Marja Mikkelsson

Contributing factors to the persistence of musculoskeletal pain in preadolescents: a prospective 1-year follow-up study.

&NA; A 1‐year follow‐up of two preadolescent age cohorts with musculoskeletal pain at least once a week was conducted to analyze predictive factors for the persistence of musculoskeletal pain. Of the 564 children with pain at baseline, representing one third of the sample studied, 515 (91.3%) could be followed and 452 (80.1%) children with complete data were included for the logistic regression analysis. A structured questionnaire included questions on pain and also on several psychosomatic symptoms and amount of exercise. Joint hypermobility together with the questionnaire data were included in the logistic regression analysis. One half of subjects with pain at baseline still reported pain at follow‐up, indicating persistent pain. Boys had a lower risk for the persistence of pain than girls and the risk for the persistence of pain increased 1.2 times per age year. When further adjusted for all the other studied risk determinants, high subjective disability index due to pain (OR 3.2, 95% CI 1.5–6.6) and day tiredness (OR 1.9, 95% CI 1.2–3.0) were the most significant predictors. This might indicate that psychological distress contributes to the persistence of non‐specific musculoskeletal pain of different locations in preadolescents. In clinical work not only pain but its interference with daily activities should be noticed.

Non-specific musculoskeletal pain in preadolescents. Prevalence and 1-year persistence

&NA; A 1‐year follow‐up study of 1756 third‐ and fifth‐grade schoolchildren was conducted with a structured pain questionnaire to assess the prevalence and persistence of self‐reported musculoskeletal pain symptoms and disability caused by pain. At follow‐up, 1626 (92.7%) children participated in the study. Pain at least once a week persisted in 270 (52.4%) of the 564 children who reported musculoskeletal pain at least once a week in at least one part of the body at baseline. Of the regional pain symptoms, neck pain had highest persistence and, in girls, significantly more than in boys. Persistence of pain was not related to school grade. Widespread pain, determined as in the criteria for fibromyalgia, was found in 132 children (7.5%) and persisted in 35 children (29.7%, 95% CI 21.9–38.4) at follow‐up. Disability was more severe in children with pain symptoms in more than one area. This study showed that about half of the preadolescents complaining of musculoskeletal pain at least once a week at baseline had persistent pain symptoms at follow‐up. The prognosis of widespread pain in preadolescents was almost the same as the previous findings in adults.

Prognosis of non-specific musculoskeletal pain in preadolescents: A prospective 4-year follow-up study till adolescence

&NA; Musculoskeletal pain is common in children but studies on the outcome and predictive factors for persistence/recurrence of these symptoms are scarce. A baseline cross‐sectional survey of 1756 schoolchildren (mean age 10.8) identified 564 (32.1%) children with musculoskeletal pain. At baseline, these children were evaluated using a structured questionnaire and examined for hypermobility and physical fitness. The children were re‐evaluated after one year, and four years (at adolescence) using the same pain questionnaire. At 1‐year follow‐up, 53.8% (95% CI 48.8–58.8) of the children reported pain persistence (persistent preadolescent musculoskeletal pain). At 4‐year follow‐up, 63.5% (95% CI 58.7–68.1) of them had musculoskeletal pain. Neck was the site with most persistent/recurrent musculoskeletal pain. Those with persistent preadolescent musculoskeletal pain had approximately three times higher risk of pain recurrence (OR=2.90 [95% CI 1.9–4.4]). In the univariate analysis, female gender, older age group (11+), hypermobility, co‐existence of psychosomatic symptoms, having high disability index, and reporting combined musculoskeletal pain at baseline predicted pain recurrence at adolescence. In the multivariate analysis, age, headache, hypermobility and having combined musculoskeletal pain were found as independent predictors. Statistically significant sex interactions were found for age, depressive feelings, waking up during nights and hypermobility. More psychosomatic symptoms predicted pain recurrence in girls than in boys, and hypermobility was a strong predictor in females only. Musculoskeletal pain in preadolescents is not a self‐limiting phenomenon and more studies are still warranted to explore its determinants aiming to improve the long‐term outcome of these symptoms.

Adolescent flexibility, endurance strength, and physical activity as predictors of adult tension neck, low back pain, and knee injury: a 25 year follow up study

Objective: To examine whether adolescent flexibility, endurance strength, and physical activity can predict the later occurrence of recurrent low back pain, tension neck, or knee injury. Methods: In 1976, 520 men and 605 women participated in a sit and reach test (flexibility) and a 30 second sit up test (endurance strength). In 1976 and 2001 (aged 37 and 42 years) they completed a questionnaire. Lifetime occurrence and risk of self reported low back pain and self reported, physician diagnosed tension neck and knee injury were calculated for subjects divided into tertiles by baseline results of strength and flexibility tests. Results: Men from the highest baseline flexibility tertile were at lower risk of tension neck than those from the lowest tertile (odds ratio (OR) 0.51, 95% confidence interval (CI) 0.28 to 0.93). Women from the highest baseline endurance strength tertile were at lower risk of tension neck than those from the lowest tertile (OR 0.60, 95% CI 0.40 to 0.91). Men from the highest baseline endurance strength tertile were at higher risk of knee injury than those from the lowest tertile (OR 1.96, 95% CI 1.05 to 3.64). Men who at school age participated in physical activity were at lower risk of recurrent low back pain (OR 0.61; 95% CI 0.42 to 0.88) than those who did not. Conclusions: Overall good flexibility in boys and good endurance strength in girls may contribute to a decreased risk of tension neck. High endurance strength in boys may indicate an increased risk of knee injury.

Onset, prognosis and risk factors for widespread pain in schoolchildren: A prospective 4-year follow-up study

&NA; Little is known about the epidemiology of widespread pain (WSP) in children and adolescents. This study aims to estimate the new‐onset and prognosis of WSP in schoolchildren and investigate factors predicting its development. A prospective study was conducted among 1756 schoolchildren (age 10–12 years) in Southern Finland. At baseline, information was collected on WSP, regional musculoskeletal pain symptoms, depressiveness, fatigue, sleep problems, physical activity and joint hypermobility. These children were contacted again 1 year and 4 years later to determine the outcome and the new‐onset of WSP. A total of 1282 children (73%) of the baseline study population were found at both follow‐ups. Of the children who had WSP at baseline, 31% and 30% reported persistence/recurrence of symptoms at 1‐ and 4‐year follow‐up, respectively. However, only 10% of these children reported WSP at both 1 and 4 years. Of the children who were free of WSP at baseline, 18% reported new‐onset WSP at 1‐year follow‐up and 3% reported these symptoms at both follow‐up times. The independent baseline risk factors of WSP were older age (OR 1.3 95% CI 1.0–1.8), female gender (OR 1.4, 1.1–1.9), depressiveness (OR 1.5, 1.1–2.2) and regional back pain symptoms (Neck pain: OR 1.7, 1.1–2.4; Upper back pain: OR 2.1, 1.1–4.1; Lower back pain: OR 3.0, 1.6–5.7). Both psychological factors and somatic pain symptoms predict future development of WSP in adolescents.

Risk factors for development of non-specific musculoskeletal pain in preteens and early adolescents: a prospective 1-year follow-up study

BackgroundMusculoskeletal pain symptoms are common in children and adolescents. These symptoms have a negative impact on childrens physical and emotional well-being, but their underlying aetiology and risk factors are still poorly understood. Most of the previous cohort studies were conducted among mid and/or late adolescents and were mainly focused on a specific pain location (e.g. low back pain or neck pain). The purpose of this study is to estimate occurrence of new-onset pain symptoms, in all musculoskeletal locations, in preteens and early adolescents and investigate risk factors for development of these symptoms.Methods1756 schoolchildren (mean age 10.8) were recruited from schools in southern Finland. Information was extracted as to whether they experienced musculoskeletal pain and a total of 1192 children were identified as free of musculoskeletal pain symptoms. Information was collected on factors which could potentially predict the development of musculoskeletal pain: headache, abdominal pain, sadness/feeling down, day-time tiredness, difficulty in falling asleep, waking up during nights, level of physical activity and hypermobility. These children were followed-up 1-year later and those with new episodes of non-traumatic and traumatic musculoskeletal pain symptoms were identified.ResultsA total of 1113 schoolchildren (93% of baseline pain-free children) were found at one-year follow-up. New episodes of musculoskeletal pain were reported by 21.5% of these children. Of them 19.4% reported non-traumatic pain and 4.0% reported traumatic pain. The neck was the most commonly reported site with non-traumatic pain, while the lower limb was the most common site for traumatic pain. The independent risk factors for non-traumatic musculoskeletal pain were headache (OR = 1.68, [95% CI 1.16–2.44]) and day-time tiredness (OR = 1.53, [95% CI 1.03–2.26]). The risk factors for traumatic musculoskeletal pain were vigorous exercise (OR = 3.40 [95% CI 1.39–8.31]) and day-time tiredness (OR = 2.97 [95% CI 1.41–6.26]).ConclusionThis study highlights that there may be two types of pain entities with both distinct and common aspects of aetiology. For primary prevention purposes, school healthcare professionals should pay attention to preteens and early adolescents practicing vigorous exercise (predictor of traumatic pain), reporting headache (predictor of non-traumatic pain) and reporting day-time tiredness (predictor of both types of pain).

Muscle tenderness in pericranial and neck-shoulder region in children with headache. A controlled study

Increased pericranial muscle tenderness is connected with tension-type headache in adults. In children, the importance of muscle tenderness in the pericranial or neck-shoulder region in the pathogenesis of different types of headache is unknown. The present study evaluated muscle tenderness in the pericranial and neck-shoulder region in children with migraine, those with tension-type headache and those without headache. An unselected population-based questionnaire study concerning headache was carried out in 1135 Finnish schoolchildren aged 12 years. Of them, 183 children were randomly selected for a face-to-face interview and a clinical examination. Muscle tenderness was recorded by manual palpation and dolorimeter. Children with migraine had increased overall tenderness, recorded by manual palpation, compared with those without headache. They also self-reported tenderness in the neck-shoulder region during daily activities more often than the children of the other groups. Muscle tenderness was not associated with paediatric tension-type headache. The mean pressure pain thresholds did not differ among the three groups. However, a negative correlation between the total tenderness score and the dolorimeter score was found in each group. In conclusion, children with migraine had increased muscle tenderness at palpation of the pericranial and neck-shoulder muscles and they also reported pain symptoms in the neck-shoulder region most frequently. Instead, increased pericranial and neck-shoulder muscle tenderness was not associated with tension-type headache in children.

Lower Limb Pain in a Preadolescent Population: Prognosis and Risk Factors for Chronicity—A Prospective 1- and 4-Year Follow-up Study

Objective. To determine the short-term and long-term prognosis of preadolescent lower limb pain and to assess factors that contribute to pain persistence at 1-year follow-up and pain recurrence at 4-year follow-up. Methods. A 1- and 4-year follow-up was conducted of a population-based 10- and 12-year old cohort of schoolchildren with lower limb pain at baseline Results. Of the baseline students with lower limb pain, 32% reported pain persistence at 1-year follow-up and 31% reported pain recurrence at 4-year follow-up. Vigorous exercise was the only statistically significant predictor of lower limb pain persistence at 1-year follow-up (odds ratio [OR]: 2.43; 95% confidence interval [CI]: 1.16–5.05), whereas at 4-year follow-up (at adolescence), hypermobility was predictive of pain recurrence (OR: 2.93; 95% CI: 1.13–7.70). Traumatic lower extremity pain had a 50% lower risk for pain recurrence compared with nontraumatic pain (OR: 0.48; 95% CI: 0.19–0.92). Conclusion. Trauma-induced lower extremity pain in preadolescents has a favorable long-term natural course. Children’s involvement in vigorous exercise predicts short-term outcome of lower limb pain, whereas hypermobile children have a worse long-term prognosis.

Genetic and environmental influences on non-specific low back pain in children: a twin study

Aggregation of low back symptoms in families of children with low back pain (LBP) has been described. However, this may be due to genetic factors or common exposure to environmental factors. The aim of this study was to evaluate the relative contribution of genetic and environmental factors to childhood LBP by comparing the pairwise similarity of LBP in pairs of monozygotic (MZ) and dizygotic (DZ) twin children. Data was collected from 1995 to 1998 from a national sample of Finnish 11-year-old twins born between 1984 and 1987. This study sample constituted of 1,790 twin pairs: 610 MZ pairs, 598 same-sex DZ pairs, 582 opposite-sex DZ pairs. LBP pain was determined by using a validated pain questionnaire designed to assess musculoskeletal pains during the preceding 3xa0months. The outcome measure, LBP, was considered in three categories: none, once a month and at least once a week. Twin similarity in the report of LBP was quantified by correlations. Variance components for genetic and environmental factors were estimated by using biometric structural equation modelling techniques. The prevalence of LBP at least once a month was 15.7%, and at least once a week was 6.6%. The prevalence of frequent LBP in boys was significantly higher than that in girls (Pxa0=xa00.04). In both genders, there were no differences in LBP reporting by zygosity (Pxa0>xa00.2). There were no statistically significant differences between polychoric correlations in male MZ and DZ pairs and between polychoric correlations in female MZ and DZ pairs, suggesting little genetic influence. Results obtained from the best-fitting genetic model suggests that, of the total variance in LBP, 41% (95% CI 34–48) could be attributed to shared environmental factors within families; and 59% (52–66) to unique (unshared) environmental factors. Our results suggest that genetic factors play, at most, a minor role in LBP in children; instead, symptoms seem to be related to a mixture of shared and unshared environmental factors. This study underscore the need for further high-quality research, preferably prospective studies, to identify important modifiable risk factors in order to guide interventions that may prevent LBP in childhood.

Non-specific neck pain in schoolchildren: Prognosis and risk factors for occurrence and persistence. A 4-year follow-up study

&NA; This study investigated the natural course of neck pain (NP) in 9–12‐year‐olds during a 4‐year follow‐up. Risk factors for the occurrence and persistence of weekly NP were explored separately for boys and girls. At baseline, 1756 schoolchildren completed a questionnaire eliciting musculoskeletal pain symptoms, other physical, and psychological symptoms and frequency of physical activity, and were tested for joint hypermobility. Symptoms during the preceding three months were asked using a five‐level frequency classification. Re‐evaluation was performed after one and four years using identical questionnaires. During follow‐up, 24% reported none, 71% fluctuating, and 5% persistent weekly NP. The frequency of NP at baseline was linearly related to weekly NP during follow‐up in both genders (P < 0.001). Furthermore, a significant increasing linear trend towards a more persistent course of NP was seen in children with weekly other musculoskeletal and/or other physical and psychological symptoms at baseline. Among originally neck pain‐free pre‐/early adolescents, weekly other musculoskeletal pain symptoms (only in girls) and other physical and psychological symptoms (in both genders) predicted the occurrence of weekly NP during follow‐up. In conclusion, neck pain in schoolchildren tends to fluctuate, but there also seems to exist a subgroup (5%) with persistent NP already in pre‐/early adolescents, or even earlier. Co‐occurrence of frequent other musculoskeletal symptoms and/or markers of psychological stress with frequent NP are risk indicators for a more persistent course, at least within next few years. Since adult chronic NP problems might originate in childhood, further studies are needed, including preventive interventions.