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

Spinal pain, back pain, and/or neck pain begins early in life and is strongly associated with spinal pain in adulthood. Understanding the relationship between psychological and social factors and adolescent spinal pain may be important in both the prevention and treatment of spinal pain in this age group. We aimed to determine if psychological and social factors were associated with spinal pain in a cross-sectional study of a school-based cohort of 1279 Danish adolescents aged 11-13, who were categorized into "any" and "substantial" spinal pain. "Substantial spinal pain" was defined as a lifetime frequency of "sometimes" or "often" and a pain intensity of at least two on the revised Faces Pain Scale. Logistic regression analyses, stratified by sex, were conducted for single and all variables together. Eighty-six percent of participants reported "any spinal pain" and 28% reported "substantial spinal pain". Frequency of psychological and social factors was significantly higher in those with spinal pain compared to those without. As the frequency of psychological and social factors increased, the odds of both "any spinal pain" and "substantial spinal pain" also increased.Conclusion: Psychological and social factors may be important determinants in adolescent spinal pain. What is Known: • Spinal pain begins early in life to reach adult levels by age 18. Spinal pain in adolescence is strongly associated with spinal pain in adulthood. • In adults, psychological and social factors and spinal pain are strongly related; however, this relationship in adolescence is poorly understood. What is New: • Adolescents with spinal pain reported a significantly higher frequency of psychological factors and loneliness and lower levels of pupil acceptance. • Adolescents reporting higher levels of loneliness, lower levels of pupil acceptance, and increased frequency of psychological factors had increased odds of reporting "substantial spinal pain".

The Global Spine Care Initiative: classification system for spine-related concerns.

PURPOSE: The purpose of this report is to describe the development of a classification system that would apply to anyone with a spine-related concern and that can be used in an evidence-based spine care pathway. METHODS: Existing classification systems for spinal disorders were assembled. A seed document was developed through round-table discussions followed by a modified Delphi process. International and interprofessional clinicians and scientists with expertise in spine-related conditions were invited to participate. RESULTS: Thirty-six experts from 15 countries participated. After the second round, there was 95% agreement of the proposed classification system. The six major classifications included: no or minimal symptoms (class 0); mild symptoms (i.e., neck or back pain) but no interference with activities (class I); moderate or severe symptoms with interference of activities (class II); spine-related neurological signs or symptoms (class III); severe bony spine deformity, trauma or pathology (class IV); and spine-related symptoms or destructive lesions associated with systemic pathology (class V). Subclasses for each major class included chronicity and severity when different interventions were anticipated or recommended. CONCLUSIONS: An international and interprofessional group developed a comprehensive classification system for all potential presentations of people who may seek care or advice at a spine care program. This classification can be used in the development of a spine care pathway, in clinical practice, and for research purposes. This classification needs to be tested for validity, reliability, and consistency among clinicians from different specialties and in different communities and cultures. These slides can be retrieved under Electronic Supplementary Material.

The Global Spine Care Initiative: model of care and implementation.

PURPOSE: Spine-related disorders are a leading cause of global disability and are a burden on society and to public health. Currently, there is no comprehensive, evidence-based model of care for spine-related disorders, which includes back and neck pain, deformity, spine injury, neurological conditions, spinal diseases, and pathology, that could be applied in global health care settings. The purposes of this paper are to propose: (1) principles to transform the delivery of spine care; (2) an evidence-based model that could be applied globally; and (3) implementation suggestions. METHODS: The Global Spine Care Initiative (GSCI) meetings and literature reviews were synthesized into a seed document and distributed to spine care experts. After three rounds of a modified Delphi process, all participants reached consensus on the final model of care and implementation steps. RESULTS: Sixty-six experts representing 24 countries participated. The GSCI model of care has eight core principles: person-centered, people-centered, biopsychosocial, proactive, evidence-based, integrative, collaborative, and self-sustaining. The model of care includes a classification system and care pathway, levels of care, and a focus on the patient's journey. The six steps for implementation are initiation and preparation; assessment of the current situation; planning and designing solutions; implementation; assessment and evaluation of program; and sustain program and scale up. CONCLUSION: The GSCI proposes an evidence-based, practical, sustainable, and scalable model of care representing eight core principles with a six-step implementation plan. The aim of this model is to help transform spine care globally, especially in low- and middle-income countries and underserved communities. These slides can be retrieved under Electronic Supplementary Material.

The Global Spine Care Initiative: methodology, contributors, and disclosures.

PURPOSE: The purpose of this report is to describe the Global Spine Care Initiative (GSCI) contributors, disclosures, and methods for reporting transparency on the development of the recommendations. METHODS: World Spine Care convened the GSCI to develop an evidence-based, practical, and sustainable healthcare model for spinal care. The initiative aims to improve the management, prevention, and public health for spine-related disorders worldwide; thus, global representation was essential. A series of meetings established the initiative's mission and goals. Electronic surveys collected contributorship and demographic information, and experiences with spinal conditions to better understand perceptions and potential biases that were contributing to the model of care. RESULTS: Sixty-eight clinicians and scientists participated in the deliberations and are authors of one or more of the GSCI articles. Of these experts, 57 reported providing spine care in 34 countries, (i.e., low-, middle-, and high-income countries, as well as underserved communities in high-income countries.) The majority reported personally experiencing or having a close family member with one or more spinal concerns including: spine-related trauma or injury, spinal problems that required emergency or surgical intervention, spinal pain referred from non-spine sources, spinal deformity, spinal pathology or disease, neurological problems, and/or mild, moderate, or severe back or neck pain. There were no substantial reported conflicts of interest. CONCLUSION: The GSCI participants have broad professional experience and wide international distribution with no discipline dominating the deliberations. The GSCI believes this set of papers has the potential to inform and improve spine care globally. These slides can be retrieved under Electronic Supplementary Material.

The Global Spine Care Initiative: World Spine Care executive summary on reducing spine-related disability in low- and middle-income communities.

PURPOSE: Spinal disorders, including back and neck pain, are major causes of disability, economic hardship, and morbidity, especially in underserved communities and low- and middle-income countries. Currently, there is no model of care to address this issue. This paper provides an overview of the papers from the Global Spine Care Initiative (GSCI), which was convened to develop an evidence-based, practical, and sustainable, spinal healthcare model for communities around the world with various levels of resources. METHODS: Leading spine clinicians and scientists around the world were invited to participate. The interprofessional, international team consisted of 68 members from 24 countries, representing most disciplines that study or care for patients with spinal symptoms, including family physicians, spine surgeons, rheumatologists, chiropractors, physical therapists, epidemiologists, research methodologists, and other stakeholders. RESULTS: Literature reviews on the burden of spinal disorders and six categories of evidence-based interventions for spinal disorders (assessment, public health, psychosocial, noninvasive, invasive, and the management of osteoporosis) were completed. In addition, participants developed a stratification system for surgical intervention, a classification system for spinal disorders, an evidence-based care pathway, and lists of resources and recommendations to implement the GSCI model of care. CONCLUSION: The GSCI proposes an evidence-based model that is consistent with recent calls for action to reduce the global burden of spinal disorders. The model requires testing to determine feasibility. If it proves to be implementable, this model holds great promise to reduce the tremendous global burden of spinal disorders. These slides can be retrieved under Electronic Supplementary Material.

Validity of Commonly Used Clinical Tests to Diagnose and Screen for Spinal Pain in Adolescents: A School-Based Cohort Study in 1300 Danes Aged 11-15 Years.

OBJECTIVE: The overall aim of this study was to determine the ability of 2 selected clinical tests to detect or predict neck pain, mid back pain, and low back pain in a school-based cohort of Danish 11- to 15-year-olds. METHODS: A school-based 2-year prospective cohort study was conducted. Data were collected at the age of 11 to 13 (n = 1224) and 2 years later (n = 963). Spinal pain (neck pain, mid back pain, and low back pain) was assessed by an electronic survey completed during school time, and reference standard was defined as both lifetime prevalence and frequent pain as a proxy of severity. The tests included assessments of scoliosis, hypermobility, global mobility, intersegmental mobility, end range pain, and isometric endurance of back extensors. Sensitivity, specificity, negative and positive predictive values, and odds ratios were calculated for each test individually, and area under the receiver operating characteristic curve was calculated for evaluation of all tests combined. RESULTS: The sensitivity was low, and specificity was high for all tests at both baseline (age, 11-13 years) and follow-up (age, 13-15 years). When all tests were evaluated collectively in 1 model, the area under the receiver operating characteristic curve ranged from 0.60 to 0.65. None of the selected tests could predict incidence cases of neck pain, mid back pain, or low back pain. CONCLUSION: Clinical tests commonly used in spinal screening in adolescents could not detect present spinal pain or predict future spinal pain. However, some statistically significant associations between spinal pain and tests involving a pain response from the participant were found.

Spinal pain in adolescents: prevalence, incidence, and course: a school-based two-year prospective cohort study in 1,300 Danes aged 11-13.

BACKGROUND: The severity and course of spinal pain is poorly understood in adolescents. The study aimed to determine the prevalence and two-year incidence, as well as the course, frequency, and intensity of pain in the neck, mid back, and low back (spinal pain). METHODS: This study was a school-based prospective cohort study. All 5th and 6th grade students (11-13 years) at 14 schools in the Region of Southern Denmark were invited to participate (N=1,348). Data were collected in 2010 and again two years later, using an e-survey completed during school time. RESULTS: The lifetime prevalence of spinal pain was 86% and 89% at baseline and follow-up, respectively. A group of 13.6% (95% CI: 11.8, 15.6) at baseline and 19.5% (95% CI: 17.1, 22.0) at follow-up reported that they had pain frequently. The frequency of pain was strongly associated with the intensity of pain, i.e., the majority of the participants reported their pain as relatively infrequent and of low intensity, whereas the participants with frequent pain also experienced pain of higher intensity. The two-year incidence of spinal pain varied between 40% and 60% across the physical locations. Progression of pain from one to more locations and from infrequent to more frequent was common over the two-year period. CONCLUSIONS: Spinal pain is common at the age of 11-15 years, but some have more pain than others. The pain is likely to progress, i.e., to more locations, higher frequency, and higher pain intensity over a two-year period.

Screening of the spine in adolescents: inter- and intra-rater reliability and measurement error of commonly used clinical tests.

BACKGROUND: Evidence on the reliability of clinical tests used for the spinal screening of children and adolescents is currently lacking. The aim of this study was to determine the inter- and intra-rater reliability and measurement error of clinical tests commonly used when screening young spines. METHODS: Two experienced chiropractors independently assessed 111 adolescents aged 12-14 years who were recruited from a primary school in Denmark. A standardised examination protocol was used to test inter-rater reliability including tests for scoliosis, hypermobility, general mobility, inter-segmental mobility and end range pain in the spine. Seventy-five of the 111 subjects were re-examined after one to four hours to test intra-rater reliability. Percentage agreement and Cohen's Kappa were calculated for binary variables, and interclass correlation (ICC) and Bland-Altman plots with Limits of Agreement (LoA) were calculated for continuous measures. RESULTS: Inter-rater percentage agreement for binary data ranged from 59.5% to 100%. Kappa ranged from 0.06-1.00. Kappa ≥ 0.40 was seen for elbow, thumb, fifth finger and trunk/hip flexion hypermobility, pain response in inter-segmental mobility and end range pain in lumbar flexion and extension. For continuous data, ICCs ranged from 0.40-0.95. Only forward flexion as measured by finger-to-floor distance reached an acceptable ICC(≥ 0.75). Overall, results for intra-rater reliability were better than for inter-rater reliability but for both components, the LoA were quite wide compared with the range of assessments. CONCLUSION: Some clinical tests showed good, and some tests poor, reliability when applied in a spinal screening of adolescents. The results could probably be improved by additional training and further test standardization. This is the first step in evaluating the value of these tests for the spinal screening of adolescents. Future research should determine the association between these tests and current and/or future neck and back pain.

Spinal pain increases the risk of becoming overweight in Danish schoolchildren.

Spinal pain is common in adolescence, and overweight in children and adolescence is an increasing public health problem globally. Since musculoskeletal pain is a known barrier for physical activity which potentially can lead to overweight, the primary objective of this study was to determine if self-reported lifetime spinal pain in 2010 was associated with being overweight or obese in 2012 in a cohort of 1080 normal-weighted Danish children, aged 11-13 years at baseline. Overweight was based on body mass index measured by trained staff. Spinal pain was self-reported by questionnaires during school hours. Estimates were adjusted for relevant covariates. The 2-year incidence rate of overweight was 5.3% (95% CI 3.98-7.58) for children with spinal pain at baseline versus 1.6% (95% CI 0.19-5.45) for children without. There was stepwise and statistically significant increased risk of overweight with increasing frequency of pain and for having pain in more than one part of the spine. Despite the short follow-up time where only 40 children developed overweight, these results indicate that spinal pain might increase the risk of subsequent overweight.

Contextualizing the lived experiences of patients with low back pain from different countries according to the ICF framework.

OBJECTIVE: To explore perspectives, including social and psychological aspects, of patients seeking manual care for low back pain, in order to understand constructs of functioning that are important across different cultural contexts. The International Classification of Functioning, Disability and Health (ICF) emphasizes the importance of these aspects to describe health-related functioning. DESIGN: Focus group interviews. PATIENTS: Patients from Botswana, Canada and Norway seeking manual care for their low back pain. METHODS: Interviews were conducted in the 3 countries, transcribed verbatim, translated into English, and linked to the ICF according to established rules. RESULTS: Seven focus groups yielded 1,863 meaningful concepts that were linked to ICF categories. The largest proportion of responses linked to the Activities and Participation domain. The most frequently mentioned chapters related to pain and its mental aspects, suggesting that the psychological impact of living with low back pain is important to patients. CONCLUSION: Despite cultural differences, patients seeking manual care for low back pain in Botswana, Canada and Norway reported similar experiences of disability across ICF domains. The relatively high ranking of psychosocial factors highlights their importance for patients, in addition to factors of biological origin, and indicates that the contextual nature of the lived experience of low back pain may not be covered in standard examinations used in manual medicine.

"I stay in bed, sometimes all day." A qualitative study exploring lived experiences of persons with disabling low back pain.

AIM: To explore the lived experiences of persons with low back pain (LBP) and disability within the context of the International Classification of Function, Disability and Health (ICF) framework. METHODS: Qualitative study using focus group methodology. We stratified LBP patients into two low (n=9) and one high disability (n=3) groups. Transcript-based thematic analysis was conducted through an interpretivist lens. RESULTS: Four themes emerged: Invisibility, Ambivalence, Social isolation, and Stigmatization and marginalization. Participants described how environmental factors affected how they experienced disability and how their awareness of people's attitudes affected personal factors and participation in social activities. High disability participants experienced challenges with self-care, employment, and activities. The invisibility of LBP and status loss contributed to depressive symptoms. CONCLUSION: LBP patients experience physical, social, economic and emotional disability. Our findings highlight the interaction between domains of the ICF framework and the importance of considering these perspectives when managing LBP patients with varying levels of disability.

OBJECTIF: Étudier les expériences vécues par les personnes souffrant de lombalgies et de handicaps dans le cadre de la Classification internationale du fonctionnement, du handicap et de la santé (CIF). MÉTHODOLOGIE: Étude qualitative utilisant des groupes de discussion comme méthodologie. Des patients souffrant de lombalgies ont été répartis en deux groupes : l'un Déficit léger (n = 9) et l'autre Déficit grave (n = 3). Une analyse thématique fondée sur des notes a été effectuée selon un point de vue interprétatif. RÉSULTATS: Quatre thèmes ont été dégagés : invisibilité, ambivalence, isolement social, stigmatisation et marginalisation. Les participants ont expliqué de quelle façon les facteurs environnementaux se répercutaient sur leur façon de vivre avec le handicap et comment leur conscience des attitudes des gens se répercutaient sur les facteurs personnels et la participation aux activités sociales. Les participants souffrant d'un grave handicap éprouvaient des difficultés en ce qui a trait aux soins personnels, à l'emploi et aux activités. L'invisibilité de la lombalgie et la perte du statut contribuaient aux symptômes dépressifs. CONCLUSION: Les patients souffrant de lombalgies ont un handicap physique, social, économique et émotionnel. Les résultats de notre étude mettent en évidence l'interaction entre les domaines du cadre de la CIF et soulignent l'importance de prendre en compte ces perspectives dans la prise en charge des patients souffrant de lombalgies causant divers degrés d'incapacité.

The most physically active Danish adolescents are at increased risk for developing spinal pain: a two-year prospective cohort study.

BACKGROUND: The overall aim of this study was to determine to what extent objectively measured physical activity in a school-based sample aged 11-13 years predicted incident cases of spinal pain (neck pain, mid back pain or low back pain) over the following 2 years. METHODS: Data were collected at baseline (2010) and 2 years later in a school-based prospective cohort study. Spinal pain was assessed via an e-survey that the participants completed during school time. Participants who, at baseline, reported never having had spinal pain were included in the study. An incident case of spinal pain was defined as a report of pain in at least one spinal area at follow-up. Physical activity was measured objectively using the Actigraph GT3X Triaxial Activity Monitor for 1 week. RESULTS: Objectively measured sedentary activity, moderate-to-vigorous physical activity and vigorous physical activity were generally not predictive of the 2-year incidence of spinal pain. However, 10% of participants with the highest proportion of the day spent in vigorous physical activity were at increased risk of reporting spinal pain at follow-up with a relative risk (RR) of 1.44 (95% CI 1.09 to 1.91). For the overall physical activity, the RR was 1.03 (95% CI 1.01 to 1.05) for reporting spinal pain at follow-up. CONCLUSIONS: In general, physical activity did not affect the risk of spinal pain during follow-up, but the 10% most active adolescents were at increased risk of developing spinal pain. Thus, vigorous physical activity appears to be a risk factor for spinal pain in adolescents.