Low back pain in youth: Recognizing red flags
Although low back pain in children and teens is usually benign, recognizing red flags that indicate the need for imaging, referral, bracing, or surgery is critical.
PRACTICE RECOMMENDATIONS
› Be aware that low back pain is rare in children < 7 years but increases in incidence as children near adolescence. A
› Consider imaging in the setting of bony tenderness, pain that awakens the patient from sleep, or in the presence of other “red flag” symptoms. A
› Consider spondylolysis and spondylolisthesis in adolescent athletes with low back pain lasting longer than 3 to 6 weeks. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
A Cochrane review showed that PT and exercise-based treatments had no effect on back pain or disability in patients with scoliosis.29 And outpatient PT alone, in the absence of bracing, does not arrest progression of the scoliotic curvature.35 One trial did demonstrate that an intensive inpatient treatment program of 4 to 6 weeks for patients with curvature of at least 40° reduced progression of curvature compared to an untreated control group at 1 year.34 The outcomes of functional mobility and pain were not measured. Follow-up data on curve progression beyond 1 year are not available. Unfortunately, intensive inpatient treatment is not readily available or cost-effective for most patients with scoliosis.
Scheuermann disease. The mainstay of treatment for mild Scheuermann disease is advising the patient to avoid repetitive loading of the spine. Patients should avoid sports such as competitive weight-lifting, gymnastics, and football. Lower impact athletics are encouraged. Refer patients with pain to PT to address posture and core stabilization. Patients with severe kyphosis may require surgery.17,18
Bracing: Rarely helpful for low back pain
The use of lumbar braces or corsets is rarely helpful for low back pain in children. Bracing in the setting of spondylolysis is controversial.One study indicated that bracing in combination with activity restriction and lumbar extension exercise is superior to activity restriction and lumbar flexion exercises alone.43 But a meta-analysis did not demonstrate a significant difference in recovery when bracing was added.44 Bracing may help to reduce pain initially in patients with spondylolysis who have pain at rest. Bracing is not recommended for patients with pain that abates with activity modification.
Scoliosis and Scheuermann kyphosis. Treatment of adolescent idiopathic scoliosis usually consists of observation and periodic reevaluation. Bracing is a mainstay of the nonsurgical management of scoliosis and is appropriate for curves of 20° to 40°; studies have reported successful control of curve progression in > 70% of patients.36 According to 1 study, the number of cases of scoliosis needed to treat with bracing to prevent 1 surgery is 3.30 Surgery is often indicated for patients with curvatures > 40°, although this is also debated.33
Bracing is used rarely for Scheuermann kyphosis but may be helpful in more severe or painful cases.17
CORRESPONDENCE
Shawn F. Phillips, MD, MSPT, 500 University Drive H154, Hershey, PA, 17033; sphillips6@pennstatehealth.psu.edu.
