Recent research has demonstrated the multidimensional nature of causative factors related to adolescent LBP. For many, the picture is complex, with potential confounding factors including:
Biological factors:
Genetic-environmental factors may play a role in the development of LBP. A genetic contribution is difficult to quantify, and also difficult to separate from family and environment-related factors. Poor family functioning, life stress events, and poor mental health factors have all been shown to contribute. There are also complex biological pain perception factors, where some individuals have a different chemical response to noxious and non-noxious stimulation. For example, evidence of heightened stress response in 18-year-olds was predictive of later increased widespread body pain in 22-year-olds who had abnormal sensitivity to cold.
Psychosocial factors:
As for adults with chronic LBP, back pain beliefs and fear of movement and activity can play a significant role in persistence of LBP. In these individuals, there will often be avoidant coping behaviors, a history of school absenteeism, and avoidance of physical activity, as well as ADLs. There will often be the presence of altered sleep patterns, and evidence of increased psychological and social distress.
Interventions
In any adolescent with chronic LBP, it will be necessary to consider a multidisciplinary and wholistic approach to management. Important aspects of this management are listed below:
Education:
The patient needs to understand that LBP does not mean that there is damage to the spine, but rather reflects sensitization of spinal structures. It is important for the patient to accept that postural variability, movement, and functional loading are safe and important for the health of the spine. They should be encouraged to remain active, and to engage in normal levels of ADLs, school and work.
Functional:
If sport or other undue loading is considered a contributing factor, a programme of graduated conditioning should be undertaken. It is important in these individuals to identify the loading patterns that are most provocative, so they can be modified. This may be excessive lumbar flexion from slouched sitting, or excessive extension from sport such as bowling in cricket. The programme should encourage gradual building of confidence to engage in ADLs and sporting activities.
Lifestyle:
For some, it will be important to assist them to engage in more positive behaviors and a healthier lifestyle. This may include improving sleep habits, better diet, and more regular physical activity. All these factors are important for general as well as spinal and bone health.
However, these is also some evidence that there may be faulty movement patterns in a number of these individuals. One study in rowers found that those with LBP were more likely to position their spines closer to end range flexion. It is possible individual movement patterns affect vulnerability to low back stress in other sports as well. I would argue that, while there may be a weak link between static posture and low back pain, the posture may contribute to greater vulnerability during sport. This would be similar to a subgroup of adult patients I see in my clinic. They sit with slumped posture for 40 hours+ per week, and injure their back bending in the garden on the weekend. The injury is attributed to bending, not the habitual posture.
Back muscle endurance:
While this has been reported as a risk factor for low back injury in adults, the link in adolescents is less clear. There was a small group of adolescents in which lower back muscle endurance may have been a factor.
Latest Research on Contributing Factors
[What was interesting, and supported a theory I have on posture-related to LBP, was a finding that static postures may affect motor-control strategies. In other words, as I often tell my patients, “how you sit determines how you move”. Or as these authors describe it, “a postural signature may be carried into dynamic tasks”. ]
Lifestyle: These is growing evidence for the role of lifestyle factors, such as physical activity levels, cigarette smoking, diet, and sleep habits. There is evidence that disrupted sleep and sleep deficits are independent predictors of LBP and neck pain in adolescents (Auvinen et al 2010).
Reference:
O’Sullivan, P et al (2017). Understanding adolescent LBP from a multidimensional perspective: implications for management. JOSPT, 47, 10, 741-751.
Please contact me if you would like a copy of the full reference list.
Part 3 of this series will explore motor control aspects of chronic adolescent LBP.
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