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Journal of Back and Musculoskeletal Rehabilitation 28 (2015) 25–34 DOI 10.3233/BMR-140484 IOS Press

Low back pain in adolescents. An assessment of the quality of life in terms of qualitative and quantitative pain variables a,∗ and Zbigniew Nowakb ´ Szymon Swierkosz a

Beskidian Complex of Medicine and Rehabilitation, Long-term Care Hospital, Children and Adolescents Ward, Jaworze, Poland b The Jerzy Kukuczka Academy of Physical Education, Katowice, Poland

Abstract. BACKGROUND: Information concerning low back pain in adolescents with scoliosis is rather limited in literature. While the epidemiology of back pain at the age of adolescence has been described extensively, studies evaluating the effects of therapeutic interventions are still sparse. MATERIAL AND METHOD: The study was conducted in two groups with juvenile idiopathic scoliosis Io . The clinical group was 21 persons with low back pain and the control group was 11 persons without pain. In order to assess the quality of life and the level of pain We used the abridged version of WHOQOL (World Human Organizations Quality of Life questionnaire) and MPQSF (Short Form of McGill Pain questionnaire). The treatment consisted of a combination of manual therapy and rehabilitation exercises. RESULTS: We obtained a significant improvement in the area of the physical health: 7.17 in the clinical group (p = 0.000613); 6.12 for females (p = 0.015400); 9.19 for males (p = 0.022311). The assessment of the quality of life was different between the clinical and the control groups. The decrease in pain in the clinical group was 5.71 (p = 0.000132), 5.93 for females (p = 0.001474) and 5.29 for males (p = 0.027709). Data represents more than a double decrease in strong and moderate pain. CONCLUSION: A combination of rehabilitation exercises and soft manual therapy is effective in reducing the low back pain in adolescents and enhancing the somatic facet of the quality of life. Keywords: Low back pain in adolescents, quality of life

1. Introduction Pain, whether sensorial or emotional, is an unpleasant sensation. The low back pain (LBP), which often affects young people, leads to consulting specialists from various fields. The modern man excessively uses the technological advances, limiting the daily physical activity to minimum [1]. However, mechanical problems arising from the physical activity, heavy back∗ Corresponding author: Szymon Swierkosz, ´ ul. Skrzydlewskiego 21/30, 43-382 Bielsko-Biała, Poland. Tel.: +48 517 834 922; E-mail: [email protected].

packs or excessive computer use do not appear to be associated with the low back pain in adolescents [2]. The low back pain is more common in school-age children with high levels of psychosocial difficulties, conduct problems, familial LBP, and psychological distress [3,4]. Positive factors correlate with a reduction of back pain and negative ones result in an exacerbation of symptoms. Malaise, depression, morning fatigue, a wrong assessment of one’s health all increase the pain level in adolescent patients. Lower quality of life contributes to the lack of motivation, discipline problems, intensified somatic ailments [5–9]. The available data point to factors affecting the quality of life in young patients suffering from a nonspecific low back pain.

c 2015 – IOS Press and the authors. All rights reserved ISSN 1053-8127/15/$35.00 

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´ S. Swierkosz and Z. Nowak / Low back pain in adolescents

This study aimed to assess the quality of life of patients with the low back pain who suffer from juvenile idiopathic scoliosis. We also compared this data with patients with similar scoliosis but without pain to see more precisely how pain was affecting adolescents’ quality of life. Furthermore, We wanted to see whether a rehabilitation programme would affect the psychosocial aspects of the quality of life. Scoliosis is usually painless [10]. Untreated, it may lead to back pain [11]. The association between the back pain and idiopathic scoliosis in children and adolescents has been a matter of controversy [12]. Most cases of the back pain are non-specific and selflimiting, and in nearly 80% of cases it is impossible to determine its causes [13]. The problem becomes apparent when the pain does not subside with time and begins to affect important spheres of the patient’s life. The intensity of the low back pain, which often results in the loss of employment, limitation of activity and high medical costs, increases with age [14]. Regardless of age and gender, the low back pain in children and adolescents is a strong predictor of the low back pain in adulthood [15]. Therefore, there is a pressing need to diagnose and treat the low back pain before the associated physical or psychological difficulties increase beyond control. The complexity of the low back pain in adolescents does not allow to asses this problem only on one level. Generally, questionnaires provide important information about various areas of a patient’s life and the advances achieved by the treatment applied which in turn facilitates the organization and management of a relevant therapy programme. In order to obtain more objective and reliable data We applied the short form of the McGill Pain Questionnaire and the Quality of Life Questionnaire (WHO) describing somatic, environmental, psychological and social experiences [16– 19]. Despite the fact that certain randomized trials found that the engagement in an exercise programme appears to bring benefits after at least 8 weeks, We proposed a shorter period of treatment [20,21]. It was due to the standard length of the rehabilitation period under the present health care system, which provides only for 3 weeks of treatment. In this context, We proposed an integrated strategy that connects soft manual therapy techniques with PNF exercises.

2. The aim of the study The aim of the study was to assess whether a short programme of rehabilitation combining two methods

of treatment could bring benefits in terms of a decrease in the low back pain and an improvement of the quality of life.

3. Methods 3.1. Research problems 1. Does the rehabilitation programme result in a significant change in the assessment of the quality of life and the level of pain in the research male/female groups? 2. Does the assessment of the quality of life of adolescents with the low back pain differ between the clinical and the control groups? 3. Does the proposed rehabilitation programme result in a significant change in the assessment of qualitative pain variables? 4. Does the proposed rehabilitation programme influence the descriptive features of the low back pain in the clinical group? Inclusion criteria: – The diagnosis of the low back pain based on the anamnesis and radiological documentation performed by physicians (neurologist, orthopaedist, radiologist,) – idiopathic scoliosis up to I◦ (x < 30◦ ) as calculated by the Cobb’s method, – The age brackets: 15–18 – No congenital defects of the spine, – Time from the onset of the first symptoms: not less than two months and not more than six months. Exclusion criteria: – Inflammatory/infectious changes – Spine injures, compression fractures, transverse processes fractures – Digestive system diseases, gynaecological diseases – Previously unhealed injuries of other joints – Psychogenic syndrome, depression, other mental illness – Central nervous system diseases, spina bifida, spondylolisis, spondylolistesis – Compensating curves, greater degree of curvature – No caregivers/parents consent – Shorter period of stay (less than 3 weeks) – Out-patient visits

´ S. Swierkosz and Z. Nowak / Low back pain in adolescents

3.2. Material The clinical group: 21 people (random selection), aged 15–18 years 15,86 ± 0,85 (14 ♀ and 7 ♂), weight 61.55 kg ± 11.25 kg (49–97 kg), height 166 cm ± 9.5 cm (150–188 cm), BMI 22.29 ± 2.95 (19.43– 28.30). Degree of scoliosis in the frontal plane 14.67◦ ± 4.39◦ (10–25◦). Patients who suffered from the back pain, and for whom the standard approach had not given the expected results. The primary care physicians had recommended rehabilitation. Standard thoracolumbar radiograph views performed in a rehabilitation centre included the standing anteroposterior (AP) and lateral projections. A radiogram showed thoracolumbar scoliosis with long “C” shape curved I◦ (81%) and lumbar short C shape (19%). No other defects had been found (spondylolisis, spondylolistesis, spina bifida,etc). Medical diagnosis – juvenile idiopathic scoliosis M 41.1 and low back pain M 54.5. For the purposes of this study I◦ of scoliosis was defined as a visible deviation from the vertical axis in the upright position, the curvature can be compensated partly actively, completely passively, Adam’s forward bending test mostly shows no asymmetry contours of the back, small and initial changes in the transverse plane (possible various range of rotation), changes in frontal plane < 30◦ . Control group: 11 people (random selection) age: 15–18, average age: 15.7 ± 0.67. weight 51.65 kg ± 5.94 kg (43.5–63 kg), Height 159 cm ± 7.5 cm (149– 171 cm), BMI 20.43 ± 1.90 (16.58–24.12), degree of scoliosis in the frontal plane 16.5◦ ± 2.64◦ (14–21◦). Patients after school screening, which showed abnormalities in the contours of the back, referred for rehabilitation. Standard thoracolumbar radiograph views performed in a rehabilitation centre included the standing anteroposterior (AP) and lateral projections. The radiogram showed thoracolumbar scoliosis with long “C” shape curved I◦ (91%), and lumbar short C shape (9%). Medical diagnosis – juvenile idiopathic scoliosis M 41.1. Group without pain received no intervention. The hospital did not have any more accurate medical data in its database. The advanced imaging in the form of MRI, computed tomography (CT), or bone scan had not been considered as the clinical picture was not alarming enough to warrant additional exposure to radiation [22, 23].

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3.2.1. Physiotherapy assessment During the assessment the physiotherapist tried to reproduce the patients’ pain through palpation and movement. Active movement performed by patient Flexion – patients bent forward as far possible with knees straight. Extension – patients bent backward as far as possible with knees straight and lumbar spine supported by examiner. Lateral flexion – patients bent to the side as far as possible. Lateral rotation – patients rotated the trunk as far as possible. A number of variations of this exercise were conducted with the help of the therapist. Passive movement performed by the physiotherapist The test of segmental mobility and “ joint play” of the spine (performed mostly in the supine position, or side lying) and specialist functional tests to reproduce and relive the pain according to Kaltenborn-Evjenth Concept. Palpation: tenderness over the spinous processes, facet joints, paraspinal muscles, sacroiliac joints, gluteal muscles, posterior superior iliac spines, posterior iliac crest, ligaments of the pelvis and spine. The length of the hamstrings, iliopsoas and rectus femoris muscles was determined by means of the standard muscles length tests. 3.2.2. Intervention The experimental group participated in a 3-week rehabilitation programme in the Long-term Care Hospital in Jaworze on the Children and Adolescents Ward. The subjects were treated according to the KaltenbornEvjenth Concept: 45 minutes/ 3 times/ week (9 sessions). According to the method, procedures included mostly lumbo-sacral segment mobilization (L5-S1) in the restricted movement direction and segmental traction mobilization (L5-S1) (single mobilization duration: 1.5 minute or 3 × 30 sec.) The patients should not feel pain during the therapeutic actions. We also used muscle mobilization techniques including functional massage of the erector spinae and quadratus lumborum and post isometric relaxation of shortened lower limb muscles, 10–15 minutes/ session, 9 sessions/3 weeks. These techniques were passive. The rehabilitation programme was strictly adjusted to the condition and functional capabilities of the young patients. The doctor had consented to the use of gentle manual techniques. Each session included in the fol-

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´ S. Swierkosz and Z. Nowak / Low back pain in adolescents

lowing order: functional massage and joints mobilization, post isometric relaxation, and PNF exercises. PNF exercises are based on the combinations of patterns of the shoulders and pelvis. The muscles on the concave side were stretched using the techniques involving the depression of the pelvis and the elevation of the scapula (with the patient lying on the side). The muscles of the convex side were strengthened by the pattern of scapula depression and elevation of the pelvis. When a patient was lying on the “convex side” of the curvature, passive correction was applied with the use of a rolled blanket or a small roller. We used 4 patterns, each with 3 × 10 repetitions, lasting 5–7 seconds each. A stay of 24 hours, 7 days a week allowed the patients to undergo the full therapy programme. The above described techniques were active. The research was financed from own resources. The rehabilitation programme was implemented by two qualified physiotherapist. The manual therapy was conducted by a physiotherapist, who had completed 256 hours of postgraduate continuing clinical education in manual therapy and passed the final exam in the Examination and Mobilization of the Extremity Joints and the Spine Manual Therapy Kaltenborn-Evjenth Concept. The therapist had 5 years of professional experience. The physiotherapist who conducted the exercises had completed the IPNFA – Proprioceptive Neuromuscular Facilitation Basic and Developing Course (M. Knott Concept) and passed the final exam. Total: 150 hours of instruction. The therapist had 5 years of professional experience. The applied rehabilitation programme affected a few factors which may lead to the low back pain. Only a comprehensive approach may lead to desirable results, which are usually unattainable by one-dimensional proceeding in relatively moderate dysfunctions such as scoliosis [20]. Children and their caregivers were informed in detail about the aim of the experiment. Only children who had signed the consent and whose parents signed the consent to therapy were included in the study. The Ethical Committee of the Academy of Physical Education in Katowice (Poland) also approved of the study.

from the patients and their caregivers. The respondents could ask questions and resign from the study at any time. The interviewer gave relevant instructions before filling in the questionnaires. The interviewer did not see the answers to the questions, but could provide guidance during the filling in of the questionnaires (as is allowed by the authors of questionnaires.) The person who collected the data and entered them into the computer did not affect the therapeutic management and he was not biased. The questionnaires were carried out on admission, before treatment and two days after the last session. We applied the abridged version of World Human Organization Quality of Life Questionnaire (WHOQOL -BREF) to assess the quality of life before and after the rehabilitation programme. The particular items in the questionnaires were grouped and summed up according to the WHOQOL-BREF evaluation protocol. The health related quality of life consisted of 4 facets: Physical Health: (6 – Q3) + (6 – Q4) + Q10 + Q15 + Q16 + Q17 + Q18, Psychological Quality of Life: Q5 + Q6 + Q7 + Q11 + Q19 + (6 – Q26), Social Relationships: Q20 + Q21 + Q22, Environmental Quality of Life Q8 + Q9 + Q12 + Q13 + Q14 + Q23 + Q25, (The Arabic numerals refer to particular questions (Q) in the questionnaire). The assessment of the level of back pain was based on the Short Form of McGill Pain Questionnaire (MPQ-SF). The vocabulary part was made of words which were most frequently chosen by patients filling in the full form of the McGill Questionnaire (presence in 33% of the questionnaires returned). The short form of the questionnaire consists of 15 adjectives (11 sensory, 4 affective) which may be graded from 0 (no pain) to 3 (strong pain). Such approach enables creating a pain evaluation index (PEI) which accounts for the sensory and affective factors. The questionnaire also aims to determine pain patterns – words which are specific to groups of patients with a similar dysfunction. The description of sensory features concerns temporal and spatial characteristics like pressure or temperature. Affective adjectives, describing tension, anxiety or the autonomic system reactions, are also part of the pain experience.

3.3. Methods 3.4. Statistical methods To obtain data for analysis We used a questionnaire. At first, We carefully explained the aim of the testing and the therapeutic procedures, then obtained consents

The person who prepared the statistical analysis is a qualified medical statistician, does not belong to the

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Table 1 The variables with near normal distribution (p > 0.05) Quantitative variable Whole QOL-BEFORE-SOMAT QOL-BEFORE-PSYCH QOL-BEFORE-SOC QOL-BEFORE-ENVIR QOL-AFTER-SOMAT QOL-AFTER-PSYCH QOL-AFTER-SOC QOL-AFTER-ENVIR PEI-S-BEFORE PEI-A-BEFORE PEI-S-AFTER PEI-A-AFTER PEI-BOTH-BEFORE PEI-BOTH-AFTER

N − N N N − − N − − − − − −

Group Gender Boys Girls N N N N N N N N N N N − N − N N N N − − N − − − − N − −

Study group Clinical Control N N N N N N N N N nd − nd − nd N nd − nd − nd − nd − nd − nd − nd

QOL – Quality of Life facet, PEI- Pain Evaluation Index, PEI-S-Sensory, PEI-Aaffective, N- normal distribution, nd- no data, − the distribution is not normal.

research team and thus could not have any influence on the test results. The collected data was analyzed separately for the clinical and the control groups and separately for male and female patients. Furthermore, all relevant combinations of these grouping variables were used. In order to perform the statistical analysis We used computer programmes included in the Open Office 3.3.0 and the StatSoft Statistica 10 package. Descriptive statistics used for the characterization of the quantitative variables of the sample: – To measure average values: arithmetic mean with 95% confidence interval, median, lower and upper quartile – To measure distribution: variance, standard deviation with 95% confidence interval (used only with the normal distribution of the feature described), standard error of the mean, variance, the minimum and maximum values. – To measure asymmetry: skewness – To measure concentration: kurtosis In order to describe the qualitative variables frequency tables were used. The verification of statistical hypotheses assumed significance level α = 0.05 (p > 0.05) The verification of the statistical test assumption – study of the normal distribution variables. In order to investigate the compliance of the empirical distributions of the variables tested with the normal distribution the Shapiro-Wilk test was used and histograms were constructed showing the distribution of a number of the test variables.

The variables with near normal distribution (p > 0.05) are shown in Table 1. The verification of the statistical test assumptions – the homogeneity of the variance. Before performing the t-test for independent variables the homogeneity of variance was examined by means of the Brown-Forsyth test. Verification of the statistical hypothesis. The statistical tools used for the purpose of verification of statistical hypotheses were: – Parametric t-test (“the difference test”) for the dependent variables whose distribution is consistent with the normal distribution – Nonparametric Wilcoxon test for dependent variables whose distribution is not consistent with the normal distribution – Parametric t-test for independent variables whose distribution is consistent with the normal distribution

4. Results After the treatment We observed an increase in the quality of life index for each of the assessed facets of life. The greatest change was 7.17 in the physical health facet in the clinical group (p = 0.000613), 6.12 in female (p = 0.015400), and 9.19 in male (p = 0.022311). The assessment of the quality of life facets is shown in Table 2. There was no statistically significant change in the psychological, social and environmental facets of the quality of life. Full statistical evaluation of the quality of life facets is shown in Table 3.

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Table 2 The assessment of the Quality of Life facets Quality of Life facets Psychological Social 66.96 72.02 70.54 76.43 3.58 4.41

Group Girls before Girls after Girls Δ

Somatic 61.74 67.86 6.12

Environmental 67.86 69.20 1.34

Boys before Boys after Boys Δ

61.73 70.92 9.19

75.59 79.76 4.17

67.26 67.86 0.5

71.43 70.98 −0.45

Clinical before Clinical after Clinical Δ

61.73 68.88 7.15

69.84 73.61 3.77

70.44 73.57 3.13

69.05 69.79 0.74

Control before Clinical/Control

80.71 18.98

80.42 10.58

80 9.56

77.82 8.77

Table 3 The statistical evaluation of the Quality of Life facets Quality of Life facet Somatic Psychological Social Environmental

Clinical Significant (p = 0.000613) Insignificant (p = 0.075869) Insignificant (p = 0.378675) Insignificant (p = 0.753152)

Study group Boys Significant (p = 0.022311) Insignificant (p = 0.266791) Insignificant (p = 0.902720) Insignificant (p = 0.916754)

Girls Significant (p = 0.015400) Insignificant (p = 0.168168) Insignificant (p = 0.343253) Insignificant (p = 0.654548)

Table 4 Comparison of the Quality of Life facets in the clinical and control groups Quality of Life facet Somatic Psychological Social Environmental

Clinical vs. Control Significant (p = 0.000005) Significant (p = 0.031553) Insignificant (p = 0.064735) Significant (p = 0.036307)

The parametrical t-test for independent variables with the normal distribution shows that the assessment of the quality of life is different between the clinical and control groups (statistical significance) for the following facets: Physical – the whole sample 18.98 (p = 0.000005); females 18.97 (p = 0.000324); Psychological – the whole sample 9.88 (p = 0.031553), females 13.46(p = 0.028388); Environmental – the whole sample 8.77 (p = 0.036307), females 8.62 (p = 0.008671); Social – males 12.74 (p = 0.015393); Comparison of the Quality of Life Facets in the clinical and control groups can be seen in Table 4. Before the rehabilitation programme, the pain evaluation index (PEI) was 12.19 in the clinical group, it was remarkably higher for the female group (13.57 ♀ vs. 9.43 ♂). After the rehabilitation, we observed a statistically significant change in the assessment of the pain level (PEI) in the clinical group: 5.71 (p = 0.000132),

Group Boys Insignificant (p = 0.230193) Insignificant (p = 0.296972) Significant (p = 0.015393) Insignificant (p = 0.530441)

Girls Significant (p = 0.000324) Significant (p = 0.028388) Insignificant (p = 0.321595) Significant (p = 0.008671)

5.93 for females (p = 0.001474) and 5.29 for males (p = 0.027709). The change in the sensory part of the pain level assessment was statistically significant in the clinical group −4.19 (p = 0.000342), females 5.0 (p = 0.001474); the change in the affective part was significant in the clinical group −1.10 (p = 0.032855) (Ttest and Wilcoxon test). The changes of Pain Evaluation Index can be seen in Table 5. The relevance of the PEI is shown in Table 6. After the therapy we recorded a significant change in the assessment of the qualitative pain variables in the clinical group: a decrease in strong pain was 21 marks (p = 0.017818), a decrease in moderate pain was 27 marks (p = 0.002487). There was no significant change in mild pain (1 mark). The results concerning the qualitative pain variables are shown in Table 7. The relevance of qualitative variables is shown in Table 8. We observed a significant change of parameters for the descriptive pain features as expressed by the following words: stabbing (chosen by 95.24% of respon-

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Table 5 The Pain Evaluation Index Group

Rehabilitation

PART PEI-Sensory 9.76 5.57 1.38

PEI-Affective 2.48 4.19 1.10

Clinical

Before After Δ

PEI-whole sample 12.19 6.48 2.48

Boys

Before After Δ

9.43 4.14 5.29

7.86 5.29 2.57

1.71 0.29 1.43

Girls

Before After Δ

13.57 7.64 5.93

10.71 5.71 5.00

2.86 1.93 0.93

Table 6 The relevance of the Pain Evaluation Index Group Clinical Boys Girls

PEI-whole sample Significant (p = 0.000132) Significant (p = 0.027709) Significant (p = 0.001474)

PART PEI-Sensory Significant (p = 0.000342) Insignificant (p = 0.067023) Significant (p = 0.001474)

Table 7 The assessment of the Qualitative Pain variables Rehabilitation Before After Δ

Mild 69 68 1

Moderately 47 20 27

Strong 31 10 21

dents, p = 0.00257), aching (chosen by 85.71% of respondents, p = 0.00982) (McNemara test). Descriptive features of the low back pain in adolescents with statistical evaluation are shown in Table 9.

5. Discussion In the case of young people back pain is increasingly treated as a set of factors – both physical and mental, which may be described as the biopsychosocial approach [24–26]. The results of this study suggest that the individual facets of the quality of life were evaluated differently by both female and male respondents in comparison to the control group. It supports Wirth’s view [27]. The difference observed in the responses of girls and boys may be due to a different level of sensitivity to health issues shown by boys and girls, girls’ lower self-esteem and more attention paid to appearance, security and finances, although these are speculations only. In the studies of other authors the quality of life disorders related to the condition of health were two times more frequent in children with pain than children without pain [28]. In the data collected under this study (in the group with small scoliosis I◦ )

PEI-Affective Significant (p = 0.032855) Insignificant (p = 0.201244) Insignificant (p = 0.090970)

We observed smaller but also clear and significant differences. While the epidemiology of back pain at young age has been described extensively, studies evaluating the effects of interventions to prevent LBP or the consequences of LBP in schoolchildren are still sparse [29]. After the rehabilitation programme the biggest changes were observed on the somatic level in each group. It should be noted that this facet belongs to the domain of physiotherapist work, containing daily physical activity, fitness, energy and fatigue, mobility, pain and discomfort, sleep and rest, and efficiency. Sollerhed et al. research indicates that higher levels of physical activity assessment associated with the somatic plane correlates with a decrease of the symptoms in children, and better coping with unpleasant bodily sensations [30]. Mansourian et al. study also points to a significant effect of comprehensive rehabilitation on the quality of life of patients with LBP, and their improved performance [31]. After rehabilitation the changes on the psychological, environmental and social levels were not statistically significant. The relationship between psychological factors, pain acceptance, depression and functional disability is noticeable in studies of children with chronic low back pain. The poor psychosocial assessment and the lack of improvement in these areas of life may be due to the factors identified by Lindstrom-Hazel, Reneman, Cieply and Milbrandt [24, 25,32]. They believe that depression, anger, aggression, poor focus, back pain in parents, fatigue, other ailments beside the back pain and other psychosocial

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Table 8 The relevance of the assessment of qualitative pain variables Group Clinical Boys Girls

Mild Insignificant (p = 0.965263) Insignificant (p = 0.753153) Insignificant (p = 0.783652)

Pain intensity Moderately Significant (p = 0.002487) Significant (p = 0.043115) Significant (p = 0.020796)

Strong Significant (p = 0.017818) Insignificant (p = 0.422679) Significant (p = 0.027709)

Table 9 Descriptive features of the low back pain in adolescents with statistical evaluation Stabbing Aching Tiring-exhausting Cramping Heavy Throbbing Tender

Before 95.24% 85.71% 71.43% 61.9% 57.14% 52.38% 52.38%

factors which correlate with a child’s back pain may inhibit the rehabilitation process and recovery. Some authors believe that the pain may be a result of stress somatisation and unpleasant emotions [33]. In Watson et al. it was suggested that psychosocial factors were more important than mechanical factors for LBP occurring in young populations [34]. Although it is hard to deny the validity of their research work, data collected under this study appear to suggest different conclusions. We used the mechanical therapy, which brought the greatest improvement in the somatic health with no statistical improvement in the other areas of the adolescents’ life. It is also visible in the results that We obtained in terms of the decrease in the pain level without any change of psychosocial factors. Fanucchi et al. arrived at nearly the same conclusions [21]. It should be noted that the 3-week period of rehabilitation, even taking into account the good conditions provided by the hospital, did not change the psychosocial and environmental conditions of the patients’ homes. After the rehabilitation We observed a statistically significant decrease in the level of pain, which can be explained by the complexity of the applied rehabilitation programme based on the Kaltenborn-Evjent’s method and PNF. Meta-analysis of Muñoz Calvo studies on the effectiveness of physiotherapy in adolescents with LBP clearly indicate that the most effective therapeutic strategies are those based on manual therapy and physical exercises [35]. A recent research showed a significant difference in the hamstring length between subjects with and without LBP in all categories [36]. This study did not consider the assessment of risk factors such as muscles

After 57.14% 66.67% 47.62% 33.33% 28.57% 47.62% 42.86%

Significance Significant (p = 0.00257) Significant (p = 0.00982) Insignificant (p = 0.42268) Significant (p = 0.00195) Insignificant (p = 0.57910) Insignificant (p = 0.78927) Insignificant (p = 0.68309)

length, range of motion. The use of non-surgical, nonpharmacological therapies (based on stretching and relaxation of the muscles) is still preferred in the therapy of the back pain in adolescents to surgical and pharmacological treatments [37]. It seems that combined strategies are safe to patients’ health and also may bring desired results in a short time. Low back pain patterns in adolescents with scoliosis I◦ are characterized by such descriptive terms as: stabbing and aching. We believe that this is linked to the achievement of the final range of motion in bending and segmental compression tests manifested by stabbing sensation in L5-S1 junction. Hyperalgesia in the painful area, which can be caused by sensitization of the central nervous system, was found in patients with chronic LBP in Imamura et al. studies but this mechanism should be further investigated [38]. Muscle imbalance, active trigger points, higher myoelectric activity of lumbar muscles in flexion, rigid and less variable patterns of muscle activation in patients with low back pain leads to excessive energy expenditure, fatigue and exhaustion [39,40]. These factors negatively affects the health of adolescents which manifests essentially as aching pain. Patients who did not see any recovery over a long period of time reported to the rehabilitation centres to solve the problem, so spontaneous recovery cannot be identified as a possible limiting factor here. The effects of therapy presented above seem promising both in terms of quantitative and qualitative pain variables. Nonetheless, there is a need for the examination of the therapy effects six months after its termination. It would also be desirable to study the effects of longer treatment, preferably on a larger sample and

´ S. Swierkosz and Z. Nowak / Low back pain in adolescents

with the consideration of risk factors. Such study is already underway.

6. Conclusion A combination of physical exercises and soft manual therapy is effective in reducing the low back pain in adolescents and enhancing the somatic facet of the quality of life.

Acknowledgements The authors thank the Director of Beskidian Complex of Medicine and Rehabilitation, Long-term Care Hospital in Jaworze (Poland).

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