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Low back pain in adolescent athletes
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Sports medicine.ORCID iD: 0000-0001-8762-024
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Globally Low back pain (LBP) is one of five leading causes of years lived with disability (YLD), and LBP is a common complaint among adults as well as adolescents and adolescence athletes. During adolescents, the LBP often is considered as non- specific without structural findings and thus not needed to be further diagnosed or treated specifically. However, LBP that begins in adolescence often continue through adulthood, and since adolescent athletes with high physical activity seems to have more LBP than less physically active adolescents, high physical loading during adolescence, might be a risk factor for LBP later in life.

Studies: Epidemiology: The Standardized Nordic Questionnaire adjusted for adolescence was used to investigate the prevalence of LBP during adolescence (16-19 years old individuals).

Retrospective study: A ten-year follow-up on symptomatic low back spondylolysis patients identified on MRI or CT. Sixteen out of nineteen identified patients agreed to answer a questionnaire and to have their case-history reviewed.

Case-control study: Twenty-five patients (13-19-year-old boys and girls) with LBP and 13 pain free individuals (controls, 14-19-year-old boys and girls) were investigated with physical examination and MRI. If the patients had findings on MRI a CT investigation was performed.

Clinical study: Twelve of 14 patients (a subgroup from the case-control study) with Spondylolysis on MRI and CT were evaluated with a modified Hollenberg classification (six levels). These patients were re-evaluated with MRI and CT after 3 months of treatment with complete rest from sports activity.

Differential diagnosis: Five adolescent patients with on-going LBP/thigh pain previously treated in other clinics, were reevaluated for a “second opinion”.

Results: Epidemiology study: The prevalence of LBP among adolescents was 46% (N= 2522) with an annual incidence of 42 %. Girls reported more LBP than boys (52 % versus 40 %). Individuals who were active in sports > 6 h/w had significantly more LBP compared with less physically active individuals. 

Retrospective study: Thirteen of the 16 individuals had a second MRI/CT investigation and thus 52 out of the initial 64 pars interarticularis where investigated a second time (mean 3 months after the first investigation). These patients had had different treatments, most commonly rest for 3 months. In total, 7 out of 16 individuals healed (44%).

Case control study: In 22/25 patients (88%) there were clinical findings and MRI findings such as spondylolysis, disc herniated discs, disc degeneration and injuries to the vertebral body. In 13/25 patients (52%) spondylolysis of different stages were found. No clinical test alone, or in combination, could reliably diagnose spondylolysis, and could thus not be used as a selection test for patients who need further diagnostics with MRI and CT.

Clinical study: Using a combination of MRI and CT examination the early signs of skeletal injury (oedema, incomplete fracture) to the pars interarticularis were detected. Patients diagnosed with these early stages healed significantly better than if diagnosed in later stages (complete fracture and pseudoarthrosis).

Differential diagnosis: The second opinion with careful physical examination and MRI examination diagnosed stress reactions in the pelvic ischial tuberosity in the patient seeking help for pain in the lower back/thigh. After guided rehabilitation, all these patients returned to previous sport activities.

Conclusions: LBP is common during adolescence, more common in girls and in highly active individuals. LBP must be taken seriously, especially in adolescent athletes who not seldom have fractures in pars interarticularis (Spondylolysis). If diagnosed early, there seems to be good potentials to heal the fracture with 3 months ́ of rest from loading (sport activity). Differential diagnoses such as stress reactions in the pelvic ischial tuberosity should be taken into consideration.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet , 2019. , p. 59
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2014
Keywords [en]
Adolescence, Ischial Tuberosity, Low Back Pain, Oedema, Pars Interarticularis, Physical Activity, Pseudoarthrosis, Sport Activity, Stress fracture, Stress reaction
National Category
Physiotherapy
Research subject
Sports Medicine
Identifiers
URN: urn:nbn:se:umu:diva-155848ISBN: 978-91-7855-024-1 (print)OAI: oai:DiVA.org:umu-155848DiVA, id: diva2:1283926
Public defence
2019-02-22, Aulan, Vårdvetarhuset, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Funder
Swedish National Centre for Research in Sports, 330610018Available from: 2019-02-01 Created: 2019-01-30 Last updated: 2019-01-31Bibliographically approved
List of papers
1. Stress Fractures of Pars Interarticularis in Adolescent Athletes a Classification System with MRI and CT Enabling Evaluation of The Healing Process
Open this publication in new window or tab >>Stress Fractures of Pars Interarticularis in Adolescent Athletes a Classification System with MRI and CT Enabling Evaluation of The Healing Process
2018 (English)In: Journal of Exercise, Sports & Orthopedics, E-ISSN 2374-6904, Vol. 5, no 1Article in journal (Refereed) Published
Abstract [en]

Introduction: The purpose of this study was to evaluate healing frequency in different stages of stress reactions in the Pars Interarticularis (PI) using a classification system with MRI and CT. The intervention was 3-month rest from physical activity, without a brace, with the exception of activities of daily living.

Materials & Method: Twelve adolescent athletes with different stages of Spondolysis were included in the study. They had pathology in the Pars Interarticularis and were clinically examined with MRI and CT 3-6 weeks after debut of Low Back Pain (LBP) and re-evaluated after 3 months intervention with rest from physical activity.

Results: A combination of MRI and CT scanning to investigate suspected injuries to Pars Interarticularis in adolescent athletes revealed 6 different stages of Spondolysis that ranged from marrow oedema to pseudoarthrosis. After 3 months of rest from physical activity the early stages of Pars Interarticularis injuries healed significantly better than the later stages with rest from physical activity.

Conclusion: The combination of MRI and CT revealed 6 stages of stress reactions instead of 4 as in Hollenberg’s staging with MRI only. In the 3 earliest stages, of these 6, rest from physical activity for 3 months can heal the stress reaction.

Keywords
Low Back Pain, Oedema, Pseudoarthrosis, Spondylolysis, Medical and Health Sciences, Health Sciences, Sport and Fitness Sciences, Medicine/Technology, Oedema, Pseudoarthrosis, Spondylolysis, Medicin och hälsovetenskap, Hälsovetenskaper, Idrottsvetenskap, Medicin/Teknik
National Category
Other Medical Sciences
Research subject
Sports Medicine
Identifiers
urn:nbn:se:umu:diva-154472 (URN)10.15226/2374-6904/5/1/00169 (DOI)
Available from: 2018-12-18 Created: 2018-12-18 Last updated: 2019-01-30Bibliographically approved
2. Clinical Examination, Spondylolysis and Adolescent Athletes
Open this publication in new window or tab >>Clinical Examination, Spondylolysis and Adolescent Athletes
2013 (English)In: International Journal of Sports Medicine, ISSN 0172-4622, E-ISSN 1439-3964, Vol. 34, no 3, p. 263-267Article in journal (Refereed) Published
Abstract [en]

Symptomatic spondylolysis is a stress reaction caused by microtrauma during physical exercise, an imaging diagnostic subgroup of Adolescent Low Back Pain (ALBP), found in adolescent athletes. Early diagnosis increases the possibility of healing. Thus, it is important to divide ALBP into subgroups. The aim of this study was to evaluate clinical tests that can distinguish symptomatic spondylolysis from other forms of ALBP in order to facilitate early referral for diagnostic imaging. The investigation subjects were a prospective case series with a control group, 25 subjects with ALBP and 13 subjects that had no history of LBP. The 2 groups were examined using the same clinical protocol. MRI of the whole lumbar spine was performed in both the case and control groups and CT investigations of the L4 and L5 vertebrae were performed in the case group. Significant differences between the 2 groups were found in 8 of our clinical tests. No clinical test, alone or in combination, could distinguish between spondylolysis and other forms of ALBP. As 88% of the subjects in the case group had MRI findings and almost 50% had spondylolysis, MRI should be performed at an early age in young athletes with ALBP.

National Category
Sport and Fitness Sciences
Identifiers
urn:nbn:se:umu:diva-60941 (URN)10.1055/s-0032-1321723 (DOI)000315166200014 ()23027361 (PubMedID)
Available from: 2012-11-05 Created: 2012-11-05 Last updated: 2019-01-30Bibliographically approved
3. Low back pain and associated disability in Swedish adolescents
Open this publication in new window or tab >>Low back pain and associated disability in Swedish adolescents
2019 (English)In: Scandinavian Journal of Medicine and Science in Sports, ISSN 0905-7188, E-ISSN 1600-0838, Vol. 29, p. 393-399Article in journal (Refereed) Published
Abstract [en]

Introduction: Low back pain (LBP) defined as ache or pain in the lowest part of the back is a common experience among people all over the world. The lifetime prevalence is reported to be as high as 84%, and the prevalence of LBP seems to be almost the same among adolescents as among adults. The risk for having LBP later in life if you experienced LBP in adolescence is high.

Material and Methods: In this cross‐sectional study of 2550 students aged 16‐20 years, we used the Standardized Nordic Questionnaire for the analysis of musculo‐skeletal symptoms. We studied gender difference, prevalence, and disability of Low back pain. We also studied differences in LBP in adolescent athletes depending on hours spent on sports or physical activity.

Results: Significantly, more girls than boys had had problems sometimes during their life. Those who participated in sports reported LBP to a significantly higher extent than those who were physically inactive in their spare time. Gender and spare time sports were important risk factors for getting LBP some time in life. There was a higher risk for girls to have low back pain problems more than 30 days or daily the last year if they had had low back pain some time earlier in life.

Conclusion: This study shows that low back pain (LBP) is common among Swedish adolescents, more common among girls than boys. High sport activity was associated with the risk of having LBP, length of time with LBP, and disability due to LBP.

Place, publisher, year, edition, pages
John Wiley & Sons, 2019
Keywords
low back pain, adoloscents, disability, back trouble, epidemiology, female, male, sports, Swedish, young people
National Category
Other Medical Sciences not elsewhere specified
Research subject
Sports Medicine
Identifiers
urn:nbn:se:umu:diva-154449 (URN)10.1111/sms.13335 (DOI)000458294800008 ()30421820 (PubMedID)
Funder
Swedish National Centre for Research in Sports
Available from: 2018-12-18 Created: 2018-12-18 Last updated: 2019-04-16Bibliographically approved
4. Physical Examination and Magnetic Resonance Imaging of Stress-Related Bone Injuries in Tuber Ischiadicum
Open this publication in new window or tab >>Physical Examination and Magnetic Resonance Imaging of Stress-Related Bone Injuries in Tuber Ischiadicum
2017 (English)In: Journal of Exercise, Sports & Orthopedics, ISSN 2374-8354, Vol. 4, no 1, p. 1-3Article in journal (Refereed) Published
Abstract [en]

Introduction: Stress-Related Bone Injuries (SRBI) in the Tuber Ischiadicum (TI) is a possible preliminary diagnosis in adolescent athletes with pain in the pelvic region or in the back of the thigh. The condition requires an early diagnosis in order to heal properly. We describe five cases of young athletes seeking a physiotherapist for pelvic or back thigh pain.

Materials and methods: Five patients previously diagnosed with lower back pain, groin pain, pelvic or back thigh pain underwent a Physical Examination (PE) by a physiotherapist to identify the pathogenesis of the pain. The PE led to the preliminary diagnosis of SRBI in the TI, which was confirmed by an MRI. The patients were treated with rest and Personally Guided Rehabilitation (PGR).

Results : All cases had a positive eccentric hip extension test and pain provocation on palpation on the TI. MRI found different levels of stress reactions/fractures in the enthesis of the TI. After rest and rehabilitation, all subjects returned to their previous level of physical activity.

Conclusion: PE appeared to identify adolescent athlete patients with SRBI in the TI requiring an MRI. The correct diagnosis led to a quick return to the previous level of physical activity.

Clinical relevance: An early and correct diagnosis thru a thorough PE can lead to complete healing and a return to sports.

Keywords
Tuber ischiadicum, stress reaction, stress fracture, Physical Examination
National Category
Physiotherapy
Identifiers
urn:nbn:se:umu:diva-155833 (URN)10.15226/2374-6904/4/1/00154 (DOI)
Available from: 2019-01-29 Created: 2019-01-29 Last updated: 2019-01-30Bibliographically approved
5. Low back stress fracture, spondylolysis and the importance of diagnosis: a retrospective MRI/CT and clinical study of stress reactions in the spine of young athletes
Open this publication in new window or tab >>Low back stress fracture, spondylolysis and the importance of diagnosis: a retrospective MRI/CT and clinical study of stress reactions in the spine of young athletes
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Low back pain (LBP) is common in adolescence as well as in adulthood but the reason for LBP differs between the different age groups. Stress reaction is a reason for LBP in adolescence and there is a discussion about the progression from stress reactions to spondylolysis, which in turn can develop into spondylolisthesis.

Sixteen out of nineteen MRI identified subjects with spondylolysis agreed to take part in the whole investigation that included a questionnaire and reexamination of MRI scans performed at the time of diagnose and after the initial treatment (84,2%) with mean age of 15,5 years at diagnosis and mean age of 20.8 at the time of follow-up 1-12 years after diagnosing.

We found a mean time between first symptom of low back pain and time of diagnosis of 28 weeks (0-127 weeks) and a mean activity level of 8.9 hours a week at follow-up with the questionnaire. From the studied MRI investigations seventeen pedicels out of 31 had healed with rest from physical activity as treatment. Seven individuals that displayed spondylolysis on the final MRI had at follow-up (1-12 years after diagnosing) got relief of symptoms and had return to a high level of physical activity. The subject that developed spondylolysis with out healing could thus to a great extent still be physically active.

Keywords
CT, MRI, Stress fracture
National Category
Physiotherapy
Research subject
Sports Medicine
Identifiers
urn:nbn:se:umu:diva-155869 (URN)
Available from: 2019-01-30 Created: 2019-01-30 Last updated: 2019-01-31

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