Spine (Phila Pa 1976). 2004 (Nov 1); 29 (21): 2452–2457 ~ FULL TEXT
Astrid Noreng Sjolie, PhD
Department of Public Health and Primary Care,
Faculty of Medicine,
University of Bergen,
STUDY DESIGN: This is a 3-year prospective study of juvenile low back pain (LBP).
OBJECTIVES: To investigate persistence and change in LBP.
SUMMARY OF BACKGROUND DATA: Earlier episodes of LBP are a strong risk factor for LBP in adults, while the persistence of LBP through adolescence is not known.
METHODS: The material comprised all pupils in eighth and ninth grades (N = 105, mean age 14.7 years), living within two geographic areas in Eastern Norway in January 1997. The analyses included 88 adolescents at baseline, and 85 at follow-up. The questionnaire, which identified LBP as pain or ache in the low back during the preceding year, was answered at baseline in the classroom and at follow-up by post.
RESULTS: LBP was reported by 58% at baseline and by 39% at follow-up, and LBP provoked by manual work by 40% at baseline and 26% at follow-up. Thirty-one percent reported LBP at both occasions. LBP more than 7 days was reported by 32% at baseline, by 26% at follow-up, and by 18% at both occasions. Twenty-two percent of those reporting LBP at baseline rejected ever LBP at follow-up. Baseline reports of LBP predicted corresponding reports of LBP at follow-up: Odds ratio was 4.7 (95% confidence interval 1.7–12.7) for LBP generally, 9.1 (3.0–27.2) for LBP more than 7 days, 9.2 (2.9–28.8) for LBP provoked by manual work, and 3.8 (1.3–11.3) for LBP provoked by sitting at school.
CONCLUSION: The findings indicate a persistent, but changeable, trend in LBP from midadolescence until late adolescence. The consistency and the high rates of reports of LBP provoked by manual work and sitting imply needs for more research on the persistence of LBP, and on relevant interventions during school age.
KEYWORDS: low back pain, adolescents, persistence, change.
From the Full-Text Article:
Unspecific low back pain (LBP) seems to increase over
time in children and adolescents1 as well as in adults. 
The prevalence of weekly LBP has increased 150% and
123% among Finnish girls and boys from 1991 until
2001.  In aWorld Health Organization survey, 25% and
22% of 15–year-old European girls and boys reported
weekly backache. 
There are few prospective studies following the development
and course of LBP in children and adolescents,
but risk factors are reported to be increasing age, female
gender, high levels of sport participation, long periods
spent sitting, poor well-being, smoking, and participation
in manual work. [1, 5] Former episodes of LBP are
strong predictors for future LBP in adults,  while the
studies of children and adolescents show an inconsistent
pattern concerning the persistence in the reports of
LBP. [5, 7] There are, however, indications that LBP in adolescence
and young adulthood is associated with LBP
later in adulthood. [8, 9] The persistence of LBP and of painprovoking
situations in late adolescence is thus uncertain,
and it is also an open and interesting question how
reports of LBP provoked by manual work and sitting
may predict future LBP, on the background of the high
levels of physical disability due to LBP among adults. 
In our two former studies of a group of Norwegian
adolescents, LBP was associated with poor endurance
strength and stability  and poor well-being, but not
with social class or parental LBP.  The aim of the
present study was to investigate the persistence and
change in reports of LBP among the same adolescents,
and to explore whether reports of pain-provoking situations
at baseline were significant predictors of later reports
of LBP. It was hypothesized that both pain per se
and pain provoked by manual work and sitting would
predict later LBP.
Materials and Methods
Design and Implementation.
The study was an epidemiologic investigation, following a group of adolescents from 1997
until 2000. Written consent was obtained from the ethical committees,
the adolescents, and the parents in 1996. The questionnaires
were completed at baseline in the classrooms in the presence
of a teacher and the author. As some potential means to
reduce LBP was wanted by parents, teachers, and adolescents,
a minor back-school based intervention was performed, comprising
information to the teachers and one individual instruction
session to those reporting recurrent LBP. The session emphasized
consciousness of keeping a stable back during sitting
and lifting  and strengthening extension exercises for the lumbar
spine. School furniture was adjusted, mostly by elevation,
according to principles of ergonomic school furniture  for five
adolescents who reported LBP during sitting at school and dissatisfaction
with the table height. The questionnaires at follow-
up were sent to the adolescents’ homes and returned to the
author by post.
The inclusion criteria was all schoolchildren in
eighth and ninth grades in two geographic areas in Eastern
Norway in January 1997, and their parents. One of the areas
was an urban municipality, Rendalen, where the total population
was 2300 inhabitants, and the relevant students numbered
44. The other area was a nearby rural region, Hanstad in Elverum
municipality. The total population in Hanstad region was
2100, and the relevant students numbered 61. All participants
belonged to the only junior secondary school in their areas,
respectively. The exclusion criterion was serious disease that
could interfere with physical performance or LBP; none was
excluded. At baseline, 38 girls and 50 boys participated, making
the response rate 84%. Mean (standard deviation) age was
14.7 (0.7) years, and the range was 14.1 to 16.1 years. The
follow-up was performed 3 years later. Two nonresponders
were boys who confirmed and rejected LBP, respectively, at
baseline. Another boy reported serious LBP in the follow-up
period, due to a bicycle crash during a competition. The data
concerning these three boys were omitted from the study.
LBP was measured by a slightly adjusted
Nordic questionnaire, designed, and validated for schoolchildren 
(Salminen JJ, personal communication 1996). The questionnaire,
displayed previously,  included a drawing of the
back and defined LBP as pain, ache, or discomfort in the lower
back during the preceding year, not related to trauma or menstrual
pain. The questions comprised duration of LBP from
daily to lifetime occurrence, consequences of LBP, such as intake
of pain relievers and visits to health professionals, and
different situations provoking LBP, such as sitting at school,
using television/computer or working manually. Additional
questions treated frequency, time use, and types of physical
activity, well-being, and satisfaction with school furniture. The
questionnaire at follow-up also included open questions concerning
the adolescents’ own opinions of causes of potential
improvement of LBP.
Social class was measured as parental occupations. Eightyseven
percent of the fathers and 91% of the mothers informed
of their occupations and their LBP in a questionnaire sent by
post in 1996. The occupations were registered in seven categories 
according to the parent with the highest level.
Social class was condensed into three levels as follows.
Lower class: skilled or unskilled manual worker, farmer.
Middle class: service occupations, skilled health worker, elementary
school teacher, office clerk.
Upper class: business-owner, executive, university-educated
The level of significance was set to P ≤ 0.05. Univariate
analyses of the categorical data included comparisons between
baseline and follow-up data, using McNemar’s test (McN) and
two-tailed t tests, binary logistic regression analyses, and ordinal
regression analyses, in which baseline data were compared
with ordinal data at follow-up. The interpretation of the odds
ratio is the same as in binary logistic regression analyses. The
ordinal levels ranged LBP during the preceding year as follows:
1, no LBP; 2, LBP 1 to 30 days; 3, LBP 31 days to daily. The
multivariate analyses were performed by multiple ordinal logistic
regression analyses, including gender and social class as
covariates. Significant findings were marked with bold types in
the tables. The program Minitab, version 13.1, was used in the
Plain Comparisons Between Baseline and Follow-up
The distribution of the duration, consequences, and situations
provoking LBP at baseline and at follow-up is
described in Table 1. The most frequently reported painprovoking
situations were performance of manual work,
followed by sitting at school during examination days,
sitting during ordinary school days, and performance of
leisure physical activity. Manual work and sitting at
school provoked pain among 69% and 47% of those
reporting LBP at baseline, and among 67% and 55% at
follow-up, respectively. Corresponding figures for those
reporting LBP more than 7 days were 70% and 63% at
baseline, and 70% and 68% at follow-up, respectively.
Forty-three percent of those who reported LBP provoked
by sitting at school at baseline also reported LBP provoked
by using television/computer, and 35% of those
reporting LBP provoked by sitting at school at baseline
also reported LBP provoked by leisure physical activity.
Baseline and follow-up reports of LBP were associated
for the whole group (McN: P = 0.007) and for girls
(McN: P = 0.009), and there was a tendency to an association
for boys (McN: P = 0.1). Thirty-one percent of
the whole group reported LBP at both occasions, and
53% of those who reported LBP at baseline still reported
LBP at follow-up. Among girls and boys, 59% and 45%,
respectively, of those who reported LBP at baseline still
reported LBP at follow-up.
In Table 2, the recollection of ever LBP at follow-up is
displayed according to the baseline reports of LBP during
the preceding year. Rejecting answers to the question of
ever LBP at follow-up were given by 22% of those reporting
LBP during the preceding year at baseline, and by
11% of those reporting LBP more than 7 days at baseline.
All those who had been treated or used painkiller
due to LBP at baseline answered confirmatory to the
question of ever LBP at follow-up. Three of those still
reported LBP at follow-up, and two of them had used
painkiller due to LBP during the preceding year at follow-
up. Four of the five adolescents whose school tables
were adjusted at baseline still reported LBP at follow-up.
Among the 49 adolescents who reported LBP at baseline,
23 did not report LBP at follow-up. Four of those 23
informed that they believed training was the main reason
for the improvement, another four that knowledge of
ergonomic principles like sitting and lifting with straight
back had improved their back health. Two adolescents
reported cessation of pain-inducing physical activity as a
reason for improvement, and another two reported both
training and cessation of pain-inducing physical activity
as reasons. Nine of the 49 reporting LBP had received
treatment during the preceding year, of whom six still
reported LBP at follow-up.
Among the 36 adolescents who reported no LBP at
baseline, 29 reported no LBP at follow-up. Five of the 29
reported that training and/or ergonomic principles had
helped them to recover from episodes of LBP during the
follow-up period. Three had received treatment in the
period; two of those reported no LBP at follow-up. One
third of those reporting LBP more than 7 days at follow-
up had changed their activity due to LBP during the
There were significant associations between baseline
and follow-up reports of LBP provoked by manual work
for the whole group (McN: P = 0.02) and for girls
(McN: P = 0.02), but not for boys (McN: P = 0.7).
Twenty-six percent of the whole group reported LBP
provoked by manual work at both occasions, and 50%
of those who reported LBP provoked by manual work at
baseline still reported the same LBP at follow-up. The
corresponding figures were 48% and 55% for girls and
boys, respectively. Eleven percent reported LBP provoked
by sitting at school at both occasions. Thirty-one
percent (12 boys and 14 girls) reported LBP provoked by
either manual work or sitting at school at follow-up.
Associations by Regression Analyses
In Table 3, the univariate associations between the various
corresponding reports of LBP at baseline and at follow-
up are displayed as odds ratios (OR) by binary logistic
Baseline reports of LBP ever, LBP during the preceding
year, LBP more than 7 days, LBP provoked by manual
work, and by sitting at school predicted corresponding
reports at follow-up; the strongest correspondences
were found for LBP more than 7 days and LBP provoked
by manual work.
Table 4 displays associations between various reports
of LBP at baseline and LBP at follow-up in univariate and
multiple ordinal regression analyses, adjusting for gender
and social class:
Associations were found between LBP at follow-up
and baseline reports of LBP. The strongest baseline predictors
in univariate and multiple analyses were LBP
more than 7 days (OR = 8.0 and 11.7, respectively), LBP
provoked by manual work (OR = 5.2 and 7.1, respectively),
and LBP provoked by sitting at school (OR = 5.8
and 6.2, respectively). No associations were found between
baseline reports of LBP provoked by use of television
and computer or leisure physical activity and LBP at
Answers to the open questions concerning painprovoking
situations were various forward-leaning positions
both during sitting and leisure physical activity;
none mentioned carrying the school bag, either at baseline
or at follow-up. LBP at baseline was associated in
multivariate analyses with female gender, seldom physical
activity, much time spent using television or computer, and a perception of poor well-being. The frequency
of weekly manual work was 60% at baseline and
56% at follow-up, and quite similarly reported by both
genders at both occasions. The frequency of regular leisure
physical activity three times weekly or more was
65% at baseline and 39% at follow-up. Mean reported
time spent weekly on television or computer was 16
hours at baseline and 15 hours at follow-up. Approximately
half of the group was classified in the lower social
class, and one fourth in the middle and upper social class,
The main findings of the study were that baseline reports
of LBP were strongly associated with future LBP among
adolescents. The 1-year prevalence of LBP both at baseline
and at follow-up was high, even if a reduction was
measured. Although girls reported LBP more frequently
than boys, the pattern and hierarchy of pain-provoking
situations was similar among the genders. The strength
of the predictions of baseline reports of LBP more than 7
days, LBP provoked by manual work and by sitting at
school for future LBP was amazing. It is a possibility that
those who report LBP provoked by manual work and
sitting at school at age 15 and 18 may experience problems
also later when performing manual work and prolonged
sitting, and thus contribute to the steadily growing
high rates of disability due to LBP among adults. 
Scandinavian studies indicate that juvenile LBP is a
strong predictor of LBP 20 to 25 years later. [8, 9] In a British
population-based study of adults, 78% of those reporting
chronic pain at baseline still reported chronic
pain 4 years later. 
Sitting at school predicted future LBP, in contrast to
LBP provoked by use of television or computer. One
explanation may be that it is possible to vary positions at
home during use of television and computer. The correspondence
between LBP provoked by sitting at school
and during using television/computer indicates that the
sitting position per se is a problem for some of the students,
but not for others. Another reason for the difference
might be that the use of television/computer was
initiated by free choice, and thus possibly associated with
more positive attitudes and emotions than the compulsory
sitting at school; there is a large amount of evidence
that LBP in young people is associated with poor wellbeing.
1 The combination of television and computer in
the question may also disguise potential associations between
LBP and the two different situations of using television
The 1–year prevalence of LBP at baseline of 58% corresponds
to 51% in Danish 13– to 16–year-old adolescents 
but is lower than French data of 83%.  The high
frequency corresponds to 1–month prevalence reports of
24% among 11– to 14–year-old children in a recent British
survey,  and 20% and 12% among 14–year-old
Finnish girls and boys.  The high reports of LBP provoked
by manual work and sitting at school are in agreement
with reports of disability and pain during sitting at
school among 94% and 53%, respectively, of schoolchildren
reporting LBP in the British survey,  and one conclusion
in a review that sitting is the main aggravating
factor for LBP among children and adolescents. 
The strong association between LBP at baseline and at
follow-up corresponds to findings of an OR of 7.4 (95%
CI, 4.3–11.4) for persistence of substantial LBP in Feldman’s
1-year prospective study,  and the findings in a
prospective Finnish study, showing a consistent pattern
in recurrent LBP among adolescents 15 years old at baseline
and 18 years old at follow-up.  However, the lack
of recollection of former LBP at follow-up among 22%
of those reporting LBP at baseline indicates that juvenile
LBP also includes minor episodes that are forgotten and
probably have no associations with future low back
function. The finding is in correspondence with another
Norwegian study, which showed a persistent pattern in
neck pain, but not in LBP in a follow-up study after 9 to
12 years in 16-year-old adolescents at baseline. 
Similar results were found in a British 4–year prospective study,
in which poor associations were found between LBP reports
of children 11 years old at baseline and at followup.  Although lifetime prevalence rose from 12% at age 11 to 50% at age 15 in the British study, reports of LBP
showed an inconsistent pattern, and episodes at baseline
were often forgotten later.  Similar findings were made
in a recent Belgian 2–year prospective study of 9– and
11–year-old schoolchildren at baseline.  The age differences
in the material may account largely for the difference;
the persistence of LBP may be less in younger children,
and there is also a possibility that the reports may
be less accurate among children of younger age. The
longer time interval in the British study may also cause
The lower 1–year prevalence of LBP at follow-up compared
with baseline contrasts the common trend that age
is an independent risk factor for LBP in children and
adolescents  but corresponds to the decline of LBP in
Feldman’s 1–year prospective study.  One reason may be
the different collection methods of data at baseline and at
follow-up in our study, as the presence of the researcher
during the baseline examination may have induced
higher reports of LBP than at follow-up, where there was
no personal contact. This interpretation is supported by
the fact that 11% of those reporting LBP more than 7
days at baseline did not recollect to have experienced
LBP at follow-up. However, good agreements have been
found between use of questionnaire and interview concerning
juvenile LBP. 
Other possibilities may be indicated
by the answers given by 13 adolescents regarding
potential recovery from LBP, suggesting that some of the
lower prevalence at follow-up may be due to training and
use of ergonomic principles. Several studies have shown
a protective effect concerning LBP among schoolchildren
by back-school interventions, including use of elevated
school furniture. [25–28] A minor McKenzie-inspired regimen
including instructions of exercises, back school, and
taping of the low back reduced the risk of developing
LBP during military service in a randomized Danish
The small sample is a limitation of the present study
and implies careful interpretations and a danger that true
associations may not be uncovered. The similarities with
other studies concerning rates and covariates of LBP indicate,
however, that the sample still may have some
general relevance. The use of the well-known questionnaire
and the high follow-up rate strengthen the study
further. By using ordinal regression analyses, data are
better used. Our results need to be confirmed in further
studies, using larger and representative material.
Our findings indicate that reports of LBP in midadolescence
are strong predictors of future LBP in late adolescence,
although half of those reporting LBP at baseline
did not report LBP at follow-up and one fourth had forgotten
minor previous episodes. The data confirm the
general trend that LBP, often provoked by manual
work and prolonged sitting, is common, and the results
indicate a consistent, but changeable, pattern of
juvenile LBP. Future research should study the significance
of reports of LBP provoked by manual work
and sitting during adolescence for future LBP and disability
A prospective study of adolescents, 14 to 15
years of age at baseline, was performed to investigate
the persistence and change in reports of low
back pain (LBP) over a 3-year period.
LBP during the preceding year was reported by
58% at baseline and 39% at follow-up, LBP more
than 7 days by 32% and 26%, respectively, and
LBP provoked by manual work by 40% and 26%,
Strong associations were found between corresponding
reports of LBP at baseline and at followup:
Odds ratio (95% confidence interval) was 4.7
(1.7–12.7) for LBP, 9.1 (3.0 –27.2) for LBP more
than 7 days, and 9.2 (2.9 –28.8) for LBP provoked
by manual work.
Twenty-two percent of those reporting LBP at
baseline rejected ever having experienced LBP at
follow-up. The findings indicate a persistent, but
changeable pattern in juvenile LBP.
The author thanks Professor A.E. Ljunggren at the University
of Bergen, Norway, for constructive discussions,
and the participating adolescents for twice allowing me
some access into their lives.
Balague F, Troussier B, Salminen JJ.
Non-specific low back pain in children and adolescents: risk factors.
Eur Spine J 1999;6:429–38.
Magnitude of the problem.
In: Wiesel SW, Weinstein JN, eds.
The Lumbar Spine, vol. 1.
Philadelphia: Saunders, 1996:8–16.
Hakala P, Rimpelä A, Salminen JJ, Virtanen SM, Rimpelä M.
Back, Neck, and Shoulder Pain in Finnish Adolescents: National Cross Sectional Surveys
British Medical Journal 2002 (Oct 5); 325 (7367): 743–745
Currie C, Hurrelmann K, Settertobulte W, et al.
Health and Health Behaviour Among Young People
Health behaviour in school-aged children:
a WHO cross-national study (HBSC) international report 1997–8:36.
Copenhagen: WHO, 2002.
Risk factors for the development of low back pain in adolescents.
Dissertation. Montreal: McGill University, 1998.
The epidemiology of spine disorders.
In: Frymoyer JW, ed. The Adult Spine: Principles and Practice, 2nd ed, vol. 1.
Philadelphia: Lippincott-Raven, 1997.
Burton AK, Clarke RD, McClune TD, et al.
The natural history of low back pain in adolescents.
Harreby M, Neergaard K, Hesselsoe G, et al.
Are radiologic changes in the thoracic and lumbar spine of adolescents risk factors for low back pain in adults?
Hellsing AL, Bryngelsson IL.
Predictors of musculoskeletal pain in men: a twenty-year follow-up from examination at enlistment.
Spine 2000;25: 3080–6.
Sjolie AN, Ljunggren AE.
The significance of high lumbar mobility and low lumbar strength for current and future low back pain in adolescents.
Psychosocial correlates of LBP in adolescents.
Eur Spine J 2002; 11:582–8.
Treat Your Own Back.
Lower Hutt, New Zealand: Spinal Publications, 1985.
The Seated Man: Homo Sedens.
Copenhagen, Denmark: Dafnia, 1985.
Salminen JJ, Pentti J, Terho P.
Low back pain and disability in 14-year-old schoolchildren.
Acta Paediatr 1992;81:1035–9.
National Bureau of Statistics.
Standard Classification of Socio-economic Status.
Elliott AM, Smith BH, Hannafjord PC, et al.
The course of chronic pain in the community: results of a 4-year study.
Harreby M, Nygaard B, Jessen T, et al.
Risk factors for low back pain in a cohort of 1389 Danish schoolchildren: an epidemiologic study.
Eur Spine J 1999;8:444–50.
Viry P, Creveuil C, Marcelli C.
Nonspecific Back Pain in Children. A Search for Associated Factors in 14-year-old Schoolchildren
Rev Rhum Engl Ed. 1999 (Jul); 66 (7-9): 381-388
Watson KD, Papageorgiou AC, Jones GT, et al.
Low back pain in schoolchildren: occurrence and characteristics.
Vikat A, Rimpela¨ M, Salminen JJ, et al.
Neck or shoulder pain and low back pain in Finnish adolescents.
Scand J Pub Health 2000;28:164–73.
Salminen JJ, Erkintalo M, Laine M, et al.
Low back pain in the young: a prospective three-year follow-up study of subjects with and without low back pain.
Prediction of cervical and low-back pain based on routine school health examination.
Scand J Prim Health Care 1985;3:247–53.
Szpalski M, Gunzburg R, Balague F, et al.
A 2-year longitudinal study on low back pain in primary schoolchildren.
Eur Spine J 2002;11:459–64.
Staes F, Stappaerts K, Vertommen H, et al.
Comparison of selfadministration and face-to-face interview for surveys of low back pain in adolescents.
Acta Paediatr 2000;89:1352–7.
Cardon GM, De Clercq DL, De Bourdeaudhuij IM.
Back education efficacy in elementary schoolchildren: a 1-year follow-up study.
Davoine P, Troussier B, Grison J, et al.
Influence du mobilier sur les rachialgies en milieu scolaire.
Ann Readaptation Med Phys 1994;37:99–103.
Faouen P, De Mauroy J-C, Coudouy G, et al.
Effet du mobilier sur les positions assises d’enfants et d’adultes.
Cah Kinesither 1995;171:35–9.
Linton S, Hellsing AL, Halme T, et al.
The effects of ergonomically designed school furniture on pupils’ attitudes, symptoms and behaviour.
Appl Ergon 1994;25:299–304.
Larsen K, Weidick F, Leboeuf-Yde.
Can passive prone extensions of the back prevent back problems?
A randomized, controlled intervention trial of 314 military conscripts.
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