Research Review By Dr. Brynne Stainsby©


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Date Posted:

April 2019

Study Title:

The association between psychological and social factors and spinal pain in adolescents


Batley S, Aartun E, Boyle E, Hartvigsen J. Stern PJ, Hestbæk L.

Author's Affiliations:

Department of Graduate Studies, Canadian Memorial Chiropractic College (CMCC), Toronto, Canada; UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation University of Ontario Institute of Technology (UOIT), Oshawa, Canada; Institute of Health and Society, University of Oslo, Forskningsveien, Norway; Sport Sciences and Clinical Biomechanics, Clinical Biomechanics, University of Southern Denmark; Dalla Lana School of Public Health, Toronto, Canada; Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark.

Publication Information:

European Journal of Pediatrics 2019; 178(3): 275-286. doi: 10.1007/s00431-018-3291-y.

Background Information:

Spinal pain is a global health concern that begins early in life and may contribute significantly to years lived with disability (1). With lifetime prevalence as high as 86%, spinal pain may begin in early in life and increase in prevalence through adolescence (2-4). A small portion of adolescents experiencing spinal pain have persistent and recurring pain that impacts their activities of daily living and well-being, including absence from school, healthcare-seeking behaviours, and avoidance of sports (2, 5, 6).

While the evidence regarding adults with spinal pain demonstrates a link between spinal pain and psychosocial factors, few studies have examined this link in an adolescent population (7-13). It appears that adolescents with spinal pain have higher levels of stress, depression, negative behaviors, emotional problems, poorer well-being and higher levels of peer problems (10-13).

Given the strong association between spinal pain in adolescence and adulthood (14, 15), the primary objective of this study was to determine if psychological and social factors are associated with spinal pain in a cohort of Danish adolescents.

Pertinent Results:

Study Participants:
  • A total of 1348 students were invited to participate in the study and 1279 (94.9%) completed the study. Nineteen students did not assent to participate, 12 students were too old at the time of data collection and 38 were absent from school on the day of data collection.
  • The average age of participants was 12.6 (SD = 0.61) and 660 (51.6%) were male.
  • There were 378 participants missing socioeconomic status (SES) data who were excluded from the adjusted, multivariate analysis. At baseline, these participants had higher frequencies of low mood, nervousness and loneliness, and lower levels of pupil acceptance than the cohort included in the study.
Prevalence of Spinal Pain:
  • The lifetime prevalence of “any spinal pain” was 86.2% (95% CI: 84.2 – 88.0) while “substantial spinal pain” was reported by 28.3% (95% CI: 25.9 – 30.8). Girls reported a significantly higher prevalence of both types of spinal pain.
  • Neck pain was the most prevalent, followed by mid-back and low back pain.
  • The mean intensity of “any spinal pain” was highest in the neck (1.5, 95% CI: 1.5–1.6), followed by the mid-back (1.5, 95% CI: 1.4–1.6) and low back (1.3, 95% CI: 1.2–1.4). The mean intensity of “substantial spinal pain” was highest in the low back (3.2, 95% CI: 3.0–3.4), followed by the mid-back (2.9, 95% CI: 2.8–3.1) and the neck (2.9, 95% CI: 2.8–3.1).
Prevalence of Psychological Factors:
  • Girls consistently reported higher prevalence of feeling low, feeling irritable/bad mood, feeling nervous or having difficulties sleeping, and this was statistically significant for each variable.
  • The prevalence of participants that reported “almost every week” they were feeling low was 17.7% (95% CI: 15.7–19.9), feeling irritable/bad mood was 25.2% (95% CI: 22.8–27.6), feeling nervous was 18.4% (95% CI: 16.3–20.6), or had difficulties sleeping was 34.3% (95% CI: 31.7–36.9). The prevalence of participants that reported they had ever been feeling low was 39.5% (95% CI: 36.8–42.2), feeling irritable/bad mood was 54.7% (95% CI: 51.9–57.4), feeling nervous was 45.6% (95% CI: 42.8–48.3), or had difficulties sleeping was 54.1% (51.4–56.8).
  • Participants with “any spinal pain” or “substantial spinal pain” reported significantly higher frequency of all psychological variables than those with no spinal pain.
Prevalence of Social Factors:
  • The prevalence of participants that reported feeling lonely at least “sometimes” was 26.3% (95% CI: 23.9 – 28.8). Only 2.9% (95% CI: 2.1–4.0) and 1.5% (95% CI: 0.9–2.3) reported feeling lonely “often” or “very often”, respectively.
  • When asked whether “other pupils accept me as I am?”, 82.5% (95% CI: 80.3 – 84.5) of participants “agreed” or “strongly agreed”, whereas only 3.8% (95% CI: 2.8 – 4.9) “disagreed” or “strongly disagreed” that other pupils were accepting of them.
  • Similar to psychological factors, girls consistently reported a higher prevalence of loneliness and lower levels of pupil acceptance. However, none of these differences were statistically significant.
  • Due to small cell sizes, the response categories for social factors were collapsed for the descriptive analysis. Participants with “any spinal pain” or “substantial spinal pain” reported a significantly higher frequency of loneliness and lower levels of pupil acceptance compared to those with no lifetime spinal pain.
  • Increasing odds ratios (ORs) for reporting spinal pain were seen with an increased frequency for each psychological factor. Difficulties with sleep were related to “any spinal pain” in girls, and bad mood, nervousness, and sleep difficulties were related to “any spinal pain” in boys. Odds ratios were statistically significant for all psychological factors in both girls and boys with “substantial spinal pain”.
  • Increasing ORs were seen for loneliness and pupil acceptance in those with “any spinal pain” in both girls and boys (these OR were not significant except for loneliness “sometimes” in both sexes). Increasing ORs were also seen with “substantial spinal pain”, however they were significant in this population.
  • The OR of reporting spinal pain increased with an increase in the composite psychological score for both spine pain outcomes. All ORs were significant except for girls with “substantial spinal pain” with a composite psychological score of 1–4.
  • For the combined logistic regression analysis of social variables and spinal pain, the OR for loneliness and pupil acceptance remained significant in girls with “substantial spinal pain”, while the OR for reporting loneliness “sometimes” was significant for both spinal pain outcomes in girls and boys, as was reporting loneliness “often/very often” in girls with “substantial spinal pain”.

Clinical Application & Conclusions:

This study demonstrates the importance of understanding psychological and social factors in adolescents with spinal pain and also highlights the high prevalence of these factors among the adolescents in this study cohort. Participants reporting spinal pain reported significantly higher frequencies of the four psychological factors measured, reporting multiple psychological factors more frequently as well. This data is in line with other studies of adolescents, which have reported that stress, poorer well-being, depressive symptoms and “negative behaviors” may be associated with increased reports of spinal pain (10-13, 16). It is also important to note that participants reporting spinal pain also reported significantly higher levels of loneliness and lower levels of acceptance by peers than those without spinal pain. When both psychological and social factors were included in the same analysis, the estimates were reduced, indicating that they are likely interdependent.

This study reflects the importance of inquiring and addressing psychosocial factors in young patients with spinal pain, and when appropriate, referring for management of these concerns. As depression, stress, anxiety, sleeping difficulties, and loneliness can all result in negative health-related consequences, it is important to understand these factors, and recognize they may be associated with the development and perpetuation of spinal pain in adolescents. Although the direction of association or causation cannot be determined by a cross-sectional study like this one, a better understanding of these factors may lead to better preventive measures, as well as more comprehensive intervention strategies in adolescents with spinal pain.

Study Methods:

  • This was a cross-sectional, secondary analysis of baseline data collected in connection with the School site, Play spot, Active transport, Club fitness, and Environment (SPACE) study (17).
  • Data was collected in May and June 2010 from 14 schools in the Region of Southern Denmark to test the effect of optimizing the physical environment around schools.
  • Students, aged 11-13, completed a baseline survey about spinal pain, psychological and physical factors under the supervision of a teacher during school time.
  • The Young Spine Questionnaire (YSQ) was a component of the SPACE study (17) and was used to assess lifetime occurrence of spinal pain. Participants were asked: “Have you ever experienced pain in your [neck, mid-back and low back] (each region was assessed separately), and asked to respond with “often”, “sometimes”, “once or twice”, or “never”. For those who reported pain, they were asked to assess their worst pain with the revised Faces Pain Scale (rFPS) (18).
  • The three regions were collapsed to one category to indicate spinal pain in any region, as a previous study indicated a high level of overlap among the three spinal regions (2).
  • Responses were categorized as “any spinal pain” (frequency above never) or “substantial spinal pain” (“sometimes” or “often” with a pain intensity of at least 2).
  • Data regarding psychological and social factors was collected using the Health Behaviour in School-Aged Children: World Health Organization Collaboration Cross-National Survey (HBSC) (19).
  • Age, socioeconomic status (SES), smoking and alcohol were identified as covariates, and data regarding these covariates was collected as well.
  • Descriptive statistics were used to present results as frequencies and percentages. Logistic regression models were constructed to determine the association between psychological and social variables and spinal pain. The models were adjusted for age and SES, however, smoking and drinking alcohol were not included due to the small percentage of adolescents partaking in these behaviours. Regression analyses were stratified by sex. Adjusted odds ratios with 95% confidence intervals were reported.
  • The psychological variables loaded onto the same factor during exploratory factor analysis, and thus a composite score was developed. As there was not a linear relationship between psychological score and the spinal pain outcomes, the psychological scores were categorised into: (1) no psychological complaints (score of 0), (2) low composite psychological score (value of 1-4), and (3) high composite psychological score (value of 5-16). A one-factor solution for social variables could not be found.
  • Statistical significance was set at p < 0.05 for all analyses.

Study Strengths / Weaknesses:

  • This study had a high rate of participation (94.9%).
  • The included population is representative of the Danish adolescent population, which increases the generalizability of the study.
  • The outcome measures used were specific to the age of the population, and have demonstrated good psychometric properties.
  • This study assessed both the presence and severity of spinal pain.
  • The methodology of the study allowed for comment on the association between the severity of spinal pain and the frequency of psychological and social factors.
  • The primary limitation of this study relates to its cross-sectional design. Although associations can be determined, the directionality of the association cannot be.
  • The 95% CI for many of the reported associations are quite wide, and thus require interpretation with caution.
  • A crucial consideration is that those participants without SES data were excluded from the study, however it is important to recall that those participants reported significantly higher frequencies of low mood, nervousness, loneliness, and pupil acceptance at baseline, and it is possible their exclusion may have resulted in an underestimation of the reported ORs.

Additional References:

  1. Vos T, Allen C, Arora M et al. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the global burden of disease study 2015. Lancet 2016; 388(10053): 1545–1602.
  2. Aartun E, Hartvigsen J, Wedderkopp N et al. Spinal pain in adolescents: prevalence, incidence, and course: a school-based two-year prospective cohort study in 1,300 Danes aged 11-13. BMC Musculoskelet Disord 2014; 15:187.
  3. Calvo-Munoz I, Gomez-Conesa A, Sanchez-Meca J. Prevalence of low back pain in children and adolescents: a meta-analysis. BMC Pediatr 2013; 13:14.
  4. Dunn KM, Hestbaek L, Cassidy JD (2013) Low back pain across the life course. Best Pract Res Clin Rheumatol 2013; 27(5): 591–600.
  5. Jones MA, Stratton G, Reilly T et al. A school-based survey of recurrent non-specific low-back pain prevalence and consequences in children. Health Educ Res 2004; 19(3): 284–289.
  6. Kjaer P, Wedderkopp N, Korsholm L, et al. Prevalence and tracking of back pain from childhood to adolescence. BMC Musculoskeletal Disord 2011; 12(98): 1–11.
  7. Hemingway H, Shipley M, Standfield Set al. (1997) Sickness absence from back pain, psychosocial work characteristics and employment grade among office worker. Scand J Work Environ Healt 1997; 23:8.
  8. Linton SJ. A review of psychological risk factors in back and neck pain. Spine 2000; 25(9): 9.
  9. Mustard CA, Kalcevich C, Frank JW et al. Childhood and early adult predictors of risk of incident back pain: Ontario child health study 2001 follow-up. Am J Epidemiol 2005; 162(8): 779–786.
  10. Diepenmaat AC, van der Wal MF, de Vet HC et al. Neck/shoulder, low back, and arm pain in relation to computer use, physical activity, stress, and depression among Dutch adolescents. Pediatrics 2006; 117(2): 412–416.
  11. Murphy S, Buckle P, Stubbs D. A cross-sectional study of self-reported back and neck pain among English schoolchildren and associated physical and psychological risk factors. Appl Ergon 2007; 38(6): 797–804
  12. Watson K, Papageorgiou A, Jones G et al. (2003) Low back pain in school children - the role of mechanical and psychosocial factors. Arch Dis Child 2003; 88: 6.
  13. Harreby M, Neergaard K, Hesselsoe G et al. Are radiological changes in the thoracic spine and lumbar spine of adolescents risk factors for low back pain in adults? A 25-year prospective cohort of 640 school children. Spine 1995; 20(21): 2298–2302.
  14. Hestbaek L, Leboeuf-Yde C, Kyvik KO et al. The course of low back pain from adolescence to adulthood - eight-year follow-up of 9600 twins. Spine 2006; 31(4): 5.
  15. Stallknecht SE, Strandberg-Larsen K, Hestbaek L et al. (2017) Spinal pain and co-occurrence with stress and general wellbeing among young adolescents: a study within the Danish National Birth Cohort. Eur J Pediatr 2017; 176(6): 807–814.
  16. Jones GT, Watson KD, Silman AJ et al. Predictors of low back pain in British schoolchildren: a population-based prospective cohort study. Pediatrics 2003; 111(4): 8.
  17. Toftager M, Christiansen LB, Kristensen PL et al. SPACE for physical activity - amulticomponent intervention study: study design and baseline findings from a cluster randomized controlled trial. BMC Public Health 2011; 11(777): 11.
  18. Hicks CL, von Baeyer CL, Spafford PA et al. The faces pain scale–revised - toward a common metric in pediatric pain measurement. Pain 2001; 93(2): 11.
  19. Roberts C, Freeman J, International HSG et al. (2009) The health behaviour in school-aged children (HBSC) study: methodological developments and current tensions. Int J Public Health 2009; 54(Suppl 2): 140–150.