Treatment Options for Lower Back Pain in Teenagers

Lower back pain in teenagers is an all-too-common occurrence with 30%-70% of adolescents experiencing what can be characterized as insidious onset, where the cause is unknown. This is an obvious problem; if the cause is unknown, the LBP cannot be effectively treated or prevented. When chronic pain is present in such a high percentage of a group, it results in a lower quality of life and decreased activity levels. Coleman and colleagues completed a cross-sectional study of 1081 adolescents aged 13-15 and found that LBP was associated with a lower level of free time activity and was shown to restrict activity more often in girls than in boys. This decrease in activity levels can result in an increased risk of developing comorbidities such as obesity and cardiovascular disease. During teenage years, an individual’s mental health can be fragile, and suffering from chronic pain can have an impact on emotional well-being. It is key to prevent these future health issues and increase the quality of life of teenagers with LBP. Early effective treatment is the answer.

Understanding Lower Back Pain in Teenagers

Healthcare professionals, and in particular physicians working in primary care, physiotherapists, and occupational therapists, play a key role in the management of lower back pain. However, given the range of available interventions and a lack of clear clinical guidelines, it is a complex area for treatment. It is often managed by self-referral to physiotherapists and other treatment providers. Primary care-based management often involves medication prescribed by a GP and further investigation and referral to secondary care if symptoms do not improve.

Lower back pain is defined as having pain or discomfort located in the lower back region. It is a major public health problem and the leading cause of disability in the world. An estimated 70-85% of the population will experience lower back pain at some time in their lives. As adolescents enter adulthood, the incidence of back pain is estimated to rise, although it is unclear to what extent this occurs. As chronic lower back pain can affect an individual’s ability to work and is also associated with social isolation and depression, it is important to understand the implications of these disorders beginning in the teenage years.

Importance of Early Treatment

Let’s consider the importance of early treatment in a hypothetical health condition. An individual with health problem ‘X’ has two possible timelines for this health condition. He can spend two years with problem ‘X’, or he can have the same health problem ‘X’ for four years. Now, if this individual knew in advance that he would have health problem ‘X’ for four years, and health problem ‘X’ would negatively affect his life in those four years, he would undoubtedly want to shorten the duration of problem ‘X’. This would be in order to reduce the time ‘X’ has a negative affect on his life. Now, health problem ‘X’ is an acute condition that has no drastic affect on an individual’s future wellbeing. The answer changes when this health problem is converted into an acute on chronic condition in low back pain. Recurrent or persistent LBP is increasingly becoming a burden in western societies, and interventions to stop onset of persistent LBP are becoming a focus in LBP research. Early intervention is now more than ever a priority in the treatment of low back pain. This is especially the case with teenagers given that an episode of LBP in this age group is a strong predictor of future LBP. In theory, it is possible to prevent onset of chronic or persistent LBP by lower back pain teenager treatment. This could be said to ‘nip in the bud’ future LBP problems. By effectively preventing acute LBP from developing into chronic or persistent LBP, there is a reduced burden of LBP on both the individual and society. This is a similar concept to the prevention of early onset knee osteoarthritis in athletes who have undergone ACL reconstructions.

Lower back pain (LBP) is a common health problem in adolescence. Early onset LBP in teenagers is a strong predictor of LBP in adulthood. The economic burden of LBP is already a major issue in western societies and will continue to be an increasing problem as the current teenagers reach adulthood. It is estimated that 70-80% of people will suffer significant LBP in their lifetime. Therefore, research into effective ways to prevent and manage LBP is of great importance. Step one in the vast majority of treatment pathways for a health condition is prevention of the condition. The significance of prevention is clearly evident by the resources put into stopping health problems such as cancer, diabetes, and heart disease. If effective prevention strategies are implemented, then the incidence and subsequent burden of LBP can be reduced. For example, it is believed that a specific exercise prescription can prevent LBP episodes reoccurring. That being said, optimal management strategies for LBP still need to be uncovered.

Non-Medical Treatments

There are many non-medical treatment options for lower back pain, some of which are better than others. Treatment for any condition should begin with the use of conservative therapy, with the focus being on techniques that are not invasive. Even with the most conservative of treatments, the specific cause of the lower back pain can often be difficult to diagnose. In most cases, the cause is non-specific and the teenager will experience relief from his or her pain by using conservative therapy techniques. In the instances where a teenager has a specific diagnosis, for example spondylolysis, spondylolisthesis, discogenic disc disease, or isthmic or degenerative spondylolisthesis, specific therapy or treatment may be indicated. In the cases of spondylolysis and spondylolisthesis, the teenager and parents will benefit from early consultation with a therapist or chiropractic doctor to discuss specific exercises and the feasibility of using a back brace. With any of these specific conditions, it is important for the patient and the parents to consult with the treating physician prior to initiating specific forms of therapy.

Physical Therapy Exercises

It is in the best interest of a young person with low back pain to return to normal activity as soon as possible. Bed rest is not recommended. Physical activity can help diminish pain and speed recovery. A healthcare provider will recommend the best type of exercise, but most teens will find it useful to try many of the following: Low-impact aerobic activities have been shown to be effective in reducing chronic low back pain. These are activities such as swimming, bicycle riding, or walking. These activities increase blood flow, which in turn helps promote healing. Patients generally find that water therapy helps to control pain. This is primarily because the buoyancy of the water helps to support the body’s weight, which reduces stress on the joints. In addition, the water can create resistance, which helps to build muscle strength. Dynamic lumbar stabilization exercises are used to improve control of the lumbar spine. This, in turn, can help resolve and prevent recurrence of low back pain. These exercises are designed to be the most beneficial for specific individual patients and their diagnoses. Singer tells adolescents attempting physical therapy for the first time to expect some soreness and increased pain initially, particularly if their low back pain has been ongoing. If it doesn’t improve after three sessions, then it’s doubtful the therapy will help. The extensiveness of physical therapy exercises evokes the importance of a skilled professional to guide these patients. Many adults with lower back pain can serve as role models for adolescents and teens who may be reluctant to try these treatments. Singer says that the use of motivational techniques and ensuring the workouts are an enjoyable experience can also help to maintain the adolescent’s compliance with the therapy. Although it may not be the most enjoyable task, physical therapy exercises are a valuable treatment for many adolescents with chronic or recurrent low back pain.

Stretching and Strengthening Techniques

Stretching and strengthening the muscles of the back and/or abdomen has been recommended by healthcare providers for patients with chronic back pain, but few have been studied using specific treatments or comparison groups. Most studies have involved adults; information on adolescents is limited. Humphreys et al. showed that exercise involving the abdominal and back muscles for 2 hours weekly for 12 weeks could decrease back pain in 27 adolescents aged 14-16 years. The exercises included leg lifts, side bridges, a variety of planks, and partial sit-ups/curl-ups. Exercises were initially performed and progressed in the authors’ lab with weekly supervision and advanced to home practice. Pain provocation exercises were not included. At 4-week follow-up, 50% of the participants reported their pain was improved and 26% reported no pain. The exercises were found to be safe, as there was only 1 incidence of an increase in leg pain and 1 incident of an increase in LBP which only lasted for 24 hours. This is the only clinical trial for adolescents that authors are aware of that included specific strengthening and/or stretching of the back and stomach muscles, and the result was favorable. More studies are needed to devise optimal exercise treatment regimens for painful LBP conditions in this age group.

Posture Correction

Firstly, it is essential to identify poor postural habits before implementing the changes to the posture. Studies show that teenagers often have a poor idea of what good posture actually is, and this can change dependent upon the person’s activity. In order for a teenager to identify their postural habits, education is an essential tool. Understanding what good posture is and being able to recognise the signs of poor posture can be done through a variety of educational methods. These include, but are not limited to, verbal instruction from a health professional or parent, printed materials which consist of good and poor postural examples and the implications of both, and the use of video and computer technology for postural assessment and re-education. It is important for a teenager to be able to recognise their postural habits as many are not aware that their posture may be linked to their back pain. When it comes to actually changing the posture, there are a variety of methods that may be implemented. Ergonomic modifications to the home and school environment is an important start. This relays to the altering of the environment to decrease any factors that may lead to poor posture. An example at home may be the altering of a teenager’s sleeping position or pillow. At school, a person may require an adjustment of their chair and desk. In both environments, this may also incorporate a reduction in the time spent in certain postures. This could mean less time spent slouching in front of the TV, or breaking up long periods of sitting with a short walk or stretch. The less time spent in poor postures, the less likely it is that pain caused by the postural is contributing to chronicity.

Medical Treatments

Step one recommendations is non-drug treatment. However, in cases of severe pain, step two recommendations involve the use of NSAIDs, co-codamol, or a combination of NSAIDs and weak opioids. This type of medication should be used in the lowest dose possible for the shortest period of time. Step three involves the use of strong opioids, and step four is a last resort involving the use of invasive treatments and is beyond the scope of this guideline.

It has been reported that in some adults, opioid medications for chronic back pain have been associated with functional impairment, i.e. the ability to perform normal work or home activities has been limited. Sufferers have a tendency to overuse these medications, and there are recent concerns of opioid dependence. This is an issue of high relevance to adults with CLBP. However, surprisingly there is no literature addressing opioid use in adolescents with back pain. Therefore, research is needed in this area to understand whether opioid medications are being inappropriately overused by teenagers.

Pain medications and analgesics are also commonly used. They reduce the intensity of pain but do not affect the inflammation. Dose should be kept to a minimum and timely manner to avoid side effects. Regular use of paracetamol is often not effective, but combined with codeine it can be more beneficial. Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are effective for pain associated with inflammatory conditions. However, they are often underdosed and inappropriate use can cause side effects involving the gastrointestinal, kidney, cardiovascular, and other systems. This can be particularly dangerous in the elderly. Aspirin can prevent back pain associated with inflammation and is well tolerated, although it should be avoided in patients with asthma and a history of gastric ulcers.

Medical treatments are traditional pharmacological remedies that have been used for many years by patients experiencing back pain. Lower back pain treatment muscle relaxants are a group of medications that have been effective for low back pain. They are prescribed to relieve muscle spasms and back pain. Some have a sedative effect and may cause drowsiness. This is a normal physiological response to the medication. Some muscle relaxants like Diazepam can be addictive and should only be taken for a short period of time.

Muscle Relaxants for Lower Back Pain

Muscle relaxants are medicines that work on the central nervous system to relieve muscle spasm, pain or stiffness. These drugs are useful in the management of pain that is related to muscle spasm as the most common adverse effect is drowsiness. The impact of drowsiness on daily function may be useful in patients whose back pain is preventing them from sleeping. There is little evidence for the use of muscle relaxants in children and adolescents and in adult populations it is noted that their use is based on habit rather than evidence. However, a multi-centre randomised double-blind trial found that in a group of 240 adults with acute lower back pain, no difference in pain reduction or increase in functional status was noted between patients taking muscle relaxants (cyclobenzaprine) and patients taking a placebo. A recent systematic review that assessed the efficacy of medicines for the management of acute and chronic low back pain in adults concluded that very few medicines were effective for pain relief in the short or long-term and there was evidence of an increase in adverse effects from the medicine. This result, combined with the relative lack of data on the use of any medicines for low back pain in adolescents, suggests that use of muscle relaxants should be limited in this population. This is especially important in the context of potential adverse effects and the fact that habit-forming potential of muscle relaxants can lead to their continual use or misuse.

Pain Medications and Analgesics

Nonsteroidal anti-inflammatory drugs (NSAIDs) can be very effective for acute muscular pain and may be all that is needed for patients with a sudden onset of low back pain during an activity. If an NSAID is ineffective, a simple analgesic is often effective. If a patient has severe pain that is not relieved by the above medications, an opioid analgesic combined with an NSAID is often tried. Medication should always be used along with other treatment such as supervised exercise and physical therapy. The use of medications does not substitute for the need to identify the pain generator and to work to eliminate it.

Pain medications can improve function and reduce pain in patients with acute low back pain. There are several types of medication that can be helpful for patients with acute low back pain. It is generally agreed that nonsteroidal anti-inflammatory drugs are the first type of medication to try.

Heat and Cold Therapies

Contrast bathing or the use of spas This refers to the use of both heat and cold. Heat sources include hot water bottles, warm showers, or microwaveable wheat packs. The heat should be applied for about 20 minutes. Cold sources could be a bag of frozen peas/cold pack, or ice from the backyard mixed with water in a shallow cup. Cold should be applied for about 5-10 minutes. Both heat and cold can be applied for longer if the initial pain relief properties are beneficial. A warm spa or a few minutes in a heated pool provides the heat component with the advantages of being able to gently exercise and rehabilitate the back. Both heat and cold provide some pain relief and help with flexibility. Heat is good for tight and stiff muscles, cold is good for acute pain or pain within a deep muscle. It is difficult to predict which – heat or cold, will provide the most benefit. A suitable recommendation may be to try applying one, and if there is no improvement, try the other. On a comparative level, the use of a spa is definitely the best method for the in-depth heat treatment of a large area, and the gentle exercise available is a valuable tool for furthering back rehabilitation.

Seeking Professional Help in Singapore

Singapore General Hospital’s Department of Orthopaedic Surgery is a well-known and established institution in Singapore and in the region. There are specialists in various fields within orthopaedics. Request an appointment with a specialist in pediatric orthopaedics as they would be able to give the best advice as to what treatment options are available for a teenager. Treatment and procedures at government restructured hospitals are subsidized for Singaporeans and permanent residents. Specialty care from a pediatric orthopaedic specialist would mean that the problem would not be passed over and would likely result in a better treatment outcome. A referral to a pediatric orthopaedic specialist at KK Women and Children’s Hospital in Singapore is also an option.

Most people who have lower back pain will not need extensive treatment. A Singapore orthopaedic clinic can help advise you on what treatment options may be best for you, and guide you through various orthopaedic spine treatment options for children and teenagers. In this section, we will discuss the different professionals you can approach in Singapore and the various treatment options available.

Finding a Specialist in Adolescent Orthopedics

This process begins with the primary care physician, who will refer the patient to an adolescent orthopedic specialist or surgeon. While this seems relatively simple, the unfortunate reality is that suitable orthopedic care for an adolescent is hard to come by. In general, adult orthopedic surgeons are not specifically trained to address the needs of growing children. Though it is tempting to seek help from the nearest, most skilled surgeon, the authors would emphasize the young patient’s unique needs and encourage a search for a surgeon specializing in pediatric or adolescent orthopedics. This can be done by searching the internet, making inquiries at nearby medical schools, or directly seeking the advice of an adult orthopedic surgeon, who may in turn be able to recommend a pediatric specialist. The patient’s pediatrician can also be a valuable asset in this process. Families of lower socioeconomic status may consult a public health plan to seek an orthopedic specialist. Unfortunately, the number of providers accepting public insurance is small and many require long wait times for appointments. In this case, the pediatrician can act as a liaison between the orthopedic surgeon and the patient’s family. This can involve the exchange of medical records and test results, which can be critical in helping the surgeon better understand the acuity of the patient’s condition and to make a more informed decision regarding acceptance of the patient. In certain situations, the pediatrician may even have to go as far as to petition the insurance company to make an exception and allow the patient to be seen by a specific specialist who would otherwise be out of network. This is undoubtedly a complex process, but the consistent guidance and advocacy of a concerned pediatrician can be highly valuable in helping families locate the most suitable care for their child’s condition.

Understanding Treatment Options in Singapore

Spondylolysis and low-grade spondylolisthesis have been increasingly recognized as common sources of back pain in the local adolescent population. For symptomatic spondylolysis with no slippage of the vertebra, treatment is akin to that of a stress fracture. Invasive treatments like injections or surgery are usually reserved for those with lingering symptoms after 6 months of nonsurgical treatment. High-grade spondylolisthesis has the potential to cause neurological damage in the long run. Any progressive slippage of the vertebra or neurological symptoms should be promptly evaluated by a specialist.

To begin with, the simplest cases of muscular pain and small stress fractures. These are commonly termed soft tissue injuries. They can be readily treated by the primary care physician and mostly resolve with analgesics, rest, and physiotherapy for a duration of weeks to a few months. Deeper muscle massage, spinal manipulation, and anti-inflammatory medication may also be employed to speed the adolescent’s recovery. If pain persists or the symptoms recur, investigations may be carried out to look for an underlying spinal condition. This is to ensure specific tailored treatment instead of primary care treatment for recurrent symptoms.

Medical care for lower back pain in teens often depends on the underlying cause of the pain. Adolescent back pain has been documented in Singapore for many years. It is initially treated by pediatricians, while prevalent symptoms may result in referral to a pediatric orthopedic surgeon. Understanding of the more serious underlying back conditions has evolved in recent times with the availability of advanced imaging studies like MRI. Treatment is tailored to be condition specific and will be addressed in the following paragraphs.

Rehabilitation and Follow-Up Care

Other forms of physical therapy are less common. For example, manual therapy or acupuncture. There is currently little information on how effective these treatments are for back pain in teenagers. It is generally more difficult to access psychological therapy for teenagers with back pain, but this type of treatment should not be overlooked for those with significant disability, particularly if there are also problems of low mood or anxiety.

Rehabilitation programmes for back pain often include physical therapy. This may take place as an outpatient, or in some cases a therapist may visit the home. The starting point is usually an assessment of posture and movement, to help the teenager improve the way they use their back. Treatment may then include exercise therapy to improve general fitness and specific exercises to strengthen muscles in the back.