Author Names
Peter O’Sullivan, Anne Smith, Darren Beales, Leon Straker
Reviewer Name
Madison Lapsley, SPT
Reviewer Affiliation(s)
Duke University Doctor of Physical Therapy Division
Paper Abstract
Synopsis Low back pain (LBP) is the leading cause of disability worldwide. It often begins in adolescence, setting a course for later in life. We have tracked the course of LBP in the Raine Study cohort from the age of 14 years into early adulthood. Our work has found that LBP is already prevalent in individuals at 14 years of age and increases throughout adolescence and into early adulthood. It is often comorbid with other musculoskeletal pain. For some adolescents, LBP has little impact; for others, its impact includes care seeking, taking medication, taking time off from school and work, as well as modifying physical and functional activity. Of concern is the increasing prevalence of LBP with impact across adolescence, reaching adult rates by 22 years of age. The predictors of disabling LBP in adolescence are multidimensional. They include female sex, negative back pain beliefs, poor mental health status, somatic complaints, involvement in sports, and altered stress responses. Genetics also plays a role. Ironically, the factors that we have historically thought to be important predictors of LBP, such as “poor” spinal posture, scoliosis, carrying school bags, joint hypermobility, and poor back muscle endurance, are not strong predictors. This challenges our clinical beliefs and highlights that adolescent LBP needs a flexible and targeted multidimensional approach to assessment and management. In most cases, we recommend a cognitive functional approach that challenges negative LBP beliefs, educates adolescents regarding factors associated with their LBP, restores functional capacity where it is impaired, and encourages healthy lifestyle habits.
NIH Risk of Bias Tool
Quality Assessment of Case-Control Studies
- Was the research question or objective in this paper clearly stated and appropriate?
- Yes
- Was the study population clearly specified and defined?
- Yes
- Did the authors include a sample size justification?
- Yes
- Were controls selected or recruited from the same or similar population that gave rise to the cases (including the same timeframe)?
- Cannot Determine, Not Reported, Not Applicable
- Were the definitions, inclusion and exclusion criteria, algorithms or processes used to identify or select cases and controls valid, reliable, and implemented consistently across all study participants?
- Cannot Determine, Not Reported, Not Applicable
- Were the cases clearly defined and differentiated from controls?
- Cannot Determine, Not Reported, Not Applicable
- If less than 100 percent of eligible cases and/or controls were selected for the study, were the cases and/or controls randomly selected from those eligible?
- Cannot Determine, Not Reported, Not Applicable
- Was there use of concurrent controls?
- Cannot Determine, Not Reported, Not Applicable
- Were the investigators able to confirm that the exposure/risk occurred prior to the development of the condition or event that defined a participant as a case?
- Cannot Determine, Not Reported, Not Applicable
- Were the measures of exposure/risk clearly defined, valid, reliable, and implemented consistently (including the same time period) across all study participants?
- Cannot Determine, Not Reported, Not Applicable
- Were the assessors of exposure/risk blinded to the case or control status of participants?
- Cannot Determine, Not Reported, Not Applicable
- Were key potential confounding variables measured and adjusted statistically in the analyses? If matching was used, did the investigators account for matching during study analysis?
- Cannot Determine, Not Reported, Not Applicable
Key Finding #1
“Interventions that reinforce positive back pain beliefs, functional restoration, and a healthy lifestyle hold promise to reduce the disability burden of this disorder.”
Key Finding #2
“A systematic review on physical therapy treatments for LBP in children and adolescents concluded that only 8 studies of limited quality had been conducted. Interventions in these trials consisted of education, exercise, or manual therapy, or a combination of the 3. Meta-analysis showed a positive effect for these interventions over control interventions, although the low number of studies and methodological limitations prevent definitive conclusions from being made.”
Please provide your summary of the paper
The overarching conclusion of this study was that a multidimensional approach consisting of the Cognitive Functional Approach alongside manual therapy techniques, exercise, education, etc for teens and adolescents with low back pain. Teens and adolescents are the most susceptible to back pain and issues due to environmental factors. The authors want to use the Cognitive Functional Approach to explore areas such as “Levels of disability and pain responses to functional activities, Avoidant coping behaviors, such as taking time off school or avoiding physical activity and activities of daily living, Back pain beliefs and fear of movement and activity, Levels of psychological and social distress, Lifestyle behaviors, such as sleep patterns and activity levels, Red flags, specific pathology, and comorbid health conditions.” The authors of this study recommend the use of multidimensional screening questionnaires to facilitate this process. This approach “combined with specific targeting of certain negative functional and lifestyle behavioral responses to low back pain” will hopefully reach the goal of the study. The hope is that with this approach, there is a shift in the perception of low back pain.
During this study, they found modifiable factors for the interview and examination components of the examination process. This includes 3 broad areas: Education, Functional Restoration, and Healthy Lifestyle. Under the Education component, using Reflective Questioning and Experimental Learning to “reinforce positive back pain beliefs” is the central component. For Functional Restoration, the overarching goal is to gradually engage in activities that usually cause pain by employing graduating conditioning and other techniques to build confidence. Lastly, a Healthy Lifestyle is always a good way to look at the health of the body globally. In this context, it will be used to build self-management strategies. The authors of this study want to modify these factors to provide multidimensional care to teens and adolescents with low back pain.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
The use of this approach would only benefit teens and adolescents dealing with low back pain. It would allow clinicians to view all aspects of the patient’s life to effectively manage their care. I also believe that, as stated in the literature, a strong therapeutic approach is needed so that patients learn to move effectively and combat negative perceptions of low back pain. The authors want to use questionnaires to facilitate a Cognitive Functional Approach to low back pain. The implementation of the use of these questionnaires would require the least amount of effort on staff and be cost-effective for clinics.
