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Back Pain in Children: A Holistic Approach to Diagnosis and Management

      Abstract

      Back pain is a relatively common complaint presenting to the primary care practitioner and is addressed with increasing frequency in the pediatric literature. Back pain is not uncommon in adolescents and often is symptomatic of a relatively benign musculoskeletal etiology. Back pain in children less than 10 years of age and most especially less than 4 years of age can signal a more alarming underlying condition. Evaluation requires a complete history including psychosocial and cultural considerations. Additionally a thorough clinical examination, strategic lab work and judicious imaging are imperative. Management and appropriate referral is specific to the underlying disease process. A holistic, individualized plan of care with inherent involvement of the child and parent/caregiver is essential to ensure safety and enhance outcomes.

      Key Words

      Back pain is a relatively common complaint reported by patients to primary care practitioners and is addressed with increasing frequency in the pediatric literature. It can be acute (2 to 4 weeks' duration), or chronic (> 13 weeks' duration) and can create anxiety, frustration, or fear in the child and his or her parents/caregivers. Although low back pain is not uncommon in children younger than 10 years of age (
      • Hill J.J.
      • Keating J.L.
      A systematic review of the incidence and prevalence of low back pain in children.
      ) and is often musculoskeletal in origin and self-limiting, back pain in children younger than 10 to 11 years of age should raise a red flag in the diagnostic process. Back pain in younger children occurs less frequently than in adolescents and is more likely to be linked with a distinct cause like infection, inflammation, or neoplasm (

      American Academy of Orthopedic Surgeons. (2007). Back pain in children. Retrieved from http://orthoinfo.aaos.org/topic.cfm?topic=A00036

      ). Additional signs and symptoms may be identified to help guide the diagnostic process, and underlying pathology must be ruled out in any child presenting with more alarming symptoms (
      • Rodriguez D.P.
      • Poussaint T.Y.
      Imaging of back pain in children.
      ).
      For older children, as with adults, back pain often is related to a mechanical etiology or has no clear cause. Several factors put older children today at an increased risk for back pain. Athletic participation and training regimens, psychosocial issues and stress, carrying heavy backpacks, computer and TV use, and the increasing incidence of overweight all contribute to back pain in children who are older than 10 years (
      • Davis P.
      • Williams H.
      The investigation and management of back pain in children.
      ,
      • Jones G.
      • Watson K.
      • Silman A.
      • Symmons D.
      • MacFarlane G.
      Predictors of low back pain in British schoolchildren: A population-based prospective cohort study.
      ,
      • Lynch A.
      • Kashikar-Zuck S.
      • Goldschneider K.
      • Jones B.
      Psychosocial risks for disability in children with chronic back pain.
      ,
      • Trevelyan F.
      • Legg S.
      Back pain in school children—where to from here?.
      ). In general, children of today are more stressed, weigh more, and are either sedentary or over-involved in physical activities when compared with past generations. All of these factors put stress on the spine and surrounding structures and tighten hips and shoulders, which can adversely influence back comfort.
      …the incidence of back pain increases with age, is more worrisome in younger children (< 10 to 11 years old), and is frequently benign in older children.
      The purpose of this article is to provide the primary care provider with an approach to the diagnosis and holistic management of pediatric back pain. Foundational to this issue is the understanding that the incidence of back pain increases with age, is more worrisome in younger children (< 10 to 11 years old), and is frequently benign in older children. When accompanied by more alarming symptoms, which will be described, back pain warrants a more extensive diagnostic workup and appropriate referrals.

      Review of the Literature

      The literature indicates that the prevalence of back pain increases with age and often is related to a musculoskeletal (mechanical) etiology.
      • Olsen T.
      • Anderson R.
      • Dearwater S.
      • Kriska A.
      • Cauley J.
      • Aaron D.
      • LaPorte R.E.
      The epidemiology of low back pain in an adolescent population.
      looked at lifetime prevalence of low back pain in an adolescent population by surveying 1200 children from seventh through ninth grade. They observed no complaints of back pain prior to 10 years of age but found that by 15 years of age, complaints of back pain had increased to 36 % of this age group. Using a cross-sectional school-based survey of 1376 children aged 10 to 16 years,
      • Jones G.
      • Stratton G.
      • Reilly T.
      • Unnithan M.
      A school-based survey of recurrent non-specific low-back pain prevalence and consequences in children.
      found low back pain to be a common complaint, particularly in late adolescence. In a follow-up study, about 25% of children ages 11 to 14 years identified in the earlier study had persistent back pain 4 years later (
      • Jones G.T.
      • Macfarlane G.J.
      Predicting persistent low back pain in schoolchildren: A prospective cohort study.
      ). This study highlights the importance of identifying key factors in children that increase risk for persistent symptoms, including radiating leg pain, pain in other parts of the body, problems with peers, and long episodes of back pain (i.e., > 12 months).
      • Jones G.
      • MacFarlane G.
      Epidemiology of low back pain in children and adolescents.
      reviewed 47 studies investigating low back pain in children and adolescents. They reported that the prevalence of pain increased with age, was higher in girls, and that reported disability was not definitively associated with underlying pathology. Additionally, there was some evidence that children with low back pain weighed more and that a mechanical load (such as a school bag) may cause back pain.
      • Macias B.
      • Murthy G.
      • Chambers H.
      • Hargens A.
      Asymmetric loads and pain associated with backpack carrying by children.
      supported this assertion, suggesting that asymmetric carrying (e.g., carrying a backpack on one shoulder) may explain the relationship between shoulder and back pain. In a large study of 1126 children ages 12 to 18 years, carrying a heavy backpack was associated with back pain (
      • Sheir-Neiss G.I.
      • Kruse R.W.
      • Rahman T.
      • Jacobson L.P.
      • Pelli J.A.
      The association of backpack use and back pain in adolescents.
      ). In addition, a recent radiographic study using standing lumbar magnetic resonance imaging (MRI) scans of children revealed significant disc compression with increasing backpack loads (
      • Neuschwander T.B.
      • Cutrone J.
      • Macias B.R.
      • Cutrone S.
      • Murthy G.
      • Chambers H.
      • Hargens A.R.
      The effect of backpacks on the lumbar spine in children: A standing magnetic resonance imaging study.
      ).
      In contrast, many other studies have not shown a strong association between mechanical loads and back pain (
      • Kim H.J.
      • Green D.W.
      Adolescent back pain.
      ,
      • Lindstrom-Hazel D.
      The backpack problem is evident but the solution is less obvious.
      ,
      • Young I.A.
      • Haig A.J.
      • Yamakawa K.S.
      The association between backpack weight and low back pain in children.
      ,
      • Reneman M.F.
      • Poels B.J.
      • Geertzen J.B.
      • Dijkstra P.U.
      Back pain and backpacks in children: Biomedical or biopsychosocial model?.
      ). More research is needed to increase understanding of the relationship of heavy backpacks to back pain in children.
      • Burton A.K.
      • Clarke R.D.
      • McClune T.D.
      • Tillotson K.M.
      The natural history of low back pain in adolescents.
      surveyed 216 children (mean 11.7 years) and followed 68% of them for 5 years. They found back pain in 11.6% of respondents at 11 years compared with a 50.4% prevalence at 15 years. The etiology of the pain was not addressed in either the Olsen or Burton studies.
      • Masiero S.
      • Carraro E.
      • Celia A.
      • Sarto D.
      • Ermani M.
      Prevalence of nonspecific low back pain in schoolchildren aged between 13 and 15 years.
      investigated the prevalence of low back pain in 7542 children ages 13 to 15 years and found that more than 20% had experienced one or more episodes. A significant association was found for female gender, positive family history of low back pain, and sedentary lifestyle. This incidence corroborates previously reported data.
      The results of a large prospective study of children with a chief complaint of low back pain of greater than 3 months' duration revealed that despite an extensive workup, fewer than 30% had a definitive diagnosis (
      • Bhatia N.
      • Chow G.
      • Timon S.
      • Watts H.
      Diagnostic modalities for the evaluation of pediatric back pain: A prospective study.
      ). This finding corroborates data from other studies of older children and points to the importance of looking beyond physical factors when evaluating adolescents with back pain.
      As with adults, emotional factors can play an important role in back pain in children. Somaticizing stress and emotion frequently results in chronic pain. The back, along with abdominal musculature, provides the support that holds the body upright. This phenomenon has significant structural and psycho-emotional implications when considering chronic back pain. Lynch and colleagues (2006) studied 65 children aged 8 through 18 years with chronic back pain using visual analog scales to measure pain and the Functional Disability Inventory and the Internalizing/Catastrophizing subscale of the Pain Coping Questionnaire to assess the relationship between familial pain history, specific coping mechanisms, and level of disability. The ways family members responded to pain and the degree to which a child tended to catastrophize were strongly associated with greater levels of disability, including number of days missed from school and ability to engage in activities. The researchers concluded that the way a family communicates about the child's and their own experiences with pain influences coping ability.
      Current research suggests that a strong link between psychosocial factors and back pain exists (
      • Cieply R.
      • Milbrandt T.
      Back pain in children and adolescents.
      ,
      • Lindstrom-Hazel D.
      The backpack problem is evident but the solution is less obvious.
      ,
      • Prins Y.
      • Crous L.
      • Louw Q.A.
      A systematic review of posture and psychosocial factors as contributors to upper quadrant musculoskeletal pain in children and adolescents.
      ,
      • Reneman M.F.
      • Poels B.J.
      • Geertzen J.B.
      • Dijkstra P.U.
      Back pain and backpacks in children: Biomedical or biopsychosocial model?.
      ). These factors include depressive symptoms, difficulties getting along with peers, behaviors involving anger, aggression, hyperactivity, and attentional difficulties, having a parent with back pain, fatigue, and other types of pain beyond the back. These studies highlight the importance of working with the whole family system and assessing the need to refer to a counselor or family therapist when a child presents with chronic back pain.
      A history of regular smoking has been associated with low back pain, especially in female adolescents, and predicts back pain later in young adults who have smoked as teens (
      • 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.
      ). Smoking can be interpreted as a behavior with psychosocial roots. In a prospective cohort study,
      • Jones G.
      • Watson K.
      • Silman A.
      • Symmons D.
      • MacFarlane G.
      Predictors of low back pain in British schoolchildren: A population-based prospective cohort study.
      followed 1046 children ages 11 through 14 years for 1 year and found that those with high levels of psychosocial difficulties were much more likely to have chronic low back pain. As with many other studies, back pain was not correlated with mechanical load from carrying weighty book bags.
      In more than 30 years of working with thousands of clients with chronic back pain,
      • Sarno J.
      Healing back pain: The mind-body connection.
      has identified tension myositis syndrome, whereby tension, anxiety, and emotional states are the most common causes of chronic back pain. His premise is that pain has meaning and purpose, and those who suffer must think psychologically rather than physically to identify the cause of their pain and find relief. We can extrapolate his findings to help adolescents who are experiencing chronic back pain of unknown origin. It is empowering for many teens to learn that they can exert more control over their bodies and symptoms than they might have imagined. Many teens are motivated to make therapeutic use of the body-mind connection.

      Diagnosis

      History

      Pain that is acute in a child without history of trauma or a precipitating event and pain that occurs at rest or causes night awakening should raise suspicion of a more serious condition.
      A detailed history will provide valuable clues to guide the diagnostic workup and treatment decisions (
      • Kronberg J.
      • Small E.
      Evaluating back pain in a young athlete.
      ). Pain that is acute in a child without history of trauma or a precipitating event and pain that occurs at rest or causes night awakening should raise suspicion of a more serious condition. Back pain with radicular symptoms such as radiation and motor/ sensory changes to an extremity (e.g., limping), or bowel and bladder changes (e.g., incontinence) may indicate neurologic pathology from a disc or mass encroaching on nerve roots. Pain that worsens with a Valsalva maneuver such as coughing or sneezing may indicate nerve root involvement.
      Back pain accompanied by more systemic symptoms may signal underlying infection (e.g., vertebral osteomyelitis and discitis), inflammatory processes (e.g., juvenile rheumatoid arthritis [JRA]), or a malignancy. Fever, fatigue, additional joint symptoms, and loss of appetite should heighten the clinician's index of suspicion and prompt further investigation. It is important to differentiate pain at rest from pain that is present with activities, including sitting or standing. Pain at rest may be more indicative of infection, tumor, or neoplasm, which must then be ruled out (
      • Davis P.
      • Williams H.
      The investigation and management of back pain in children.
      ).
      The characteristics, onset, location, duration, presence of radiation, and intensity of the pain should be documented. Use of developmentally appropriate pain assessment scales provides a degree of consistency in communicating and documenting the pain experience (
      • Berman A.
      • Snyder S.
      • Jackson C.
      Pain management.
      ). Box 1 highlights instruments for assessing pain in children. The most reliable and important indicator of pain is the patient's self-report. It is best to use a multidimensional approach to pain assessment that includes self-report whenever possible, behaviors, facial expression, and input from those who know the child well to get the most accurate assessment of a child's pain. Cultural factors influence the pain experience, the expression of pain, and the meaning of pain to the child and parents. Relying on the child's facial expression, verbalizations, and requests for relief, which are all culturally mediated, may be misleading. Box 2 provides guidelines for offering culturally competent care.
      Developmentally appropriate pain assessment instruments
      • Subjective Units of Distress Scale: “On a scale of 0-10, 0 being no pain and 10 being the worst pain you could imagine, what number is your pain”?
      • Revised FACES Pain Rating Scale: Children choose from six facial expressions to show how they feel. The revised scale includes a numeric scale with each expression to allow quantification of pain intensity. It has been validated in studies of children (
        • Garra G.
        • Singer A.J.
        • Taira B.R.
        • Chohan J.
        • Cardoz H.
        • Chisena E.
        • Thode H.C.
        Validation of the Wong-Baker FACES Pain Rating Scale in pediatric emergency department patients.
        ).
      • The Facial expression, Leg movement, Activity, Cry, and Consolability (FLACC) scale allows nurses to observe behaviors and has been validated in children 2 months to 7 years of age. Facial expression, leg movement, activity, cry, and consolability yield a 0 to 10 score.
      Data from Berman, A., Snyder, S., & Jackson, C. (2009).
      Offering culturally competent care
      • Use a variety of assessments to get a clearer understanding of the child's pain
      • Include the family in the assessment process when appropriate; give adolescents privacy
      • Use interpreters whenever a language barrier is present; do not use family members to interpret if you suspect the problem is of a sensitive nature
      • Ask children to explain why they have pain and what the pain means to them
      • Respect the client's beliefs and incorporate folk treatments that seem safe into the plan of care whenever possible
      Factors that exacerbate and relieve pain should be identified. Use and effectiveness of medications and non-pharmacological measures (i.e., ice/heat, massage, or chiropractic therapy) should be documented. The level of pain as reported by the patient should be compared at follow-up visits to determine treatment effectiveness.
      In addition to the medical history, children should be interviewed to identify the presence of additional contributing factors. A brief psychosocial history can assess any recent stressors, peer or family problems, and life changes. Questions should be asked about the level of physical activity and history of smoking. Family history of back pain, the family's responses to the child with pain, and cultural factors all influence the child's pain experience (
      • Masiero S.
      • Carraro E.
      • Celia A.
      • Sarto D.
      • Ermani M.
      Prevalence of nonspecific low back pain in schoolchildren aged between 13 and 15 years.
      ). Box 3 includes psychosocial-cultural assessment questions to include in your evaluation of the child with back pain. It is always important to elicit the child's explanatory model by asking why he thinks he has back pain, or asking what she thinks caused her pain. While some children may reply, “I don't know,” many will give answers that provide clues to accurate diagnosis and point toward particular therapeutic strategies.
      Questions to assess psychosocial-cultural factors
      • Have you had any difficulties at school lately like problems with teachers or other kids?
      • Have you had any difficulties at home in the last year? Do you get along with your family members? Do you get in trouble very often?
      • How do your family members respond to your pain?
      • Do any of your family members have chronic pain?
      • Do you, or have you ever smoked regularly?
      • Do you feel like you have enough support to feel OK? To do the things you want to do?
      • Why are you having this pain? What caused this pain? Is anyone hurting you?
      • How does this pain affect you on a daily basis? What does this pain mean in your life?
      • If you had to assign a color to this pain, what would it be?
      • If you had to picture your pain as an animal, what would it be? Why?
      • Do you ever feel really down? Do you ever think of hurting yourself?
      • What do you do to help the pain? What can we do to help your pain?
      A sports history including gym class and fitness and weight training activities can identify other factors contributing to back pain. A thorough sports history will include the sport, concurrent sports played, the total amount of hours of practice and play per week, the level of play, the type of surface played on, and whether any outside conditioning/flexibility training is performed. One should ask about the use of any foot orthotics that may affect gait. Consideration of the particular mechanics for a certain sport can be helpful in determining a diagnosis. Sports that require repetitive spinal hyperextension such as gymnastics, ballet, diving, wrestling, and football place increased biomechanical stress on the posterior spinal elements, leading to increased risk for pars stress fractures (spondylolysis). In the presence of bilateral pars fractures, vertebral bodies can slip over each other (spondylolisthesis), causing pain and nerve root compression that can worsen over time. Frequent heavy weight lifting places stress on the developing vertebral endplates with increased risk for lumbar Scheuermann's Disease. Youth who engage in “vert” biking (ramp riding), skateboarding, and in-line skating frequently land with force on their feet or buttocks causing axial loading with potential risk for vertebral compression fractures and damage to discs (

      Huang, J. (2002). Potential causes of back pain in children and teens (Back Pain Center). Retrieved from www.spine-health.com/conditions/back-pain/potential-causes-back-pain-children-and-teens

      ).
      Habitual or repetitive movements, activities, and postures must be assessed because they can contribute to back pain. How the child sits, stands, walks, sleeps, and lifts is significant. Alignment and symmetry in activities of daily living can make a difference between experiencing pain and being pain free.

      Physical Examination

      Along with a detailed history, the physical examination should reveal signs of a pathologic etiology requiring initiation of a more extensive workup or immediate referral to a specialist. Careful observation of ease or difficulty moving and changing position can provide insight as to the presence of pain along with a selected pain scale. Movement should be fluid and full rather than limited or guarded. Does the child bend at the waist to pick up an object, or hold the spine erect and bend at the knees only? Observation of the gait will provide insight into general posture, balance, lower extremity weakness, and symmetry of movement. The ability to toe and heel walk and symmetrically rise from a deep knee bend can attest to the strength of the major muscle groups in the lower extremities. The skin should be inspected for cutaneous findings suggestive of other underlying pathology such as sacral dimples, cafe-au lait spots, midline tufts of hair, and rashes. In addition, one should look for signs of trauma or abuse such as abrasions and bruising.
      It is worth mentioning again that cultural factors come into play in terms of how the individual responds to the pain experience, because this affects the behavioral manifestations of pain. It may seem to the clinician that the child does not exhibit outward signs of pain, yet pain is a subjective experience and is always what the patient says it is.
      From the side, one should observe the contours of the spine, looking for the typical cervical and lumbar lordotic and thoracic kyphotic curves. Increased thoracic kyphosis may be postural or may indicate Scheuermann's kyphosis, which develops most frequently in boys between the ages of 14 to 17 years (

      American Academy of Orthopedic Surgeons. (2007). Back pain in children. Retrieved from http://orthoinfo.aaos.org/topic.cfm?topic=A00036

      ). An increased degree of lumbar lordosis may be postural, related to tight hamstrings and hip flexors, or may be compensatory for hypotonicity and lower extremity weakness as seen in some of the muscular dystrophies. A flattening of the normal cervical and lumbar lordotic contours may reflect paraspinal muscle spasm in response to pain.
      Looking at the patient from behind, one should observe overall spinal alignment in the upright position and then in the bent over position. The patient should be assessed for scoliosis and leg length discrepancy. A truncal shift (i.e., the rib cage pulling to one side) can warrant further investigation, especially if accompanied by other clinical findings that cause concern.
      Motion of the entire spine from cervical through lumbar regions should be assessed. Limits to motion and the effect of a particular motion on pain should be carefully noted. Hyperextension of the spine increases stress on the posterior elements of the spine. If hyperextension is painful, spondylolysis may be present. Alternatively, if pain is present with forward flexion (i.e., when reaching toward the toes), disc pathology may be present. Scoliosis with mechanical back pain, in the presence of an otherwise normal examination, is not definitive for underlying pathology and does not warrant an extensive diagnostic workup. Hip mobility should be assessed. The FABER test (passive flexion, abduction and external rotation of the hip) places stress on the sacroiliac joints and can localize complaints of low back pain specifically to this area. Hamstring flexibility also should be evaluated because hamstring spasm or tightness is associated with low back pain.
      The back should be palpated for generalized and focal tenderness. Particular attention should be paid to any midline vertebral tenderness and paraspinal muscle tenderness and spasm. Shoulder mobility should be examined. The scapula should be examined for winging and for asymmetry with shoulder motion. If present, this would be suggestive of long thoracic nerve palsy or decreased periscapular strength and stability.
      Neurologic testing will help rule out the presence of potential intraspinal pathology and should include strength, sensation, and deep tendon reflexes in all extremities and the presence or absence of ankle clonus. Asymmetry of the abdominal reflex also may indicate intraspinal pathology (
      • Saifuddin A.
      • Tucker S.
      • Taylor B.
      • Noordeen M.
      • Lehovsky J.
      Prevalence and clinical significance of superficial abdominal reflex abnormalities in idiopathic scoliosis.
      ). Pain with a straight leg raise in the supine and prone positions can indicate nerve root irritation or compression (
      • Davis P.
      • Williams H.
      The investigation and management of back pain in children.
      ). The Table presents underlying physical diagnoses to consider when evaluating the child with back pain.
      TableDifferential diagnosis of physical causes of back pain in children
      MusculoskeletalInfectious/inflammationRheumatologicTumor
      Direct trauma, injuryDiscitisJuvenile RheumatoidOsteoid osteoma (benign)
      Muscular strain/overuse injuriesOsteomyelitisArthritis (JRA)Hemangioma (benign)
      Ruptured/herniated DiscLeukemiaLyme diseaseGiant cell tumor (benign)
      SpondylolysisAbscessAnkylosing spondylitisOsteoblastoma
      SpondylolisthesisPyelonephritisAneurysmal bone cyst
      Transitional vertebraeOvarian pathologyOsteosarcoma
      Scheuermann's kyphosisBowel pathologyEwing's sarcoma
      Lumbar Scheuermann's
      Bertolotti's syndrome
      See
      • Rodriguez D.P.
      • Poussaint T.Y.
      Imaging of back pain in children.
      for a more extensive differential.

      Diagnostic Studies

      A variety of medical conditions can present as back pain. The history and physical examination findings will determine the need for further studies. If no red flags are raised in the history and clinical examination and findings of plain radiographs (ordered judiciously as necessary) are normal, observation of symptoms may be appropriate before proceeding with more costly testing. The workup for back pain often results in overimaging (
      • Auerbach J.
      • Ahn J.
      • Zgonis M.
      • Reddy S.
      • Ecker M.
      • Flynn J.
      Streamlining the evaluation of low back pain in children.
      ) and limited diagnostic findings (
      • Bhatia N.
      • Chow G.
      • Timon S.
      • Watts H.
      Diagnostic modalities for the evaluation of pediatric back pain: A prospective study.
      ). This is important to note in light of the evolving understanding of risks with overexposure to ionizing radiation (American Cancer Society, 2009;
      • Rodriguez D.P.
      • Poussaint T.Y.
      Imaging of back pain in children.
      ). Current recommendations regarding diagnostic imaging in children are featured in Box 4.
      Imaging recommendations
      • Perform only necessary CT examinations. When appropriate, consider other modalities such as ultrasound or magnetic resonance imaging, which do not use ionizing radiation.
      • Adjust exposure parameters for pediatric CT scan based on child size (guidelines based on individual size/weight parameters should be used); region scanned (the region of the body scanned should be limited to the smallest necessary area); and organ systems scanned (lower mA and/or kVp settings should be considered for skeletal imaging).
      • Scan resolution: The highest quality images (i.e., those that require the most radiation) are not always required to make diagnoses. In many cases, lower-resolution scans are diagnostic. Minimize the CT examinations that use multiple scans obtained during different phases of contrast enhancement. These multiphase examinations are rarely necessary and result in a considerable increase in dose.
      From the

      National Cancer Institute. (2008). Radiation risks and pediatric computed tomography (CT): A guide for health care providers. Retrieved from http://www.cancer.gov/cancertopics/causes/radiation-risks-pediatric-CT

      . Radiation risks and pediatric computed tomography (CT): A guide for health care providers. Retrieved from http://www.cancer.gov/cancertopics/causes/radiation-risks-pediatric-CT
      Visit www.imagegently.org for more information.
      If there is suspicion of infectious or inflammatory processes, laboratory studies should include a complete blood cell count with differential, sedimentation rate, and C-reactive protein (
      • Feldman D.S.
      • Straight J.J.
      • Badra M.I.
      • Mohaideen A.
      • Madan S.S.
      Evaluation of an algorithmic approach to pediatric back pain.
      ). Electrolyte and enzyme panels can be helpful if there are neuromuscular concerns. Lyme and ANA titers and HLAB27 are helpful to evaluate for spondyloarthropathy.
      Radiographic workup should begin with standing posterior anterior (PA) and lateral views of the thoracolumbar spine. The PA approach limits the amount of direct radiation to the breast tissue. The standing PA view will show any asymmetry of the spine and can identify potentially serious findings such as pedicular erosion, vertebral lesions, or congenital abnormalities. The standing lateral spine x-ray can identify changes in the normal sagittal contour along with changes as seen in Scheuermann's kyphosis. Lateral views should be used judiciously because they require larger doses of radiation. Narrowed disc spaces can result from an infectious process like discitis. A lumbosacral series may identify the presence of spondylolysis and spondylolisthesis.
      Advanced imaging in the form of MRI, computed tomography (CT), or a bone scan should be considered only if the clinical picture is alarming enough to warrant additional exposure to radiation.
      Advanced imaging in the form of MRI, computed tomography (CT), or a bone scan should be considered only if the clinical picture is alarming enough to warrant additional exposure to radiation. Auerbach and colleagues (2008) found the bone scan to be most helpful in diagnosing pathologic low back pain in pediatric patients with less than 6 weeks of non-neurologic back pain. In addition to accuracy, the study is relatively inexpensive, accessible, and less likely to require sedation. An MRI does not emit ionizing radiation and will aid in evaluating the soft tissues (i.e., spinal cord and discs) and may show signs of a pars stress fracture of the vertebrae by the presence of edema or a visible fracture line. Contrast should be used only when absolutely necessary, because adverse reactions to dye can occur. A bone scan is sensitive for active processes and is indicated if there are concerns regarding an infection or tumor.
      A CT scan is specific for diagnosing bone etiology and can clarify the healing status of a stress fracture and identify osteoid osteomas. Because of the amount of radiation in CT scans, the ordering clinician should request pediatric-specific radiation-limiting CT scan protocols and also limit the total number of vertebrae imaged to the level directly above and below the area of concern (see Box 4).

      Management

      When looking at pain management, it is important to remember that pain is only part of the experience of suffering. The following equation illustrates this maxim: Pain + Resistance = Suffering. Resistance is a result of fear, anxiety, past experiences with pain, the meaning of the pain, and muscle tension. All of these can increase the negativity of the pain experience (
      • Kleinman A.
      Pain and resistance: The delegitimation and relegitimation of local worlds.
      ). Although we may not always be able to fully eradicate pain, we can always assist in the reduction of resistance, which will reduce the net amount of suffering. When working with children, it is important to include their caregivers in the process of pain management as developmentally appropriate.
      When pain is directly related to an injury or activity, the activity should be discontinued to allow healing. Healing may take days or weeks, depending on the individual situation. Simple analgesics like ibuprofen may provide reduction in pain and inflammation and should be taken with food at the correct dose to achieve a therapeutic effect.
      Some type of physical therapy, formal or independent, should be instituted for chronic muscular pain. This approach can include modalities such as heat and cold and electrical stimulation. When muscular back pain is related to growth, overuse, mechanical issues (such as from activities, posture, sedentary lifestyle, and heavy backpacks), or from a previous unrehabilitated injury, core strengthening and flexibility should be the mainstay of therapy. This approach focuses on strengthening the overall “powerhouse” of the body—the abdominals and back muscles. Flexibility training should target hip flexors and hamstrings. Therapy should be challenging but not painful. If the patient is given a home exercise program and not sent to formal physical therapy, it is imperative that he or she is taught the appropriate technique to perform each exercise. Therapy should be a progressive program that includes the entire kinetic chain from head to toes. Year-round fitness conditioning (not just prior to starting each sport season) and promoting flexibility exercises for all patients, especially those who are still growing, is essential.
      • Fanucchi G.L.
      • Stewart A.
      • Jordaan R.
      • Becker P.
      Exercise reduces the intensity and prevalence of low back pain in 12-13 year old children: A randomised trial.
      conducted a randomized trial with seventy-two 12- to 13-year-olds experiencing low back pain. The experimental group completed weekly exercise classes for 8 weeks, and when compared with control participants, they experienced significantly reduced pain and increased well-being.
      Approaches to core conditioning such as yoga and Pilates-style regimens are especially valuable to develop strength in the abdominal and back muscles, which is essential for back support.
      • Sherman K.
      • Cherkin D.
      • Erro J.
      • Miglioretti D.
      • Deyo R.
      Comparison of yoga, exercise, and education for the treatment of chronic low back pain.
      randomly assigned 101 patients with chronic low back pain to one of three treatment groups and found that those in the yoga intervention reported significantly better back function and less pain.
      • Williams K.
      • Abildso C.
      • Steinberg L.
      • Doyle E.
      • Epstein B.
      • Smith D.
      • Cooper L.
      Evaluation of the effectiveness and efficacy of Iyengar yoga therapy on chronic low back pain.
      randomly assigned 90 participants with chronic low back pain to an Iyengar yoga intervention (24 weeks of biweekly classes) or a control group receiving standard medical care. At the end of the classes, and again at 48 weeks (6 months after the intervention), participants who participated in yoga classes continued to experience significant reductions in functional disability, pain intensity, depression, and usage of pain medication than did members of the control group. Yoga is very acceptable to the pediatric population, and studies support positive effects on well-being and quality of life, stress reduction, physical outcomes including pain, and learning in children and adolescents (
      • Berger D.L.
      • Silver E.J.
      • Stein R.E.
      Effects of yoga on inner-city children's well-being: A pilot study.
      ,
      • Galantino M.L.
      • Galbavy R.
      • Quinn L.
      Therapeutic effects of yoga for children: A systematic review of the literature.
      ,
      • White L.S.
      Yoga for children.
      ).
      Because Pilates and yoga efficiently emphasize flexibility and functional strength at the same time, practitioners of these techniques stretch while they strengthen. Because a balanced workout addresses all muscle groups, practicing these techniques provides cross-training within the workout. Through the regular deep breathing and mindfulness inherent to these practices, practitioners derive the health benefits of relaxation and stress management. Because stress and emotion can play a role in back pain with the adolescent patient, this added therapeutic benefit is significant. Adolescents can practice these disciplines independently using tapes and on-line resources once they have had formal instruction with a certified instructor (see Box 5 for guidelines on finding therapists and instructors for all management strategies mentioned in this section). Overstretching and injury can occur, especially in the sacroiliac joints and neck. A properly trained instructor will emphasize safety throughout the workout. The addition of “back friendly” styles of aerobic exercise (e.g., swimming) will assist with cardiorespiratory fitness and weight management.
      Guidelines for referrals to therapists and instructors
      In general, make sure the therapist has appropriate training and certification. Have the parent/caregiver take the child for an initial session/class to assess “fit.” Contact the following organizations to assist you in finding appropriate pediatric referrals in your geographic area:
      Structural problems that cause back pain like Scheuermann's kyphosis, spondylolysis, and spondylolisthesis often respond to rest, simple analgesics such as ibuprofen, and use of a brace. Stopping the physical activity that may have caused or contributed to the injury and pain is recommended. Physical therapy should be instituted, including core strength and flexibility. In extreme cases of painful spondylolysis and spondylolisthesis, surgery may be necessary ().
      Antibiotics are used for an infectious process like discitis or osteomyelitis. Some combination of surgery, chemotherapy, and radiation are used for neoplastic processes. Appropriate therapies are instituted in the child with JRA or other rheumatoid conditions. The following strategies may help children with back pain resulting from JRA or cancer, as well as children with chronic back pain of unknown origin.
      The Alexander Technique (AT) is a well-suited therapy for those with back pain, repetitive strain injury, and arthritis. Emphasizing spinal decompression, postural alignment, and rebalancing the muscles of the torso, certified AT teachers help clients of all ages to develop head-neck-spine awareness and control (
      • Novey D.
      Clinician's complete reference to complementary and alternative medicine.
      ). Through practice, students learn to release muscle tension and pause before acting to enhance mindful awareness. A growing number of physical therapists are seeking training as AT instructors.
      Rolfing is focused on the structural integrity of the body, and the therapist uses specific, gentle, but firm finger pressure to elongate connective tissue, free fixations in the structures, and educate the neuromuscular network to work more efficiently. Recipients can benefit by experiencing greater organization of movement, motility, and comfort in the body (
      • Novey D.
      Clinician's complete reference to complementary and alternative medicine.
      ). In the absence of genetic and structural factors, this therapy can be used to improve spine flexibility, alignment, and comfort.
      Acupuncture is used for many types of pain and has been studied for use in those with back pain. While most study results have been inconclusive as far as management of acute back pain, the Cochrane group recommends acupuncture as an important adjunctive modality for relieving pain and improving function in persons with chronic back pain (
      • Furlan A.
      • van Tulder M.
      • Cherkin D.
      • Tsukayama H.
      • Lao L.
      • Koes B.
      • Berman B.
      Acupuncture and dry-needling for low back pain.
      ). Children can respond positively to acupuncture as a treatment modality. In a study of 33 children ages 6 through 18 years who were experiencing chronic pain, parents and participants reported significant improvements in pain function after six weekly acupuncture/hypnosis sessions (
      • Zeltzer L.
      • Tsao J.
      • Stelling C.
      • Powers M.
      • Levy S.
      • Waterhouse M.
      A phase I study on the feasibility and acceptability of an acupuncture/hypnosis intervention for chronic pediatric pain.
      ). A 20-minute hypnosis session was offered while the needles were in place. No adverse effects were reported, and only two of the children refused to participate. Although more research is needed, this study supports the feasibility and acceptability of acupuncture and hypnosis as treatment modalities for children in pain.
      Massage is a valuable therapeutic strategy to offer children. The Cochrane group concluded that massage might be beneficial for patients with subacute and chronic non-specific low-back pain, especially when combined with exercises and education. The evidence suggests that some types of massage may have more potent clinical effects than others, but this question needs further evaluation (
      • Furlan A.
      • Imamura M.
      • Dryden T.
      • Irvin E.
      Massage for low-back pain.
      ).
      • Field T.
      • Diego M.
      • Hernandez-Reif M.
      Models for potential biochemical and physiological mechanisms underlying massage therapy effects.
      reviewed the literature on massage therapy across the lifespan and found that massage reduces pain, increases growth in infants, increases focus and attention, and improves neuromuscular function in research participants.
      In another study,
      • Field T.
      • Hernandez-Reif M.
      • Seligman S.
      • Krasnegor J.
      • Sunshine W.
      • Rivas-Chacon R.
      • Kuhn C.
      • et al.
      Juvenile rheumatoid arthritis: Benefits from massage therapy.
      trained parents to massage their children with JRA (N = 20) for 15 minutes a day for 30 days or to practice relaxation together (targeting large muscle groups) at bedtime for 15 minutes. At the end, both the parents who massaged and their children who received massage experienced reduced anxiety as measured by behavioral observation and lower salivary cortisol levels. Compared with those in the relaxation group, those in the massage group reported significantly less pain after the massage and throughout the week following treatment. They also experienced fewer major pain episodes as reported by parents and physicians. This study highlights the importance of touch as well as parental involvement in the therapeutic process.
      The literature reflects an increasing emphasis on a biopsychosocial approach to the diagnosis and treatment of back pain in youth rather than a strictly biomedical approach (
      • Lindstrom-Hazel D.
      The backpack problem is evident but the solution is less obvious.
      ,
      • Prins Y.
      • Crous L.
      • Louw Q.A.
      A systematic review of posture and psychosocial factors as contributors to upper quadrant musculoskeletal pain in children and adolescents.
      ,
      • Reneman M.F.
      • Poels B.J.
      • Geertzen J.B.
      • Dijkstra P.U.
      Back pain and backpacks in children: Biomedical or biopsychosocial model?.
      ). Many teens are motivated to learn more about the non-physical factors that may contribute to back pain. For them, counseling can make a difference in understanding the possible meaning and purpose of back pain. This insight often leads to pain reduction. The book Healing Back Pain: The Mind-Body Connection (
      • Sarno J.
      Healing back pain: The mind-body connection.
      ) is a helpful resource for learning to relieve back pain and sciatica using the mind-body connection.
      Although data are conflicting regarding the role of backpack weight and back pain, it makes sense to avoid overloading. According to the American Academy of Pediatrics and the American Academy of Orthopedic Surgeons, backpacks should only weigh 10-20% of an individual's weight (

      American Academy of Pediatrics. (2003). Backpack safety. Caring for your school-age child: Ages 5 to 12. Retrieved from http://www.healthychildren.org/English/safety-prevention/at-play/pages/Backpack-Safety.aspx

      ). Straps should be wide and padded. Heavier items should be placed closer to the back, and the load should be distributed symmetrically. Rolling backpacks are recommended for students with heavier loads.
      Evaluation of pediatric back pain requires a complete history, thorough clinical examination, strategic laboratory work, and judicious imaging. Back pain is not uncommon in adolescents and is often symptomatic of a relatively benign musculoskeletal etiology or accumulated stress and emotion. Back pain in children younger than 10 years of age, and especially younger than 4 years of age, can signal a more alarming underlying condition. Treatment for back pain is specific to the underlying disease process. Referral to an appropriate specialist is indicated if more worrisome musculoskeletal, infectious, rheumatologic, or tumor diagnoses are suspected. The primary provider should identify risk factors and discuss preventive measures including postural awareness, core strengthening and flexibility exercises, relaxation and stress management, and a sensible approach to sports participation. Integrative approaches to treatment can include massage, acupuncture, Pilates, Yoga, Rolfing, stress management, counseling, and AT, used alone or in conjunction with other therapies (see Box 5).
      Pain is always a body-mind-spirit experience; therefore, treatments should be aimed at healing body, mind, and spirit. Careful and complete evaluation of the child with back pain includes psychosocial and cultural considerations and full involvement of the child and caregivers. A holistic, individualized plan of care that is developed in partnership with the pediatric client and parents/caregivers will ensure safety and enhance outcomes.

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      Biography

      Christina Jackson, Holistic Nurse Practitioner, Professor, Department of Nursing, Eastern University, St. Davids, PA.
      Kristen McLaughlin, Pediatric Nurse Practitioner, Orthopedics and Sports Medicine, Childrens Hospital of Philadelphia Department of Orthopedics, Philadelphia, PA.
      Beverly Teti, Pediatric Nurse Practitioner, Orthopedics and Sports Medicine, Childrens Hospital of Philadelphia Department of Orthopedics, Philadelphia, PA.