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Welcome to Your Child's Health University lecture this
evening. I'm Nancy Sanchez and it's my great pleasure this
evening to introduce to you Dr. Meghan Imrie, who is an
Assistant Clinical Professor of Pediatric Orthopedic Surgery
for Stanford School of Medicine and Lucile Packard Children'
s
Hospital. Dr. Imrie is a graduate of Yale University and
the University of California San Diego School of Medicine.
And she did her residency at Stanford wherein she received
the Resident Research Award. Her many interests in research
areas include scoliosis, fractures and other common
pediatric orthopedic issues. Now tonight Dr. Imrie will
address the prevalence of back issues in children. Many of
us, myself included often presume that adults are the people
who are most plagued with back issues. But in fact
Dr. Imrie is here to tell us about when children have
back issues, about a variety of diagnoses and treatments for
back issues. We want you to know that this presentation is
being taped. There will be a question and answer period
afterwards that will not be taped. And it will be available
for you to view on the Packard Children's website, within a
couple of months. So, thank you Dr. Imrie for giving us
your time and welcome. Thank you guys so much and
thank you for the nice introduction. So tonight I'll be
speaking on back pain and back problems in children. Which
are not as rare as we once thought. I have sort of a minimum
number of slides so that we could do things that are a
little bit more interactive. But we'll just go ahead and
proceed and stop me if you have any questions. We always
talk about disclosures in orthopedic surgery. My only
disclosure is that I tend to talk fast so I'll do my
best to slow it down. So tonight we'll go over sort of the
scope of the issues, possible diagnoses and treatments. I
think there is a lot of concern among parents and schools
about back pain and the association with backpacks. So we'll
touch on that briefly and then we'll talk a little bit
about what few preventative measures there
are. Alright, so starting with the scope of the problem,
back pain in kids, which I'll define as people less then
eighteen years old, is much more common then we previously
thought. So our traditional teaching in orthopedic surgery
and still in some of our textbooks today says that kids don'
t
get back pain. If you have a child who is complaining of
back pain there must be something seriously wrong with them
like a tumor or an infection or something along those lines
for them to be manifesting pain. But it turns out that
that's not really the case anymore. There have been a
myriad of studies done in the literature demonstrating this
with prevalence rates of back pain in patients less then
eighteen years old ranging anywhere from about 36% to
upwards of 80%. And again in the past we used to think that
there was a very identifiable cause for back pain in a
child, that if your child had a pain in their back that
there
was a diagnosis that we could find, address and treat. And
that also is no longer the case. So specific cause is only
found about twenty percent of the time. And the majority of
the time unfortunately we don't know exactly what causes
back pain, just like in adults most of the time we really
don't know what causes back pain. We do know that the
frequency of back pain increases with increasing age. So
again there have been many studies looking at this. I quoted
a few of them here which is for seven year olds the rate is
one %, six % for ten year olds, eighteen percent for
fourteen
year olds. Another study said eleven % at eleven and fifty
% at fifteen. I like that one just cause it's easy to
remember, easy to quote. And then another that said five %
at age six, and 84% at age sixteen. And the numbers don't
necessarily matter as much as just the general trend that
there's
an increase in frequency that the older patients get. And
the differing rates depend a little bit on how the study is
done, how the question is asked, how the patients are
evaluated, that sort of thing. So that's really where that
range comes from. As opposed to adults many children don't
seek medical evaluation for their back pain. So in adults
it's the second leading reason for a visit to a doctor's
office. I was actually talking with a patient's parent
today mentioning that I was going to be giving this lecture.
He's actually a physician. And he said that every Ford
car, fifteen hundred dollars of the price of the car goes
towards health care for the worker and of that fifteen
hundred dollars, five hundred is for back pain itself. So
it's a huge issue in adults, a huge presentation to our
medical resources but in children not as much. Fewer
children seek medical evaluation. In addition many children
forget that they ever had an episode of back pain. So it
doesn't necessarily have those lasting effects that it may
in an adult. And finally there's, for most patients, no
negative impact on the quality of life questionnaire. So
we come up with these questionnaires that we give to
patients to try to figure out how the condition that they
are being treated for affects their quality of life And we
try to validate these questionnaires and make sure we are
asking the right questions in the right ways. And there have
been studies that show that unless the back pain is kind of
associated
with whole body pain, that there's no real difference in the
average quality of life of patients with back pain as
opposed to those that don't. This is within the adolescent
population. So the question is why are we seeing this
increase in back pain and I think that we don't really know
the answer but there are a few things that are interesting
at least to think about. So one is the increased rate of
obesity. So we all know that our country is becoming
increasingly obese both in the adult population and
unfortunately trickling down to our pediatric population as
well. And it's well known that obesity is associated with
increased risks of pain in general both in adults and
children but specifically with back pain. So that may be
one reason. Another may be that we're in the western
hemisphere and specifically in the United States, I'd say
also especially in California are leading more sort of
computer-based, sedentary, "comfortable
lifestyles." And so we tend to be hunched over our
computers,
or hunched over our iPhones or iPads or Smartphones or
tablets --- not to give it a specific brand. So you know, I
sort of say tongue-in-cheek, "Is this "i-back pain?"
Unclear.
Interestingly, there is a study of Mozambican adolescents.
So Mozambique, a country in Africa, where they looked at
children living in the wealthier urban center versus sort of
a
suburban area versus a rural area. And to make their
numbers more powerful they combine the sort of peripheral
kids with the rural kids and compared those to the wealthier
urban center children. And what they found is that
living in the wealthier urban center was associated with a
three fold increased risk of back pain. So, there's
something maybe about being more sedentary. Or being you
know, having your water come out of the tap and have your
food in the grocery stores, that you can spend your time not
necessarily taking care of your absolute most basic needs
but doing other things. And that that may be somehow
associated with an increased rate of back pain. And
interestingly, the wealthier urban center rates in this
study were similar to western industrialized nations. So,
there may be something there. On the other hand, we're sort
of conversely leading a more active lifestyle in a sense,
meaning that and I talked about this in my lecture last
fall, I guess,
has it really been that long? Woah. about
sports and the increased prevalence of specialization in
sports at a younger age. So kids are doing baseball for
school, a travel league, a club league and really playing
the
same sport all year. And that necessarily isn't good for a
growing skeleton. And so if you're doing just the same sport
over and over all year, you are not really giving your back
a break, nor your knees or ankles or whatever specific
muscle is stressed by that particular sport. So then again,
kind of tongue and cheek, "Is this lineback(pain)er?" And
then the
question of backpacks I'll address separately. Then also
the question, is it because we have better access to
health care? So now that more children are thankfully seeing
doctors, are they saying, "Oh you know I'm going to the
doctor and my back kind of hurts, so maybe I'll mention it."
And then it's our onus to figure out why and try to treat
it, etcetera, etcetera. So that may be a reason as well,
that we're seeing an increased rate of back pain. Maybe it's
just increased reporting but it's always been the same
rate. But now we're just asking or patients are telling us
in this venue. So finally it's important to note that back
pain is just common unfortunately, especially in adults.
And that nearly 80% of adults will experience back pain at
some point in their lives. And so it's kind of a rite of
passage. Do you get your driver license? Do you vote? Do
you drink? Do you experience back pain? It's just a part of
becoming an adult. And it's unclear. So moving on, if there
are any questions? Nope? Okay, so let's talk
about that twenty percent of the time when we do find a
diagnosis what that can be. And this will by no means be an
exhaustive list but just some of the key things to touch
on. So like I said that most of the time we can't find a
specific cause, only 22% of the time in our most recent
studies. And there are things that we as doctors pay
attention to and ask when a patient presents with back pain
that we call red flags or things to worry about that make us
think, oh there may be a specific cause and hmm, let me work
this out a little bit further. And those red flags are night
pain. And night pain is defined as pain that wakes a child
up from sleeping. So not that they have an ache in their
back or an ache in their knees and can't quite fall asleep
or needs a little Advil or a little massage or something
to get to sleep. But this is pain that wakes you up
from a deep sleep. And it's the pain that woke you up, not
you woke up because you had to pee and you notice
that you had pain at the same time. Constant pain. So pain
even at rest. You know change in position doesn't
effect it at all. Time of day doesn't effect it at all. It's
just all the time in the same exact spot. That would be
constant pain. Pain in young children. So less than eight
is, if you remember from the scope of the problem that it's
fairly rare to have back pain less than ten. So if you're
less than eight and specifically if they stop playing. So
it's not just back pain when you're going to the grocery
store, running your errands, and all of a sudden children's
backs --- Its like, "Oh, I can't come with you mom, because
my
back hurts." It's, you know, everybody in the neighborhood's
playing, usually they'd be running out, running out kicking
the
soccer ball in the neighborhood but because of their back
they're not participating in those activities. That's a red
flag for us. Of course any constitutional symptoms, we
call them, so any fevers, weight loss, lethargy, change in
their mood or energy level. All of those can be concerning.
And then if there are any associated symptoms. So not just
what they are describing but what you can actually observe.
So is the patient limping? Have they lost bowel or bladder
continence? Can they no longer control their urine or their
stool? And if they're complaining of any radicular symptoms.
So that's pain that radiates into the leg. Either pain of
numbness or tingling or certainly any weakness. So this
isn't, again not an exhaustive list. But these are sort of
the main things that we key into as possible red flags. That
would trigger a more extensive work up. And then it's
important to
know that it's not always the back. That the back pain could
be a red herring of something else, that the pain or the
problem could be elsewhere and just referring pain to the
back. And specifically UTI's is a pretty common one. So your
kidney's are --- sorry for the microphone --- right here, on
each side
of your back. So you know, kids didn't take an anatomy
lesson. When we define back as the spinal column, they don't
necessarily know that. So they might say, oh, their back
hurts, but really they're pointing to their flank and
that's where your kidneys are. And so if you have a
pyelonephritis which
is from a bad UTI, that could present as back pain.
Abdominal
disorders such as appendicitis, pancreatitis can refer to
the back. Ovarian cysts in young girls can sometimes refer
to the back. So you know, it's not always coming from the
back itself. It could be some place else and just referring
there. And your pediatrician can help ask the right
questions in this differential. These things are usually
fairly acute. So it's not that it's been going on for six
months and this is what you have. It's usually within a
couple of days, you know, you're going to be getting worse.
And
so the diagnosis is going to become fairly obvious over
time,
over a short period of time. So
[coughs] excuse me. Some of the things that it can be and
that we all worry about and the things that go bump in the
night are extremely rare but include certain tumors, both
benign, meaning they don't spread anywhere else, they just
stay in their location and cause pain or malignant, where
they spread elsewhere. Benign conditions include that top
picture, actually both of these pictures. The top picture is
an osteoid osteoma. It's a basically normal little bit of
bone, looks like a pebble in your shoe. It's a little bit of
normal bone in otherwise normal bone that's just
inflammatory for some reason and causes night pain
specifically, very easily relieved with non-steroidal anti-
inflammatories and very treatable. We take out the nitis,
that's what that little bone is called, or the pebble in
your
shoe. When we take that out the patient's pain is almost
immediately improved. We can also do fancy things like
ablate it with radio frequency and basically kinda burn it
out. But because this was one thing that would cause that
traditional night pain that wakes a patient from
sleeping. The other picture is what is called an aneurysimal
bone cyst. Its again a
benign condition, where the bone has expands and becomes
cystic almost like a balloon kind of blowing up and that can
present in the back as well. Leukemia again especially in
younger patients less than eight or ten can present as kind
of persistent back pain. And that's worked up very easily
with a CBC or a blood count usually. And then infections
are not super common but also not super rare. So we see
infections not infrequently and they can infect the spine as
well, both the disc space or the space in between the bones
as well as the bones themselves. Tuberculosis has a strong
affinity for the spine. And we don't see it that often in
this country but it's definitely seen very commonly in other
parts of the world where tuberculosis is a little bit more
common. So some more common things when we find the answer,
what is the answer? One of them is spondylolysis. So it's a
nice fancy word that basically means crack through the
spine. So spondy is spine and lysis is crack. This is
basically a stress fracture of a certain part of the back
that we call the pars interarticularis which the picture on
the top left, the black line is where the crack is. So
basically, your spinal column if you think about it, you
have the vertebral bodies in the front that basically
provide the main structure and support of your whole body.
That's in the front, here. And then you have the spinal
canal,
which is this central space. That's where your spinal cord
and your nerve root come through. That is here. And then
these
are the posterior elements, the pedicles and the lamina and
the facet joints. And that's basically like the roof over
your spinal canal that helps protect your spinal cord and
your nerve roots from any bumping in the back. And that's
all connected with ligaments so that you have overall
stability, and you're supported by muscles, etc. So, a
spondylolysis is a stress fracture through one of the
connections
to go from one vertebral body to the other. Basically
through the
lamina we call it. It's almost always in the lumbar spine
or your lower spine. And it's thought to be due from, due to
repetitive micro-trauma from hyperextension. So especially
in athletes who do a lot of arching back, excuse me, like
gymnasts, divers, dancers, linemen in football. You know
they're always bracing up against somebody as they come off
the line. It's not football season, so I'm forgetting
my vocabulary. But they're always kind of being pushed into
hyperextension. So it's very common in them as well. This is
usually low back pain with activity often exacerbated by
that extension because you're really loading that area. And
it
can radiate into the buttocks and legs although it doesn't
always. Now interestingly spondylolysis occurs in three to
six percent of the population, a pretty high number when you
think about it. But only a few of those patients are
actually symptomatic. So not everyone is symptomatic. We
also don't see it in very young children. So it's something
that develops over time. You're not born usually with a
spondylolysis. It happens from whatever activity you're
doing. And then we also don't see it in animals who walk on
all fours. So there's some conditions that we see both in
the human and animal population and this is one that we
don't. So it must be somehow related to walking in an
upright posture. And having that sort of lordosis in the
lumbar
spine or the arching of the lower back. In terms of what we
do about it, the mainstay of treatment is nonoperative. The
pictures here show a CT scan of a patient who had a
unilateral
spondylolysis or it was only on one side of the crack. That'
s
the picture on the top on the left. And then subsequently
they developed a crack on the other side, developed a
bilateral spondylolysis. So that's what those black lines
are
there. Those are the cracks through the bone. So our
treatment is usually most importantly rest from the
exacerbating activity. So it was probably the repetitive
hyperextension that caused it. So the way to hopefully help
it heal is to stop doing the exacerbating activity. That's
very hard for patients, very hard for families. Because
these
are usually pretty active kids who love doing sports, wanna
keep
doing sports. And we tell them that they really have to shut
it
down and for a long time. Cause it takes many many months
usually for this to go away. A lot of times we'll recommend
physical therapy for core strengthening. Occasionally, we'll
recommend bracing just to really help decrease movement
across the area. Or to be honest sometimes if a patient
just really either has a coach or a personality that they
just can't shut it down the brace will shut it down for
them. Sort of an outward manifestation to say, "Listen, I
have
a broken bone in my back. I gotta stop what I'm doing." The
most important thing is probably patience because it does
take a while. And it's important to know, and I always
counsel my patients and their families
to know a lot of times the fracture doesn't heal. So the
fracture develops, is inflamed and painful. And for our
treatment we shut it down, build up their core muscle
strength. The pain goes away but many times it's not because
the
fracture is healed but because the it's just become
not symptomatic anymore. And remember that 3-6% of the
population has this so having it in and of itself does not
mean that you have symptoms, if that makes sense. So it's
kind of a weird thing to wrap your head around, that sort of
a cure or healing of this is not radiographic healing but
rather how you're doing from your symptom standpoint. And
there's no significant association after you're done growing
with the persistence of spondylolysis leading to any
problems
down the line. So you think, oh, especially if I'm
bilateral, I've got two cracks, you know, one on each side
of the spine, doesn't that make my spine unstable? And I'll
talk about spondylolisthesis in the next slide, which is
sort
of related, where there's some slipping of the vertebral
bodies one on the other. But that only develops when
patients are younger and growing. So if you're done growing,
you have a bilateral spondylolysis that's asymptomatic it's
extremely unlikely that's going to progress to an unstable
condition when you're older. So we're really just going for
a symptomatic improvement. And very rarely we'll treat these
with surgery. So if a patient has tried a good six to
twelve months usually of nonoperative treatment then we'll
proceed with surgery if they're still having pain. And
either
we'll try to get the bone to heal, sort of fix the crack or
we'll fuse the segment. So if you have a L5 spondylolysis,
especially if it's bilateral, many times we'll just fuse L5
and S1 together so we'll make the bones grow together. Cause
it's hard to get this bone to heal both without surgery and
with surgery. And fusing one segment of the spine has very
low morbidity, meaning that we're not taking much away from
a patient and we have a much higher chance of success. So,
depends on where it is and what the patient's like and what
the fracture's like, but these are usually our two options,
either fixing it or fusing the segment. So I mentioned that
I'll talk about spondylolisthesis, another fancy Greek word.
Spondylo still meaning spine and listhesis meaning slippage.
So this is basically one vertebral body slipping on the
other. The picture up at the top left is a lateral of the
spine. So if you looked at your spine from this way. One of
those vertebral bodies is slipping on the other. We see
this in adults for different reasons, arthritis of the facet
joints and some other things. But in kids it usually
follows into one of two categories. Either related to
spondylolysis or an isthmic spondylolisthesis where the
pars or that lamina is elongated for some reason. They're
kind of born with an elongated bone. So they still have an
intact posterior arch. The roof is still connected to the
house so to speak but it's just much longer. And again, so
it's going to be either through the pars fracture or
through the elongated pars. If the roof is intact, if you
have an isthmic spondylolisisthesis, you're more
likely to have some nerve symptoms. Because the roof is
still on the house and it's sort of still being dragged
forward. So it might put pressure on the nerve roots which
then causes pain where those nerves go, buttock, leg,
etcetera. The treatment is based on severity of the slip. We
have a grading system. If it's zero to 25% of the width of
the vertebral body, 25 to 50, 50 to 75. Details are a little
bit inconsequential but basically if it's a small slip
then you'll probably do fine. We treat you symptomatically
just like if you only had only a spondylolysis or some
activity-
related back pain. But we'll probably follow you with x-rays
if you're still growing to make sure that it doesn't slip
more. Or if you have a severe slip then we'll usually
recommend surgery. And in the picture x-ray there shows what
we call a spondyloptosis where one vertebral body actually
completely falls off the other. So it looks crazy. It looks
like you shouldn't be able to walk around with a back
looking like that. But we do see patients who are like that
with very minimal neurologic symptoms because it's
happened slowly over time. So that's spondylolysis and
spondylolisthesis. I'd say in my practice when I do find the
diagnosis for a back pain, this is the most frequent one. So
the tumors, the infections --- those are all extremely rare.
But spondylolysis --- when we do find the diagnosis is
probably
the most frequent cause that I find. Although lately I've
been having a run of disc herniations. So disc herniations
you
hear a lot about in the adult population. We do also see
these
in children but usually in the adolescent population.
So when they're making that transition at least skeletally
not necessarily mature, maturity-wise into adulthood.
And similarly, there's something called an apophyseal
fracture, which if you look at the picture down at the
bottom you see the disc and then what's called the end
plate and the physis or the growth plate. So each vertebral
body, each one of those squares in the front part of your
spine. You have a growth plate when you're growing on
either end that's next to the disc above and below. And in
the growing skeleton, the weak point is the growth plate. So
your ligaments and your tendons and everything else
is stronger than your growth plate. So whereas when your
growth plates close you may get a disc herniation. When you'
re
younger the same sort of injury or episode may cause a
little bit of the endplate or the slip
through the growth plate where a little bit of bone comes
off with the disc. So it's sort of similar but just happens
at a different location depending on if your growth plate is
open or closed. So for a disc herniation both in adults and
children, has a fairly favorable natural history, meaning
that if left alone the vast majority of these will get
better because the body sort of chews up that
little bit of disc that's splooged out into the spinal
canal.
The body absorbs it over time. But it can take up to two
years. It takes a long long time for it to go away. So our
treatment is geared towards can you tolerate the symptom
that you currently have while nature takes it course? So
how bad is your pain? Do you have weakness? Do you
have numbness? Do you have tingling? Can you sort of get by
with what you have while your body does the rest of
the work? So we use non-steroidal anti-inflammatories.
We'll use a short period of rest. We no
longer really recommend weeks and weeks of bed-rest because
that actually makes patients worse. So we usually recommend
you
take a couple days off school or work, whatever you do and
then try to get back to walking and doing light activity.
Sometimes we'll do injections around the nerve root that's
being pressed on by the disc herniation to try to decrease
the inflammation. And therapy sometimes can help as well.
And then if your symptoms are just too bad, or you
know, too severe, the nerve root injections are not helping,
you really can't live that way because it can be a very
excruciating pain, then sometimes we'll recommend surgery.
And this is both for adults as well as adolescents. And
surgery can be very successful especially in the adult
population. These are some of the happiest patients that we
have. In orthopedics after you do surgery usually patients
don't like you very much in the recovery room, because you'
ve
broken one of their bones or dumped something kind of
painful to them initially, you know for the ultimate good
but three months down the line. So in the recovery room,
they're not necessarily so happy. The exception to that are
microdiscectomy patients. So these are patients who've had
leg pain for a while. You take the disc out and all of a
sudden their leg
pain is gone. And they wake up in the recovery room ecstatic
because they're finally pain free. So in the right setting
with the right indications, this can be a very successful
surgery. And it's important to know that both in adults as
well as in adolescents there is a high reoperation rate.
And a little bit higher in kids than in adults, up to 28%.
So
almost 30% of patients have to undergo another surgery
usually because of a recurrent disc herniation. So you've
got a little hole, some disc material squirts out. You take
what's been squirted out but there's still that hole and
you still have a lot of disc material and so it'll still
squirt out. And we've looked at trying to repair the hole,
trying to take out more of the disc, all of these things and
nothing really
changes that reoperation rate. So it's just something that
we kind of accept, tell patients about ahead of time, and
use that as part of the discussion as to what treatment
we're going to go forward with. So apophyseal fractures or
apophyseal ring fractures as they are sometimes called,
again this is sort of a disc herniation equivalent in the
growing spine. Many times it's seen with a disc herniation,
so a little bit of disc will come out as will that bit of
bone through the growth plate. It's a little tough to see
on the MRI but basically --- I don't know if I have a
pointer or
if it's going to work --- So this black line here is the end
plate. And you see how then it's gray here? And the black
line's there. So basically they've sheared off a little bit
of the endplate. Very similar symptoms cause, again it's a
compression on the nerve root that's going by that disc. But
the natural history for this isn't as favorable because it's
a little bit harder for the body to eat up that
bone. And so we tend to recommend surgery more frequently
for an apophyseal ring fracture because patients aren't
necessarily going to get
better. So unless they get better very quickly, then we're
usually a
little bit more willing to say, "Alright well, let's treat
it with surgery and get you back on the road to recovery
sooner cause the chances that nature takes care of it are
lower." So it's important to use kind of an algorithmic
approach.
Since 80% of the time we can't find the patient's back pain
and we give it names like non-specific back pain, mechanical
low back pain, musculoskeletal back pain or adult style
low back pain is what I tend to call it since parents can
kind of relate to that, which is you've got it, it's not due
to anything that's going to kill you. There's not too much
that we can do that's going to fix it quickly and so kind
of welcome to adulthood. It's not the answer that
people want to hear necessarily, but it's the truth. And so
we use this algorithmic approach and really only work up
patients who have red flags or specific symptoms that
correlate with a spondylolysis, a spondylolisthesis, a disc
herniation, that sort of thing. And that's something that we
can find while just talking to a patient and examining
them. Otherwise we recommend not working up every case of
back pain because we will be exposing kids to unnecessary
radiation, doing x-rays when they're not going to show
anything, putting them through MRI's when they don't need
it. And I will tell you that I have yet to have a patient
who underwent an MRI who said, "That was so fun. Can I do it
again?" Like, nobody likes an MRI. We try to play movies for
the kids and make it as fun as possible. They still hate it.
Lab work, nobody likes to get a needle stick. So you know
we're trying to make sure we don't miss anything and treat
children appropriately but at the same time not put them
through the wringer when we know it's not going to tell us
anything. Any question on some of the diagnoses of what it
can be? All right, moving on. So back pain and backpacks,
Hot topic. Theoretically. Alright, so we know that backpacks
are getting heavier. Some schools remove their lockers for
safety concerns, drug concerns, etcetera. Class sizes are
increasing. School campuses are staying the same size. So
there may be an insufficient number of lockers. Some schools
are giving kids less time between classes so they don't
have time to go to their locker to get their books. People
are carrying musical instruments, sports equipment. You know
again, iPhone, iPad, computer, 80,000 things loaded up on
their back. And we're seeing this increase in back pain,
excuse me, backpack weight at the same time that we're also
maybe seeing this increase in back pain. So the natural
question is are heavier backpacks to blame for these
increasing weights of back pain? And I'll skip to the
point which is we don't know. There's a lot of research
into the topic and basically an equal number of articles on
either side of the coin. So there are some articles
supporting that a heavy backpack is causing back pain. Other
articles saying no, there's no relationship. And the studies
vary based on the group that they're studying. You
know, are they high school students? Are they elementary
students? Do
they live in California? Do they live in Nigeria? Various
things. How they're asking the question about back pain? So
is it that the patient has come into their doctor
complaining
of it or is that we're asking them if they have any back
pain. And then one of my favorite quotes by Mark Twain, he's
a great guy with a lot of, many quotable quotes. But one of
my favorites is
that, "There are lies, damn lies, and statistics." So you
know
we tend, especially in medicine to really hang
our hat on the statistical significant P value. So
basically saying that the relationship that we're trying to
prove is more than chance. So A happened because of B. And
it's more than chance that that just happened. So we tend
to really hang our hat on that and say, ah-ha, this is proof
that A causes B when really you can kind of manipulate the
numbers and make all sorts of things happen. So these are
just a few examples kind of highlighting how we can get
different answers. So David Skaggs is of the Children's
Hospital of LA that do a lot of great research, published
this in the Journal of Pediatric Orthopaedics in 2006. And
they looked at over 1500 children in the Los Angeles area
aged ten to fifteen years and they actually asked kids a
question when they came in for their school screening for
scoliosis. They basically did a side study asking
about back pain and they gave a survey of nine questions. Do
you use a backpack almost every school day, yes or no? In
the backpack that you have now, is that about the same
weight you regularly carry, heavier, lighter or the same? Do
you usually carry it with one or two straps? Do you use a
belt around your waist? Do you have back pain? How bad is
your back pain on a scale of one to ten? Does it limit your
activities in any way? Do you ever take any medicine for it?
And do you think the backpack you're carrying causes your
back pain or makes it worse? So they're really trying to
kind of elucidate how many kids have back pain and how
severe it is. And what they found is that 97 kids carried
backpacks.
So basically everybody carried backpacks, nobody is really
doing the roller suitcase anymore, as much as we would love
it, the messenger bag, etcetera. You know the backpacks are
kind of the mainstay. And 37% of patients with a backpack
reported having back pain. With eighty two percent saying
that they had pain, felt that it was the backpack either
caused it or made it worse. Now, they didn't have enough
non-backpack users to really compare whether the backpack in
and
of itself causes pain because the numbers were too
small to get to the statistical significance. But they did
note and that's what the bar graph shows here, that the
increasing
weight of the backpack was associated with an increased
frequency of patients reporting back pain. In addition
having access to a locker was associated with a lower rate
of back pain than if a patient did not have access or if a
kid did not have access. So that's 25% if you could get to
your locker versus 39% if you could not get to a locker. So
their conclusions, you know they're smart people so they
don't hang
everything on their statistics, and so they don't say that a
heavy backpack causes back
pain. But they do say that patients should be allowed access
to
lockers, or kids should be allowed access to lockers. And we
should try to keep our backpacks lighter to try to decrease
the risk of back pain. Now contrast that with a study by
Wall, who I believe is in Idaho. He also published in the
Journal of Pediatric Orthopedics in 2003 and he took a very
different approach. So rather than going out to the school
and asking kids, hey, do you have back pain? Do you carry a
backpack? Do you think it causes it? He looked at 100
consecutive patients from a larger cohort seen by him for
back pain between the ages of from seven to eighteen
years. So these are kids who are actually showing up to the
doctor and specifically to the pediatric orthopedist, sort
of that subspecialist with back pain. And so he asked
those patients, called them up on the phone and said, how
bad is your back pain? What do you think makes it better?
What
do you think makes it worse? And do you think that your
backpack
contributed to it? So of those patients, 80% used backpacks
to carry their books. So maybe messenger bags are cooler
in Idaho, I don't know. And only three of the 100 patients
reported that the back pain was made worse by the backpack.
The rest, physical activity was the most common exacerbating
factor. So doing athletics or moving around a lot made it
worse. But also no answers. So nothing made it better or
worse, sitting or lying down. So his conclusion was that
backpacks, heavy backpacks are not causing a significant
increase in back pain. And the title of the article is
actually, Back Pain and Backpacks --- Where's the Epidemic?
Because there's sort of, for a while this big brew-ha-ha
about how heavy backpacks were causing back pain. And he
sort
of said hey, wait, when we really look at what the impact
is, how severe this pain is, for a patient to come and seek
treatment, it doesn't necessarily pan out. Now some studies
do show objective alterations in gait, posture and
metabolic parameters. So, for example there's an increased
forward trunk lean if you have a load that is fifteen to
twenty % of the body weight versus zero or ten %. So, if you
have a light load you stand up nice and straight. If you
have a heavier load, and we all do this, you lean forward to
kind of bear that weight. In addition there's a higher
metabolic cost with a child carrying a load twenty
percent of their body weight versus zero or ten %. So you
work harder when you've got a heavier backpack. But the
question is, do these objective parameter changes
really translate into clinically significant back pain? And
I think that the question is still unanswered. So, in my
opinion I think that back pain is too multi-
factorial to really be able to ever definitively prove or
disprove a causal relationship between pain and backpack
weight or usage. My sort of feeling or gestalt is that
having a really heavy backpack probably does make your back
hurt a little bit more when you're wearing it. But
that doesn't mean that you have a debilitating back
condition caused by your back pain. It's just like you know,
I carried my heavy purse over from clinic and towards
the end of the walk I'm like, my shoulder kind a hurts
because my bag is heavy. But when I put it down I feel
fine. But if somebody asked me after I walked over here,
hey does your shoulder hurt from your bag, I would say, yeah
it does. So we don't know to be honest, but our current
recommendations of both the American Academy of Orthopedic
Surgeons as well as the American Academy of Pediatrics is to
try to buy the lightest weight backpack you can. So don't
make things heavier by having a heavy backpack. Try to keep
the weight of it less than fifteen percent of your child's
body weight. Use two well-padded shoulder straps lightly
tightened or well-tightened, I should say, to really
distribute the load evenly. And then probably not too cool
in the high school but try to use the waist belt to again
sort of evenly distribute the load so it's not all just
hanging off the shoulders. So unfortunately we don't really
know the answer. But we'll move on to preventive measures
which again we don't really know the answer but I'll give
you my two cents. So what can we as parents do to help our
kids? I think that we want to stay as fit as we can but don'
t
overdo it with one specific sport. So I think cross
training is great in general, helps with overuse, can help
with core strength. I think it builds flexibility,
adaptability. I
think kids maybe like their sport better when they are doing
a couple
of different sports during a particular year, and I think it
can
definitely help with overuse pain including back pain.
This is a totally, biased opinion, since I do yoga myself,
for my chronic low back pain from fifteen years of
gymnastics. But consider doing a little specific core
strengthening, either yoga, pilates, swimming, that kind of
thing. Research in adults suggests that doing yoga for
chronic and recurrent low back pain can improve both back
function as well as decrease pain. So you know, I drink
the yoga Kool-aid. I fully recognize my own bias so take
that with a serious grain of salt. And then listen to your
child. Remember those red flags, the night pain, the
constant pain, radicular pain down the legs, fever,
malaise. You know, you know your child. If they're just
*** and not quite themselves, then get it worked up.
Talk to your pediatrician. And then also think about other
things that may be impacting a child's expression of pain,
of back pain. There's clear evidence in both the adult, as
well as the pediatric literature that there's a significant
role of psychological distress as well as adverse
psychosocial factors in reports of back pain as well as
other somatic complaints like headaches, migraines, stomach
aches, etcetera. So if a kid's getting bullied at school and
doesn't want to do P.E., they might manifest that. Not, not
intentionally, not consciously, but that may be manifested
as pain so always kinda keep that in mind. And you know,
know your kid. Talk to them. Have honest discussions with
them. And really try to put the whole picture together.
Because
it may be related. So my final, sort of summary statement is
that low back pain and back pain in general in children is
not as uncommon as we once thought it was. But it's not
"too bad" most of the time. So most kids forget that they
ever had it. Most kids do not have a decreased
quality of life because of it. It does not consistently
predispose a child to problems as an adult. So just because
you have an episode of back pain as a kid doesn't mean that
you're going to have chronic back pain as an adult. And then
there's some sort of question, that is, is having back pain,
just a matter of walking on two feet? Is some intermittent
back
pain a function of being human? We don't know. Certainly, we
wanna
all lead active pain-free lives as best we can but there
may be some things that are out of our control. That's it.
Thank you.