Adolesc Health. 2006;38(6):769-71. http://dx.doi.org/10.1016/j.jadohealth.2005.05.018. PMid:16730613.
http://dx.doi.org/10.1016/j.jadohealth.2...

21 Swain MS, Henschke N, Kamper SJ, Gobina A, Ottova-Jordan V, Maher CG. An international survey of pain in adolescents. BMC Public Health. 2014;14(1):447. http://dx.doi.org/10.1186/1471-2458-14-447. PMid:24885027.
http://dx.doi.org/10.1186/1471-2458-14-4...

22 Mikkelsson M, Salminen JJ, Kautiainen H. Non-specific musculoskeletal pain in preadolescents: prevalence and 1-year persistence. Pain. 1997;73(1):29-35. http://dx.doi.org/10.1016/S0304-3959(97)00073-0. PMid:9414054.
http://dx.doi.org/10.1016/S0304-3959(97)...

23 Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10(1):77. http://dx.doi.org/10.1186/1471-2474-10-77. PMid:19563667.
http://dx.doi.org/10.1186/1471-2474-10-7...

24 King S, Chambers CT, Huguet A, MacNevin RC, McGrath PJ, Parker L, et al. The epidemiology of chronic pain in children and adolescents revisited: a systematic review. Pain. 2011;152(12):2729-38. http://dx.doi.org/10.1016/j.pain.2011.07.016. PMid:22078064.
http://dx.doi.org/10.1016/j.pain.2011.07... ^-2525 Mohseni-Bandpei MA, Bagheri-Nesami M, Shayesteh-Azar M. Nonspecific low back pain in 5000 Iranian school-age children. J Pediatr Orthop. 2007;27(2):126-9. http://dx.doi.org/10.1097/BPO.0b013e3180317a35. PMid:17314634.
http://dx.doi.org/10.1097/BPO.0b013e3180... .

There are fewer studies that report the incidence of MSK pain in children, possibly due to logistical difficulty of conducting these studies. A systematic review reported 1-year incidence in the range of 18-33% for LBP and 28% for neck pain¹⁶16 Jeffries LJ, Milanese S, Grimmer-Somers KA. Epidemiology of adolescent spinal pain: a systematic overview of the research literature. Spine (Phila Pa 1976). 2007;32(23):2630-7. http://dx.doi.org/10.1097/BRS.0b013e318158d70b. PMid:17978666.
http://dx.doi.org/10.1097/BRS.0b013e3181... , another reported 1-year incidence rates for mid-back pain in the range of 15-35%²³23 Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10(1):77. http://dx.doi.org/10.1186/1471-2474-10-77. PMid:19563667.
http://dx.doi.org/10.1186/1471-2474-10-7... .

Generally, studies reported higher prevalence and incidence rates in adolescent girls than boys¹³13 Clinch J, Eccleston C. Chronic musculoskeletal pain in children: assessment and management. Rheumatol. 2009;48(5):466-74. http://dx.doi.org/10.1093/rheumatology/kep001. PMid:19202161.
http://dx.doi.org/10.1093/rheumatology/k... and a sharp rise in rates from childhood to adolescence²⁶26 Balague F, Nordin M, Skovron ML, Dutoit G, Yee A, Waldburger M. Non-specific low back pain among school-children: a field survey with analysis of some associated factors. J Spinal Disord. 1994;7(5):374-9. PMid:7819636.^,2727 Hill JJ, Keating JL. A systematic review of the incidence and prevalence of low back pain in children. Phys Ther Rev. 2009;14(4):272-84. http://dx.doi.org/10.1179/108331909X12488667116899.
http://dx.doi.org/10.1179/108331909X1248... , the boundary being at approximately 10-12 years. Differences in the timing and nature of pubertal development between the sexes²⁸28 Janssens KA, Rosmalen J, Ormel J, Verhulst FC, Hunfeld JA, Mancl LA, et al. Pubertal status predicts back pain, overtiredness, and dizziness in American and Dutch adolescents. Pediatr. 2011;128(3):553-9. PMid:21807699.

29 Lardon A, Leboeuf-Yde C, Le Scanff C, Wedderkopp N. Is puberty a risk factor for back pain in the young? A systematic critical literature review. Chiropr Man Therap. 2014;22(1):27. http://dx.doi.org/10.1186/s12998-014-0027-6. PMid:25328668.
http://dx.doi.org/10.1186/s12998-014-002... ^-3030 LeResche L, Mancl LA, Drangsholt MT, Saunders K, Von Korff M. Relationship of pain and symptoms to pubertal development in adolescents. Pain. 2005;118(1-2):201-9. http://dx.doi.org/10.1016/j.pain.2005.08.011. PMid:16213087.
http://dx.doi.org/10.1016/j.pain.2005.08... has been proposed as an explanation, but as yet this theory has not been confirmed. See Box 1 for an overview of issues related to incidence and prevalence.

Impact

Despite a view that non-specific MSK pain in children is often of little consequence, the global disability burden is large. Data from the WHO Global Burden of Disease study shows that LBP is responsible for the 2^nd most years lived with disability for 15-19 year olds of any health condition and neck pain ranks 8^th. These are both higher than well-recognised adolescent public health problems such as asthma, alcohol and drug use and road injury³¹31 Institute for Health Metrics and Evaluation – IHME. HealthData.org [Internet]. Washington: University of Washington; 2015 [cited 2015 Nov 5]. Available from: http://vizhub.healthdata.org/gbd-compare/.
http://vizhub.healthdata.org/gbd-compare... . This burden stands in stark contrast to the volume of research aimed at describing the consequences of MSK pain in children³²32 Palermo TM. Impact of recurrent and chronic pain on child and family daily functioning: a critical review of the literature. J Dev Behav Pediatr. 2000;21(1):58-69. http://dx.doi.org/10.1097/00004703-200002000-00011. PMid:10706352.
http://dx.doi.org/10.1097/00004703-20000... . Of the longitudinal research that has been done, few studies follow-up more regularly than once per year, which means that detailed information about course and consequences of MSK pain is limited³³33 Dunn KM, Jordan KP, Mancl L, Drangsholt MT, Le Resche L. Trajectories of pain in adolescents: a prospective cohort study. Pain. 2011;152(1):66-73. http://dx.doi.org/10.1016/j.pain.2010.09.006. PMid:20971561.
http://dx.doi.org/10.1016/j.pain.2010.09... .

School and school-related activities form major components of life and have substantial impacts on the development and future opportunities of children and adolescents. Similarly, involvement in sporting activities and general physical activity has physical, mental and social consequences that extend into adulthood. As such it is important that the impact of pain on participation in these areas is well-described and understood. Surveys that have been conducted suggest that a substantial minority of adolescents with MSK pain experience significant impacts on their lives. Estimates of proportions reporting these impacts are summarised in Figure 2 ³⁴34 Konijnenberg AY, Uiterwaal CSPM, Kimpen JLL, van der Hoeven J, Buitelaar JK, de Graeff-Meeder ER. Children with unexplained chronic pain: substantial impairment in everyday life. Arch Dis Child. 2005;90(7):680-6. http://dx.doi.org/10.1136/adc.2004.056820. PMid:15899922.
http://dx.doi.org/10.1136/adc.2004.05682...

35 O’Sullivan PB, Beales DJ, Smith AJ, Straker LM. Low back pain in 17 year olds has substantial impact and represents an important public health disorder: a cross-sectional study. BMC Public Health. 2012;12(1):100. http://dx.doi.org/10.1186/1471-2458-12-100. PMid:22304903.
http://dx.doi.org/10.1186/1471-2458-12-1...

36 Roth-Isigkeit A, Thyen U, Stoven H, Schwarzenberger J, Schmucker P. Pain among children and adolescents: Restrictions in daily living and triggering factors. Pediatr. 2005;115(2):e152-62. http://dx.doi.org/10.1542/peds.2004-0682. PMid:15687423.
http://dx.doi.org/10.1542/peds.2004-0682...

37 Bejia I, Abid N, Salem KB, Letaief M, Younes M, Touzi M, et al. Low back pain in a cohort of 622 Tunisian schoolchildren and adolescents: an epidemiological study. Eur Spine J. 2005;14(4):331-6. http://dx.doi.org/10.1007/s00586-004-0785-2. PMid:15940479.
http://dx.doi.org/10.1007/s00586-004-078...

38 Sato T, Ito T, Hirano T, Morita O, Kikuchi R, Endo N, et al. Low back pain in childhood and adolescence: a cross-sectional study in Niigata City. Eur Spine J. 2008;17(11):1441-7. http://dx.doi.org/10.1007/s00586-008-0788-5. PMid:18830637.
http://dx.doi.org/10.1007/s00586-008-078... ^-3939 Jones MA, Stratton G, Reilly T, Unnithan VB. A school-based survey of recurrent non-specific low-back pain prevalence and consequences in children. Health Educ Res. 2004;19(3):284-9. http://dx.doi.org/10.1093/her/cyg025. PMid:15140848.
http://dx.doi.org/10.1093/her/cyg025... .

The association between MSK pain and physical activity is difficult to unravel. There are plausible theories to explain a causal relationship in both directions, and individual studies report conflicting results regarding the existence and strength of a relationship. A systematic review of 8 studies investigating the relationship between LBP and physical activity reported positive, negative and non-existent associations⁴⁰40 Sitthipornvorakul E, Janwantanakul P, Purepong N, Pensri P, van der Beek AJ. The association between physical activity and neck and low back pain: a systematic review. Eur Spine J. 2011;20(5):677-89. http://dx.doi.org/10.1007/s00586-010-1630-4. PMid:21113635.
http://dx.doi.org/10.1007/s00586-010-163... . A more recent Danish study found no associations between spinal pain and objectively measured physical activity, either in cross-sectional or longitudinal analyses⁴¹41 Aartun E, Hartvigsen J, Boyle E, Hestbaek L. No associations between objectively measured physical activity and spinal pain in 11-15-year-old danes. Eur J Pain. 2015. http://dx.doi.org/10.1002/ejp.746. PMid:26118422.
http://dx.doi.org/10.1002/ejp.746... and a multi-national survey of 400,000 11-15 years olds found that the presence of LBP was generally associated with reduced physical activity, but the size of the relationship was small⁴²42 Swain MS, Henschke N, Kamper SJ, Gobina I, Ottová-Jordan V, Maher CG. Pain and moderate to vigorous physical activity in adolescence: an international population-based survey. Pain Med. 2015. http://dx.doi.org/10.1111/pme.12923. PMid:26350061.
http://dx.doi.org/10.1111/pme.12923... . See Box 2 for an overview of issues related to impact.

Risk and prognostic factors

Several cross-sectional and longitudinal studies report associations between back pain and psychological distress (anxiety and depression). Relationships between pain and mechanical load e.g. school bag weight, high BMI, are less clear. For instance, of 1,046 11-14 year olds, children who reported high levels of psychosocial difficulties at baseline were more likely (RR: 1.6) to develop LBP one year later, but there was no association between LBP and bag weight, BMI or sedentary levels⁴³43 Jones GT, Watson KD, Silman AJ, Symmons DP, Macfarlane GJ. Predictors of low back pain in British schoolchildren: a population-based prospective cohort study. Pediatr. 2003;111(4 Pt 1):822-8. http://dx.doi.org/10.1542/peds.111.4.822. PMid:12671119.
http://dx.doi.org/10.1542/peds.111.4.822... . Similarly, physical activity at baseline did not predict pain 12 months⁴³43 Jones GT, Watson KD, Silman AJ, Symmons DP, Macfarlane GJ. Predictors of low back pain in British schoolchildren: a population-based prospective cohort study. Pediatr. 2003;111(4 Pt 1):822-8. http://dx.doi.org/10.1542/peds.111.4.822. PMid:12671119.
http://dx.doi.org/10.1542/peds.111.4.822... or 3 years later⁴⁴44 Salminen JJ, Erkintalo M, Laine M, Pentti J. Low back pain in the young: a prospective three-year follow-up study of subjects with and without low back pain. Spine (Phila Pa 1976). 1995;20(19):2101-7. http://dx.doi.org/10.1097/00007632-199510000-00006. PMid:8588166.
http://dx.doi.org/10.1097/00007632-19951... . Other cohorts have found relationships between pain and: behavioural (sleep patterns, attention disorders)⁴⁵45 Auvinen JP, Tammelin T, Taimela S, Zitting PJ, Järvelin MR, Taanila AM, et al. Is insufficient quantity and quality of sleep a risk factor for neck, shoulder and low back pain? A longitudinal study among adolescents. Eur Spine J. 2010;19(4):641-9. http://dx.doi.org/10.1007/s00586-009-1215-2. PMid:19936804.
http://dx.doi.org/10.1007/s00586-009-121...

46 Rees CS, Smith AJ, O’Sullivan PB, Kendall GE, Straker LM. Back and neck pain are related to mental health problems in adolescence. BMC Public Health. 2011;11(1):382. http://dx.doi.org/10.1186/1471-2458-11-382. PMid:21609488.
http://dx.doi.org/10.1186/1471-2458-11-3... ^-4747 Watson KD, Papageorgiou AC, Jones GT, Taylor S, Symmons DP, Silman AJ, et al. Low back pain in schoolchildren: the role of mechanical and psychosocial factors. Arch Dis Child. 2003;88(1):12-7. http://dx.doi.org/10.1136/adc.88.1.12. PMid:12495949.
http://dx.doi.org/10.1136/adc.88.1.12... , social⁴⁸48 Grøholt EK, Stigum H, Nordhagen R, Kohler L. Recurrent pain in children, socio-economic factors and accumulation in families. Eur J Epidemiol. 2003;18(10):965-75. http://dx.doi.org/10.1023/A:1025889912964. PMid:14598927.
http://dx.doi.org/10.1023/A:102588991296... , and physical factors (headache, other illness, hypermobility, muscular tightness)⁴⁷47 Watson KD, Papageorgiou AC, Jones GT, Taylor S, Symmons DP, Silman AJ, et al. Low back pain in schoolchildren: the role of mechanical and psychosocial factors. Arch Dis Child. 2003;88(1):12-7. http://dx.doi.org/10.1136/adc.88.1.12. PMid:12495949.
http://dx.doi.org/10.1136/adc.88.1.12... ^,4949 El-Metwally A, Salminen JJ, Auvinen A, Kautiainen H, Mikkelsson M. Prognosis of non-specific musculoskeletal pain in preadolescents: A prospective 4-year follow-up study till adolescence. Pain. 2004;110(3):550-9. http://dx.doi.org/10.1016/j.pain.2004.03.021. PMid:15288395.
http://dx.doi.org/10.1016/j.pain.2004.03... ^,5050 Feldman DE, Shrier I, Rossignol M, Abenhaim L. Risk factors for the development of low back pain in adolescence. Am J Epidemiol. 2001;154(1):30-6. http://dx.doi.org/10.1093/aje/154.1.30. PMid:11427402.
http://dx.doi.org/10.1093/aje/154.1.30... . A cohort of 377, 12-14 year old adolescents found high growth rate, smoking, muscle tightness and part-time work increased risk of back pain 12 months later⁵⁰50 Feldman DE, Shrier I, Rossignol M, Abenhaim L. Risk factors for the development of low back pain in adolescence. Am J Epidemiol. 2001;154(1):30-6. http://dx.doi.org/10.1093/aje/154.1.30. PMid:11427402.
http://dx.doi.org/10.1093/aje/154.1.30... . Another longitudinal study following 1,773 15-19 years olds found that sleep quantity and quality predicted low back, neck and shoulder pain (OR range 4.4 to 2.2) 2 years later⁴⁵45 Auvinen JP, Tammelin T, Taimela S, Zitting PJ, Järvelin MR, Taanila AM, et al. Is insufficient quantity and quality of sleep a risk factor for neck, shoulder and low back pain? A longitudinal study among adolescents. Eur Spine J. 2010;19(4):641-9. http://dx.doi.org/10.1007/s00586-009-1215-2. PMid:19936804.
http://dx.doi.org/10.1007/s00586-009-121... .

While the majority of these studies aim to define risk factors which predict the development of musculoskeletal pain, inconsistent case definitions and reporting of covariates make interpretation difficult. Importantly, many studies do not control for previous history of pain, making it difficult to distinguish between risk factors and prognostic factors. Further, studies often use broad definitions of an ‘episode’ of pain, with no distinction between transient episodes and long term or consequential pain. As a consequence it is unclear whether individual factors predispose to pain, lead to a poor outcome from ‘an episode’ or are consequences of the condition.

This relationship with other adverse health risk factors suggests MSK pain may have an important role in shaping health in adulthood. Several studies have shown predictive longitudinal relationships between back pain in adolescents and factors such as smoking⁵¹51 Gill DK, Davis M, Smith A, Straker LM. Bidirectional relationships between cigarette use and spinal pain in adolescents accounting for psychosocial functioning. Br J Health Psychol. 2014;19(1):113-31. http://dx.doi.org/10.1111/bjhp.12039. PMid:23552050.
http://dx.doi.org/10.1111/bjhp.12039...

52 Mikkonen P, Leino-Arjas P, Remes J, Zitting P, Taimela S, Karppinen J. Is smoking a risk factor for low back pain in adolescents? A prospective cohort study. Spine (Phila Pa 1976). 2008;33(5):527-32. http://dx.doi.org/10.1097/BRS.0b013e3181657d3c. PMid:18317198.
http://dx.doi.org/10.1097/BRS.0b013e3181... ^-5353 Shiri R, Karppinen J, Leino-Arjas P, Solovieva S, Viikari-Juntura E. The association between smoking and low back pain: A meta-analysis. Am J Med. 2010;123(1):87.e7-e35. http://dx.doi.org/10.1016/j.amjmed.2009.05.028. PMid:20102998.
http://dx.doi.org/10.1016/j.amjmed.2009.... , poor mental health, overweight⁴⁶46 Rees CS, Smith AJ, O’Sullivan PB, Kendall GE, Straker LM. Back and neck pain are related to mental health problems in adolescence. BMC Public Health. 2011;11(1):382. http://dx.doi.org/10.1186/1471-2458-11-382. PMid:21609488.
http://dx.doi.org/10.1186/1471-2458-11-3... ^,5454 Krul M, van der Wouden J, Schellevis FG, van Suijlekom-Smit LWA, Koes BW. Musculoskeletal problems in overweight and obese children. Ann Fam Med. 2009;7(4):352-6. http://dx.doi.org/10.1370/afm.1005. PMid:19597173.
http://dx.doi.org/10.1370/afm.1005... ^,5555 Paulis WD, Silva S, Koes BW, van Middelkoop M. Overweight and obesity are associated with musculoskeletal complaints as early as childhood: a systematic review. Obes Rev. 2014;15(1):52-67. http://dx.doi.org/10.1111/obr.12067. PMid:23941399.
http://dx.doi.org/10.1111/obr.12067... , inactivity and poor sleep⁴⁵45 Auvinen JP, Tammelin T, Taimela S, Zitting PJ, Järvelin MR, Taanila AM, et al. Is insufficient quantity and quality of sleep a risk factor for neck, shoulder and low back pain? A longitudinal study among adolescents. Eur Spine J. 2010;19(4):641-9. http://dx.doi.org/10.1007/s00586-009-1215-2. PMid:19936804.
http://dx.doi.org/10.1007/s00586-009-121... . Data from a prospective cohort of overweight children suggests an association between LBP and obesity and subsequent inactivity, with inactivity reinforcing further weight gain and further pain⁵⁴54 Krul M, van der Wouden J, Schellevis FG, van Suijlekom-Smit LWA, Koes BW. Musculoskeletal problems in overweight and obese children. Ann Fam Med. 2009;7(4):352-6. http://dx.doi.org/10.1370/afm.1005. PMid:19597173.
http://dx.doi.org/10.1370/afm.1005... . Another longitudinal study found that back pain at 14 years predicted smoking at 17⁵¹51 Gill DK, Davis M, Smith A, Straker LM. Bidirectional relationships between cigarette use and spinal pain in adolescents accounting for psychosocial functioning. Br J Health Psychol. 2014;19(1):113-31. http://dx.doi.org/10.1111/bjhp.12039. PMid:23552050.
http://dx.doi.org/10.1111/bjhp.12039... . It is likely the combination of low back pain and associated health risks contribute to a series of reciprocal events contributing to higher risk of pain, health risk behaviours and poorer general health. As poor lifestyle habits developed in adolescence are known to track into adulthood⁵⁶56 Swinburn BA, Sacks G, Hall KD, McPherson K, Finegood DT, Moodie ML, et al. The global obesity epidemic: shaped by global drivers and local environments. Lancet. 2011;378(9793):804-14. http://dx.doi.org/10.1016/S0140-6736(11)60813-1. PMid:21872749.
http://dx.doi.org/10.1016/S0140-6736(11)... , and pain is related to the development of adverse health risk factors, pain may be a contributor to the onset of lifelong chronic disease and mortality⁵⁷57 Australian Institute of Health and Welfare – AIHW. A picture of Australia’s children. Canberra; 2012.. See Box 3 for an overview of issues related to risk and prognostic factors.

Care-seeking, treatment, and prevention

In order to fully understand the public health impact of musculoskeletal pain in children and adolescents, it is important to understand care-seeking patterns, as visits to health care providers contribute to the societal burden and cost of MSK pain. A number of studies have been performed to estimate the proportion of children and adolescents who seek care as a result of MSK pain. In most cases the numbers are large and there exists a significant risk of poor outcome due to a lack of evidence-based treatments and clinical guidelines.

One study in a primary care setting in Spain reported that MSK pain is responsible for approximately 6% of the primary care visits of children between 3 and 14 years, and more than 10% of visits by adolescents⁵⁸58 De Inocencio J. Epidemiology of musculoskeletal pain in primary care. Arch Dis Child. 2004;89(5):431-4. http://dx.doi.org/10.1136/adc.2003.028860. PMid:15102634.
http://dx.doi.org/10.1136/adc.2003.02886... . In Australia, MSK problems in children and adolescents are managed by general practitioners at a rate of 5.8 per 100 encounters⁵⁹59 Henschke N, Harrison C, McKay D, Broderick C, Latimer J, Britt H, et al. Musculoskeletal conditions in children and adolescents managed in Australian primary care. BMC Musculoskelet Disord. 2014;15(1):164. http://dx.doi.org/10.1186/1471-2474-15-164. PMid:24885231.
http://dx.doi.org/10.1186/1471-2474-15-1... . Upper and lower limb conditions were the most common, followed by spine and trunk. This can be extrapolated to 880,000 child or adolescent MSK problems managed by GPs per year in Australia⁵⁹59 Henschke N, Harrison C, McKay D, Broderick C, Latimer J, Britt H, et al. Musculoskeletal conditions in children and adolescents managed in Australian primary care. BMC Musculoskelet Disord. 2014;15(1):164. http://dx.doi.org/10.1186/1471-2474-15-164. PMid:24885231.
http://dx.doi.org/10.1186/1471-2474-15-1... . In the United Kingdom, 24% of children with LBP reported visiting a doctor in the past year for the condition⁶⁰60 Watson KD, Papageorgiou AC, Jones GT, Taylor S, Symmons DP, Silman AJ, et al. Low back pain in schoolchildren: occurrence and characteristics. Pain. 2002;97(1-2):87-92. http://dx.doi.org/10.1016/S0304-3959(02)00008-8. PMid:12031782.
http://dx.doi.org/10.1016/S0304-3959(02)... , in Finland the figure is 16%⁶¹61 Tiira AH, Paananen MV, Taimela SP, Zitting PJ, Järvelin MR, Karppinen JI. Determinants of adolescent health care use for low back pain. Eur J Pain. 2012;16(10):1467-76. http://dx.doi.org/10.1002/j.1532-2149.2012.00178.x. PMid:22807167.
http://dx.doi.org/10.1002/j.1532-2149.20... and from a sample in Australia; 37.6%³⁵35 O’Sullivan PB, Beales DJ, Smith AJ, Straker LM. Low back pain in 17 year olds has substantial impact and represents an important public health disorder: a cross-sectional study. BMC Public Health. 2012;12(1):100. http://dx.doi.org/10.1186/1471-2458-12-100. PMid:22304903.
http://dx.doi.org/10.1186/1471-2458-12-1... .

The most common drivers of care-seeking for MSK pain appear to be high pain intensity and activity limitation⁶¹61 Tiira AH, Paananen MV, Taimela SP, Zitting PJ, Järvelin MR, Karppinen JI. Determinants of adolescent health care use for low back pain. Eur J Pain. 2012;16(10):1467-76. http://dx.doi.org/10.1002/j.1532-2149.2012.00178.x. PMid:22807167.
http://dx.doi.org/10.1002/j.1532-2149.20... ^,6262 Masiero S, Carraro E, Sarto D, Bonaldo L, Ferraro C. Healthcare service use in adolescents with nonspecific musculoskeletal pain. Acta Paediatr. 2010;99(8):1224-8. http://dx.doi.org/10.1111/j.1651-2227.2010.01770.x. PMid:20219047.
http://dx.doi.org/10.1111/j.1651-2227.20... . There appears to be little difference in the care-seeking rate between boys and girls and the rate of MSK problems managed increases significantly with age⁵⁹59 Henschke N, Harrison C, McKay D, Broderick C, Latimer J, Britt H, et al. Musculoskeletal conditions in children and adolescents managed in Australian primary care. BMC Musculoskelet Disord. 2014;15(1):164. http://dx.doi.org/10.1186/1471-2474-15-164. PMid:24885231.
http://dx.doi.org/10.1186/1471-2474-15-1...

60 Watson KD, Papageorgiou AC, Jones GT, Taylor S, Symmons DP, Silman AJ, et al. Low back pain in schoolchildren: occurrence and characteristics. Pain. 2002;97(1-2):87-92. http://dx.doi.org/10.1016/S0304-3959(02)00008-8. PMid:12031782.
http://dx.doi.org/10.1016/S0304-3959(02)... ^-6161 Tiira AH, Paananen MV, Taimela SP, Zitting PJ, Järvelin MR, Karppinen JI. Determinants of adolescent health care use for low back pain. Eur J Pain. 2012;16(10):1467-76. http://dx.doi.org/10.1002/j.1532-2149.2012.00178.x. PMid:22807167.
http://dx.doi.org/10.1002/j.1532-2149.20... . In Denmark, care-seeking for back pain was found to be uncommon in children and much less common than the back pain prevalence (6% vs. 33%)⁶³63 Kjaer P, Wedderkopp N, Korsholm L, Leboeuf-Yde C. Prevalence and tracking of back pain from childhood to adolescence. BMC Musculoskelet Disord. 2011;12(1):98. http://dx.doi.org/10.1186/1471-2474-12-98. PMid:21575251.
http://dx.doi.org/10.1186/1471-2474-12-9... . By the age of 15, this gap had decreased (34% vs. 48%), which could indicate that either the symptoms become more bothersome or that the pain is not taken seriously by the parents until the child is older⁶³63 Kjaer P, Wedderkopp N, Korsholm L, Leboeuf-Yde C. Prevalence and tracking of back pain from childhood to adolescence. BMC Musculoskelet Disord. 2011;12(1):98. http://dx.doi.org/10.1186/1471-2474-12-98. PMid:21575251.
http://dx.doi.org/10.1186/1471-2474-12-9... . This highlights the need for studies on MSK pain to describe their findings within limited and discrete age ranges.

Medication is frequently prescribed and appears to be more often prescribed to older girls and those with spine and trunk conditions than those with upper and lower limb problems⁵⁹59 Henschke N, Harrison C, McKay D, Broderick C, Latimer J, Britt H, et al. Musculoskeletal conditions in children and adolescents managed in Australian primary care. BMC Musculoskelet Disord. 2014;15(1):164. http://dx.doi.org/10.1186/1471-2474-15-164. PMid:24885231.
http://dx.doi.org/10.1186/1471-2474-15-1... . Emerging research has highlighted problems with unrestricted use of medications in younger age groups; adolescents with recurrent pain are more likely to use medicines also for non-pain conditions, such as nervousness and sleep difficulties⁶⁴64 Gobina I, Villberg J, Villerusa A, Välimaa R, Tynjälä J, Ottova-Jordan V, et al. Self-reported recurrent pain and medicine use behaviours among 15-year olds: results from the international study. Eur J Pain. 2015;19(1):77-84. http://dx.doi.org/10.1002/ejp.524. PMid:24807819.
http://dx.doi.org/10.1002/ejp.524... . In a recent systematic review of conservative interventions for low back pain in children and adolescents, only four randomised trials of treatment and eleven of prevention were identified⁵5 Michaleff ZA, Kamper SJ, Maher CG, Evans R, Broderick C, Henschke N. Low-back pain in children and adolescents: a systematic review and meta-analysis evaluating the effectiveness of conservative interventions. Eur Spine J. 2014;23(10):2046-58. http://dx.doi.org/10.1007/s00586-014-3461-1. PMid:25070788.
http://dx.doi.org/10.1007/s00586-014-346... . The review suggested that supervised exercise has a large effect on pain compared to no treatment, but evidence quality was low, there was not enough good quality information to make conclusions regarding preventative interventions. See Box 4 for an overview of issues related to care-seeking, treatment and prevention.

Recommendations for future research

Life-course approach to understanding MSK pain

The experience of musculoskeletal pain in children obviously has consequences for them at the time, but it may be even more important in their future. Life-course epidemiology provides a framework to investigate the effect of early life and childhood factors on health in later life as adults⁶⁵65 Ben-Shlomo Y, Kuh D. A life course approach to chronic disease epidemiology: conceptual models, empirical challenges and interdisciplinary perspectives. Int J Epidemiol. 2002;31(2):285-93. http://dx.doi.org/10.1093/ije/31.2.285. PMid:11980781.
http://dx.doi.org/10.1093/ije/31.2.285... ^,6666 Kuh D, Ben-Shlomo Y, Lynch J, Hallqvist J, Power C. Life course epidemiology. J Epidemiol Community Health. 2003;57(10):778-83. http://dx.doi.org/10.1136/jech.57.10.778. PMid:14573579.
http://dx.doi.org/10.1136/jech.57.10.778... . Using a life-course approach has led to significant improvements in understanding of respiratory conditions and cardiovascular disease, has promise in the study of back pain⁶⁷67 Dunn KM. Extending conceptual frameworks: life course epidemiology for the study of back pain. BMC Musculoskelet Disord. 2010;11(1):23. http://dx.doi.org/10.1186/1471-2474-11-23. PMid:20122264.
http://dx.doi.org/10.1186/1471-2474-11-2... ^,6868 Dunn KM, Hestbaek L, Cassidy JD. Low back pain across the life course. Best Pract Res Clin Rheumatol. 2013;27(5):591-600. http://dx.doi.org/10.1016/j.berh.2013.09.007. PMid:24315141.
http://dx.doi.org/10.1016/j.berh.2013.09... , and may well be beneficial to studying musculoskeletal pain in general. There is already some evidence that the experience of pain among children is associated with the experience of pain among adults⁸8 Jones GT, Silman AJ, Power C, Macfarlane GJ. Are common symptoms in childhood associated with chronic widespread body pain in adulthood? Results from the 1958 British Birth Cohort Study. Arthritis Rheum. 2007;56(5):1669-75. http://dx.doi.org/10.1002/art.22587. PMid:17469161.
http://dx.doi.org/10.1002/art.22587... , but the pathways and mechanisms for these associations are unknown. It is possible that a physiological, psychological or behavioural trigger is set when a child has a particular painful experience, which predisposes them to pain as an adult. There may also be an underlying genetic predisposition towards experiencing pain, which could increase the likelihood of pain episodes in both childhood and adulthood: this is supported by evidence for genetic influences on MSK pain⁶⁹69 Hestbaek L, Iachine IA, Leboeuf-Yde C, Kyvik KO, Manniche C. Heredity of low back pain in a young population: a classical twin study. Twin Res. 2004;7(1):26. http://dx.doi.org/10.1375/13690520460741408. PMid:15053850.
http://dx.doi.org/10.1375/13690520460741... . Using life-course epidemiology as a framework for studying musculoskeletal conditions gives scope for a wide range of studies, and potential for far greater understanding of how and why musculoskeletal conditions occur over the life course. See Box 5 for an overview of issues related to the life-course approach to research.

Measurement of MSK pain in children and adolescents

From a measurement perspective, the need to consider assessment of pain in children in a different manner to adults is well-accepted⁷⁰70 McGrath PJ, Walco GA, Turk DC, Dworkin RH, Brown MT, Davidson K, et al. Core outcome domains and measures for pediatric acute and chronic/recurrent pain clinical trials: PedIMMPACT recommendations. J Pain. 2008;9(9):771-83. http://dx.doi.org/10.1016/j.jpain.2008.04.007. PMid:18562251.
http://dx.doi.org/10.1016/j.jpain.2008.0... ^,7171 Stinson JN, Kavanagh T, Yamada J, Gill N, Stevens B. Systematic review of the psychometric properties, interpretability and feasibility of self-report pain intensity measures for use in clinical trials in children and adolescents. Pain. 2006;125(1-2):143-57. http://dx.doi.org/10.1016/j.pain.2006.05.006. PMid:16777328.
http://dx.doi.org/10.1016/j.pain.2006.05... . However, there are few validated instruments to measure MSK conditions and consequences in children and adolescents. As is the case in adults, it is important to distinguish between trivial and consequential MSK pain and therefore simple prevalence estimates should be supplemented by information about frequency, intensity, disability and consequences⁷²72 Dionne CE, Dunn KM, Croft PR, Nachemson AL, Buchbinder R, Walker BF, et al. A consensus approach toward the standardization of back pain definitions for use in prevalence studies. Spine (Phila Pa 1976). 2008;33(1):95-103. http://dx.doi.org/10.1097/BRS.0b013e31815e7f94. PMid:18165754.
http://dx.doi.org/10.1097/BRS.0b013e3181... .

The largest population based study; The Health Behaviour in School-aged Children (HBSC) study from the World Health Organization⁷³73 Health Behaviour in School-aged Children – HBSC. HBSC Symptom Checklist 10/06/2015. United Kingdom; 2015. uses the HBSC Symptoms Checklist. This checklist has questions about the frequency of ‘backache’ but no reference to pain intensity or other types of MSK problems. The same frequency categories have been used in other studies to report both spinal and extremity pain, either with the use of a mannequin⁷⁴74 Rathleff MS, Roos EM, Olesen JL, Rasmussen S. High prevalence of daily and multi-site pain-a cross-sectional population-based study among 3000 Danish adolescents. BMC Pediatr. 2013;13(1):191. http://dx.doi.org/10.1186/1471-2431-13-191. PMid:24252440.
http://dx.doi.org/10.1186/1471-2431-13-1... , or in combination with region-specific questions²²22 Mikkelsson M, Salminen JJ, Kautiainen H. Non-specific musculoskeletal pain in preadolescents: prevalence and 1-year persistence. Pain. 1997;73(1):29-35. http://dx.doi.org/10.1016/S0304-3959(97)00073-0. PMid:9414054.
http://dx.doi.org/10.1016/S0304-3959(97)... ^,7575 El-Metwally A, Salminen JJ, Auvinen A, Kautiainen H, Mikkelsson M. Risk factors for traumatic and non-traumatic lower limb pain among preadolescents: a population-based study of Finnish schoolchildren. BMC Musculoskelet Disord. 2006;7(1):3. http://dx.doi.org/10.1186/1471-2474-7-3. PMid:16420704.
http://dx.doi.org/10.1186/1471-2474-7-3... . The Young Spine Questionnaire (YSQ) has been developed to include the three regions of the spine and includes questions on intensity and frequency. The YSQ has been validated in 12-14 year old Danish children⁷⁶76 Lauridsen HH, Hestbaek L. Development of the young spine questionnaire. BMC Musculoskelet Disord. 2013;14(1):185. http://dx.doi.org/10.1186/1471-2474-14-185. PMid:23758965.
http://dx.doi.org/10.1186/1471-2474-14-1... , but not yet in other samples and cultures.

Studies have also used a series of questions to identify the consequences of back pain³⁵35 O’Sullivan PB, Beales DJ, Smith AJ, Straker LM. Low back pain in 17 year olds has substantial impact and represents an important public health disorder: a cross-sectional study. BMC Public Health. 2012;12(1):100. http://dx.doi.org/10.1186/1471-2458-12-100. PMid:22304903.
http://dx.doi.org/10.1186/1471-2458-12-1... ^,7777 Huguet A, Miró J. The severity of Chronic Pediatric Pain: an epidemiological study. J Pain. 2008;9(3):226-36. http://dx.doi.org/10.1016/j.jpain.2007.10.015. PMid:18088558.
http://dx.doi.org/10.1016/j.jpain.2007.1... ; these questions may be useful individually in description of specific impacts and also collectively as an indicator of severity. The questions relate to seeking of professional care, medication usage, absence from school or work, interference with normal activities, and interference with physical activities. A newly developed Teen Nordic Musculoskeletal Screening Questionnaire (TNMQ-S) also includes the impact on school and/or work attendance and on sporting and/or recreational activity participation as measures of severity. This questionnaire has shown good reliability and validity in a preliminary investigation of its measurement properties in Canadian teenagers⁷⁸78 Legault EP, Cantin V, Descarreaux M. Assessment of musculoskeletal symptoms and their impacts in the adolescent population: adaptation and validation of a questionnaire. BMC Pediatr. 2014;14(1):173. http://dx.doi.org/10.1186/1471-2431-14-173. PMid:24992817.
http://dx.doi.org/10.1186/1471-2431-14-1... .

However, self-report questionnaires can only be used in literate children, so assessment of pain in younger children necessarily involves interaction with both children and their parents. This introduces complexity as it has been shown that the agreement between parent and child ratings is generally poor, but varies in relation to severity of the condition and the outcomes measured⁷⁹79 Haraldstad K, Sørum R, Eide H, Natvig GK, Helseth S. Pain in children and adolescents: prevalence, impact on daily life, and parents’ perception, a school survey. Scand J Caring Sci. 2011;25(1):27-36. http://dx.doi.org/10.1111/j.1471-6712.2010.00785.x. PMid:20409061.
http://dx.doi.org/10.1111/j.1471-6712.20...

80 Kröner-Herwig B, Morris L, Heinrich M, Gassmann J, Vath N. Agreement of parents and children on characteristics of pediatric headache, other pain, somatic symptoms, and depressive symptoms in an epidemiologic study. Clin J Pain. 2009;25(1):58-64. http://dx.doi.org/10.1097/AJP.0b013e31817fc62d. PMid:19158547.
http://dx.doi.org/10.1097/AJP.0b013e3181... ^-8181 Sundblad GNB, Saartok T, Engström LT. Child: parent agreement on reports of disease, injury and pain. BMC Public Health. 2006;6(1):276. http://dx.doi.org/10.1186/1471-2458-6-276. PMid:17092332.
http://dx.doi.org/10.1186/1471-2458-6-27... . Therefore, besides reporting intensity, frequency and consequences of MSK pain, studies should describe the degree of parents’ involvement in data collection. See Box 6 for an overview of issues related to measurement.

Conclusion

Despite concerning data regarding the prevalence, impact and long-term consequences of musculoskeletal pain in children and adolescents, the field has not been subject to a concerted and systematic research effort. As a consequence there are major gaps in our understanding of these conditions, which leaves clinicians charged with treating young people with little empirical evidence to help guide their management decisions. There is particular need for research to better elucidate the clinical course of MSK pain conditions in children and adolescents, research to enable identification of those at risk of consequential pain and disability, studies to draw out the nature of the relationships between MSK pain and other adverse health risk factors and investigation into measurement issues. The body of research into MSK pain in adults is complicated by studies of poor methodological quality and inconsistent terminology and measurement, it is hoped that we can learn from this and generate a more robust, reliable and comparable body of evidence for children and adolescents.

References

Publication Dates

History