What is the best approach to manage chronic back pain in an adolescent?

Management of Chronic Back Pain in Adolescents

The best approach to manage chronic back pain in adolescents is a biopsychosocial treatment strategy centered on exercise therapy, with cognitive behavioral therapy as a key adjunctive treatment, while avoiding medications when possible. 1, 2

Initial Assessment

• Perform a targeted biopsychosocial assessment to identify both physical and psychosocial factors contributing to pain 3
• Limited initial imaging is recommended - simple tests such as X-rays to exclude trauma or inflammatory markers (ESR) for suspected inflammatory disease are sufficient 3
• The STarTBack tool can help stratify adolescents into risk categories for chronic disability, guiding treatment intensity 3
• Laboratory evaluation with complete blood count and sedimentation rate may help evaluate systemic etiologies 3
• Clinical red flags requiring immediate imaging include constant pain, night pain, radicular pain lasting 4+ weeks, or abnormal neurological examination 3

First-Line Treatments

• Exercise therapy should be the cornerstone of treatment, showing consistent improvements in pain relief and function 3, 1, 4
• Exercise programs should be individually tailored, professionally supervised, include stretching and strengthening components, and show regular progression 4
• Heat therapy provides moderate pain relief and can be effectively combined with exercise 4
• Cognitive behavioral therapy (CBT) has good evidence for effectiveness in chronic back pain by helping patients modify situational factors and cognitive processes that exacerbate pain 3, 1
• Yoga (particularly Viniyoga) shows moderate evidence of effectiveness for adolescents with chronic back pain 1

Second-Line and Adjunctive Treatments

• Massage therapy shows moderate effectiveness for chronic low back pain 3, 4
• Mindfulness-based stress reduction has moderate-quality evidence supporting its use, with improvements in pain and function 3, 1
• Spinal manipulation may provide small to moderate benefits for pain relief and functional improvement 3, 4
• Multidisciplinary rehabilitation combining physical, psychological, and educational interventions shows good evidence of effectiveness, particularly when intensive 1, 4
• Acupuncture has fair evidence supporting its effectiveness for chronic pain 1

Pharmacologic Considerations

• Drug therapy should generally not be applied in children and adolescents with non-specific back pain 2
• If medications are necessary, NSAIDs should be the first choice, showing small to moderate pain improvement 1
• Avoid opioids due to limited evidence of long-term efficacy and significant risks 1

Common Pitfalls to Avoid

• Bed rest is contraindicated and can worsen outcomes 1
• Routine imaging without specific indications can lead to unnecessary interventions 1
• Early resort to medications before adequate trial of nonpharmacologic therapies 1, 2
• Focusing solely on physical factors while neglecting psychosocial components 3
• Lumbar supports have not shown clear benefits for chronic back pain 4
• Transcutaneous electrical nerve stimulation (TENS) shows no difference compared to sham TENS for pain intensity or function 4

Treatment Algorithm

1. Begin with supervised exercise program with individualized components and application of heat therapy 3, 4
2. Incorporate cognitive-behavioral therapy to address psychosocial factors 3, 1
3. Consider adding complementary approaches based on patient preference (yoga, mindfulness) 1
4. For more severe or persistent cases, implement multidisciplinary rehabilitation 1, 4
5. Reassess and reevaluate management plan within 6 months 3

Special Considerations for Adolescents

• Lifestyle factors including physical activity levels, backpack loads, and family history of back pain are important risk factors to address 3
• Patients who modify lifestyle factors (reduced smoking/alcohol, increased physical activity) achieve better results with non-pharmacological treatment 5
• For chronic and severe pain, intensive interdisciplinary treatment programs should be provided 2
• Different exercise regimens appear similarly effective, suggesting patient preference and adherence may be more important than specific exercise type 4