Back Pain in Children.ppt


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Back Pain in Children.ppt

  2. 2. <ul><li>Back pain in children is very much more likely to have a serious underlying disorder compared to adult back pain and deserves careful attention. </li></ul><ul><li>There are important differences in the etiology, diagnosis and management of backache in children, the younger the child and the longer the history the more likely it is that a serious underlying condition is responsible for the symptoms. </li></ul>
  3. 3. <ul><li>Unfortunately the diagnosis of serious disease causing back pain in children is often made late or missed. </li></ul>
  4. 4. EPIDEMIOLOGY <ul><li>Nonspecific back pain in children is increasingly prevalent </li></ul><ul><li>However back pain is much less common than in adults with fewer than 30% of children and adolescents reporting back pain and very few presenting to doctors with their pain. </li></ul><ul><li>Persistent back pain, unlike in adults is likely to indicate serious pathology and physical findings are likely to be found. About half will have a specific or serious cause. </li></ul>
  5. 5. <ul><li>1 in 5 school age children have back pain </li></ul><ul><li>More prevalent in the </li></ul><ul><li>14 – 16yr group </li></ul><ul><li>cf. with 8 – 10yrs olds </li></ul><ul><li>Most studies agree </li></ul><ul><li>females > males </li></ul><ul><li>Associated family history of back pain (sibling or parent) </li></ul>
  6. 6. ETIOLOGY <ul><li>Older children </li></ul><ul><li>Overuse and back strain or musculoligamentous injury </li></ul><ul><li>Disc injuries. Disc herniation. Scheuermann disease (or juvenile disc disorder) </li></ul><ul><li>Vertebral fractures </li></ul><ul><li>Spondylolysis </li></ul><ul><li>Spondylolisthesis. </li></ul>
  7. 7. Scheuermann’s disease
  8. 8. <ul><li>Younger children and older children </li></ul><ul><li>Infection. under 10 year olds: </li></ul><ul><ul><li>Discitis </li></ul></ul><ul><ul><li>Osteomyelitis. </li></ul></ul><ul><li>Tumour of bone. Primary osseous neoplasms are rare. The most common are: </li></ul><ul><ul><li>Ewing sarcoma </li></ul></ul><ul><ul><li>Aneurysmal bone cyst </li></ul></ul><ul><ul><li>Benign osteoblastoma </li></ul></ul><ul><ul><li>Osteoid osteoma </li></ul></ul><ul><ul><li>Primary lymphoma-rarer still. </li></ul></ul>
  9. 9. Benign osteoblastoma Osteoid osteoma Aneurysmal bone cyst
  10. 10. <ul><li>Tumours of spinal cord – ependymoma </li></ul><ul><li>Congenital disorders of the spine – scoliosis. </li></ul><ul><li>Systemic disease – sickle cell disease. </li></ul><ul><li>Pyelonephritis </li></ul><ul><li>Retroperitoneal infection. </li></ul>
  11. 12. HISTORY <ul><li>It is essential to take a careful history. This should incorporate: </li></ul><ul><li>History of the pain: </li></ul><ul><ul><li>Frequency, duration and severity of pain </li></ul></ul><ul><ul><li>Mechanism of onset </li></ul></ul><ul><ul><li>Length: persistent pain is very much more likely to herald a serious disorder </li></ul></ul><ul><ul><li>Severity </li></ul></ul>
  12. 13. <ul><ul><li>Characteristics: pain that disturbs sleep or is worse at night; pain which is interfering with activities (school, play or sports) </li></ul></ul><ul><ul><li>Associated and exacerbating features – particularly if pain is associated with stiffness or limitation of movement </li></ul></ul><ul><ul><li>It is important to identify accompanying symptoms – Fever / Weight loss </li></ul></ul><ul><ul><li>Radiation of pain. </li></ul></ul>
  13. 14. <ul><li>Neurological symptoms: </li></ul><ul><ul><li>Weakness </li></ul></ul><ul><ul><li>Numbness </li></ul></ul><ul><ul><li>Gait </li></ul></ul><ul><ul><li>Bowel and bladder dysfunction. </li></ul></ul><ul><li>Past medical history – Arthritis, Trauma. </li></ul><ul><li>Family history – Arthritis, Scoliosis. </li></ul><ul><li>Social history – Activities (extreme sports, gymnastics, diving, bowling, asymetric activities), School bags and activities. </li></ul>
  14. 15. EXAMINATION <ul><li>Localization and evaluation of pain </li></ul><ul><li>Tenderness – site </li></ul><ul><li>Inspection to detect deformity, wasting and scoliosis </li></ul><ul><li>Gait </li></ul><ul><li>Flexibility </li></ul><ul><li>Neurological examination – power, tone, reflexes, sensation. </li></ul>Physical findings are found, particularly in persistent back pain (unlike in adults)
  15. 16. Symptoms and signs indicate serious pathology <ul><li>Age under 4 years </li></ul><ul><li>Symptoms persisting for more than 4 weeks </li></ul><ul><li>Interference with function </li></ul><ul><li>Systemic features (fever, weight loss) </li></ul><ul><li>Worsening pain </li></ul><ul><li>Neurological features </li></ul><ul><li>Recent onset of scoliosis </li></ul><ul><li>Stiffness. </li></ul>
  16. 17. INVESTIGATIONS <ul><li>Persistent back pain in children is serious. It can be diagnosed by history, examination and relatively simple tests (blood tests, plain radiography, bone scans). </li></ul><ul><li>In the absence of indications for urgent referral it can be diagnosed in general practice. </li></ul>
  17. 18. <ul><li>Blood investigations : </li></ul><ul><ul><li>FBC, ESR and CRP </li></ul></ul><ul><ul><li>Rheumatoid factor and other rheumatological tests may be indicated if arthritis suspected </li></ul></ul><ul><ul><li>Urea and electrolytes </li></ul></ul><ul><ul><li>Liver function tests </li></ul></ul><ul><ul><li>Amylase. </li></ul></ul>
  18. 19. <ul><li>Imaging: </li></ul><ul><ul><li>Plain X-rays (PA and lateral) </li></ul></ul><ul><ul><li>CT scanning </li></ul></ul><ul><ul><li>MRI </li></ul></ul><ul><ul><li>Radionucleotide imaging studies – planar bone scanning and single-photon emission tomography scanning (SPECT) </li></ul></ul><ul><ul><li>SPECT bone scanning – in young at risk athletes with persistent symptoms, to uncover stress fractures. </li></ul></ul>
  19. 20. DIFFERENTIAL DIAGNOSIS <ul><li>It is important to pursue a diagnosis. As indicated it is more usual to make a diagnosis in children. </li></ul><ul><li>Non-specific back pain is likely to be a diagnosis of exclusion and represents a much smaller proportion of children, as compared to adults, with back pain. </li></ul><ul><li>When considering the etiology and diagnosis of back pain consider </li></ul>
  20. 21. <ul><li>Scheuermann' disease (juvenile kyphosis): </li></ul><ul><ul><li>Boys more than girls </li></ul></ul><ul><ul><li>Rare under age 10 and most common 13- 16 years </li></ul></ul><ul><ul><li>Usually intermittent low back pain (dull and aching character) in adolescents made worse with bending forward and activity. Improves when resting. </li></ul></ul><ul><ul><li>If it affects the upper thoracic spine it often presents with kyphosis </li></ul></ul><ul><ul><li>Often decreased flexibility with tenderness on palpation above and below the apex of kyphosis </li></ul></ul><ul><ul><li>Associated hamstring tightness often found. </li></ul></ul>
  21. 22. <ul><li>Vertebral fractures. Worthy of special mention is lumbar spondylolysis (a unilateral or even bilateral stress fracture of the narrow bridge between upper and lower pars interarticularis). </li></ul><ul><ul><li>This causes low back pain quite commonly in adolescent athletes </li></ul></ul><ul><ul><li>Consider especially age 11- 17 years </li></ul></ul><ul><ul><li>Occurs in sports with repetitive flexion and extension. Sports include: gymnastics, diving, weight lifting, rowing, tennis, cricket and football. </li></ul></ul>
  22. 23. <ul><ul><li>In some cases spondylosis persists to become spondylolisthesis (25% of cases). This occurs particularly in adolescent athletes. </li></ul></ul><ul><ul><li>There is also an association with spina bifida occulta (5-10% of the population) </li></ul></ul><ul><ul><li>It is often asymptomatic, but symptoms typically occur at the time of the growth spurt </li></ul></ul><ul><ul><li>Usually causes focal pain aggravated by certain activities (particularly spinal extension and to a lesser degree rotation) </li></ul></ul>
  23. 24. <ul><ul><li>Rest improves pain. Pain is sharp, mild to moderate in intensity and can radiate to the buttock. </li></ul></ul><ul><ul><li>On examination patients may have a waddling gait associated with hamstring tightness and a lordotic posture. The classic Phalen-Dickson sign (knee-flexed, hip-flexed gait) may occur especially if there is associated spondylolisthesis. </li></ul></ul>
  24. 26. <ul><ul><li>Most memorable test for spondylolysis is the stork test (stand on one leg and bring back into lumbar extension elicits pain on side ipsilateral to pars interarticularis lesion) </li></ul></ul><ul><ul><li>SPECT scanning is the most sensitive imaging test to detect spondylolysis. </li></ul></ul>
  25. 27. <ul><li>Infection: </li></ul><ul><ul><li>Pyogenic vertebral osteomyelitis is the most common form of vertebral infection </li></ul></ul><ul><ul><li>Children usually present with abrupt onset of malaise, fever and back pain with stiffness, restricted movement, guarded walking and spine tenderness </li></ul></ul><ul><ul><li>Leucocytosis, raised ESR and CRP are usual findings </li></ul></ul>
  26. 28. <ul><ul><li>CT scanning detects earlier than plain radiographs and MRI is better still </li></ul></ul><ul><ul><li>Radionucleotide scanning, especially technetium combined with gallium demonstrates virtually all pyogenic vertebral infections. </li></ul></ul>
  27. 29. <ul><li>Ankylosing spondylitis </li></ul><ul><ul><li>Peak age of onset is 15 years to 30 years and a juvenile form also exists which starts younger </li></ul></ul><ul><ul><li>Pain is of gradual onset, worse in the morning and improving during the day </li></ul></ul><ul><ul><li>Pain is better with activity and worse with rest unlike mechanical low back pain. </li></ul></ul>
  28. 30. <ul><li>Tumours. Bone tumours may present with pain and can be demonstrated on plain radiographs. </li></ul><ul><li>Overuse, non-specific back pain and musculoligamentous injury. This settles quickly with rest but caution is due particularly with respect to the diagnosis of spondylolysis. </li></ul>
  29. 32. RED FLAGS The very young Persistent and increasing pain Weight loss Fever Ridicular symptoms Sphincter disturbance No response to appropriate therapy after 2 months
  30. 33. MANAGEMENT <ul><li>About half of adolescent patients will have self limiting, short-lived pain caused by overuse or strain. Management should incorporate: </li></ul><ul><li>Confirmation of diagnosis and exclusion of serious pathology </li></ul><ul><li>Simple analgesia </li></ul><ul><li>Preventive measures with: </li></ul><ul><ul><li>Advice and education , Physiotherapy , Exercise. </li></ul></ul>
  31. 34. <ul><li>For those patients who have a serious pathology early assessment to establish a differential diagnosis and hence urgency of referral is important. </li></ul><ul><li>All will require referral and subsequent management will vary according to the underlying diagnosis. </li></ul>
  32. 35. <ul><li>Referral. Urgent referral is indicated if: </li></ul><ul><li>Pain is persistent. Particularly if under 11 years old and for several weeks. </li></ul><ul><li>Pain is worsening </li></ul><ul><li>Fever </li></ul><ul><li>Neurological deficit </li></ul><ul><li>Pain is accompanied by stiffness. </li></ul>
  33. 36. COMPLICATIONS <ul><li>A variety of complications can arise depending on the diagnosis. </li></ul><ul><li>In general terms complications may be reduced or prevented by timely diagnosis. </li></ul>
  34. 37. PROGNOSIS <ul><li>This is determined by the underlying diagnosis. </li></ul>
  35. 38. PREVENTION <ul><li>Back education programmes are effective at improving posture but whether there is an effect on back pain in later life requires further investigation. </li></ul>
  36. 39. <ul><li>Back packs. If these are too heavy or the weight is carried unevenly (over one shoulder) they can cause back pain. There is little evidence of risk of permanent injury. Recommendations include: </li></ul><ul><ul><li>Limiting weight to 10-15% of body weight (no evidence base for this and recommendations differ - from 5-20% of body weight between different physical therapy professional bodies). </li></ul></ul><ul><ul><li>Limit weight to avoid: </li></ul></ul><ul><ul><ul><li>Leaning or bending forward </li></ul></ul></ul><ul><ul><ul><li>Distorting natural curves of middle and lower back </li></ul></ul></ul><ul><ul><ul><li>Causing rounding of shoulders. </li></ul></ul></ul>
  37. 40. <ul><li>Avoid habitually carrying over one shoulder </li></ul><ul><li>Choose good back pack design: </li></ul><ul><ul><li>Lightweight material </li></ul></ul><ul><ul><li>Padded adjustable side straps (2 inches wide) </li></ul></ul><ul><ul><li>Padded back </li></ul></ul><ul><ul><li>Hip strap to distribute weight from shoulders to pelvis </li></ul></ul><ul><ul><li>Wheeled varieties to pull rather than carry. </li></ul></ul>
  38. 41. <ul><li>Educate child on correct loading and wearing: </li></ul><ul><ul><li>Use both shoulder straps </li></ul></ul><ul><ul><li>Pack heavy items low in the backpack </li></ul></ul><ul><ul><li>Use compartments to prevent suddens shifting of weight distribution </li></ul></ul><ul><ul><li>Correct adjustment of backpack </li></ul></ul><ul><ul><li>Advice on lifting backpack (bend legs not back) </li></ul></ul><ul><ul><li>Avoid overloading which causes leaning and postural changes likely to cause strain and pain. </li></ul></ul>
  39. 42. <ul><li>Vigilance: reduce weight if pain; encourage other strategies to avoid excess weight (unnecessary books, clear out bag regularly) </li></ul><ul><li>Proactive parenting: </li></ul><ul><ul><li>Enquire after pain </li></ul></ul><ul><ul><li>Help with above strategy </li></ul></ul><ul><ul><li>Lobby to help school procedures to reduce back pain (lockers, vigilance, classroom routines etc). </li></ul></ul>
  40. 43. <ul><li>Discourage high risk or extreme sports, particularly in at risk children (age, build etc) </li></ul><ul><li>Beware of certain sports in younger children (rowing, diving, gymnastics,7 cricket bowling). Advice from sporting bodies and sports medicine specialists should be sought by schools, sporting bodies and clubs. Individual children may need to consult. </li></ul><ul><li>Encourage sports which improve isometric muscle endurance as high isometric muscle endurance is associated with less back pain. </li></ul>
  41. 44. SCREENING <ul><li>Screening programmes for scoliosis are indicated but otherwise back pain in children requires vigilance and opportunistic diagnosis. </li></ul>
  42. 45. REHABILITATION <ul><li>Mainstay </li></ul><ul><li>Back education </li></ul><ul><li>Primary prevention </li></ul><ul><li>Back posture programmes in school </li></ul>
  43. 46. EXERCISES FOR THE SPINE <ul><li>The primary goals of an exercise program for spine are to make the muscles of the back, stomach, hips and thighs strong and flexible. </li></ul><ul><li>Exercises should be incorporated into an overall program of aerobic conditioning such as walking, bike riding, swimming, or jogging. </li></ul>
  44. 47. Initial Exercise Program Ankle Pumps Heel Slides Abdominal Contraction Wall Squats Heel Raises Straight Leg Raises
  45. 48. Intermediate Exercise Program Single Knee to Chest Stretch Hamstring Stretch Lumbar Stabilization Exercises with Swiss Ball Standing with Ball between Your Low Back and the Wall Lie on your Stomach over Ball
  46. 49. Advanced Exercise Program Hip Flexor Stretch Piriformis Stretch Lumbar Stabilization Exercises with Swiss Ball
  47. 50. SUMMARY <ul><li>Back pain is common in children </li></ul><ul><li>Incidence in adolescence higher with girls > boys </li></ul><ul><li>Associations with weight of school bags, availability of lockers and family history </li></ul><ul><li>Red flags </li></ul><ul><li>MRI most valuable for imaging </li></ul><ul><li>Rehabilitation and back education is mainstay of treatment </li></ul>
  48. 51. <ul><li>Try not to lift anything heavy. If you have to, then squat and pick it up instead of bending. </li></ul><ul><li>Exercise regularly but avoid straining your back. </li></ul><ul><li>Always maintain a good posture. If you slouch, this can cause back pain. If you have to work for long hours at your chair, get one that has good back support. </li></ul>Tips to Avoid Back Pain
  49. 52. <ul><li>Avoid standing or bending for too long. This can strain your back a lot. </li></ul><ul><li>It is very important to sleep on the right mattress. Get one that is not too firm or too soft. Use a pillow to support your neck. </li></ul><ul><li>Maintain a healthy weight. Obesity can cause immense back pain. So work on shedding those extra pounds. </li></ul>