In 13-year-old children, musculoskeletal pain has a relatively high prevalence and is a chronic and often daily problem.
Keywords: Musculoskeletal pain, Children, Adolescents, Generation R, Physical factors, Psychosocial factors
Abstract
Musculoskeletal (MSK) pain is a common reason for consultation in general practice and frequently reported in children and adolescents. This study examined the prevalence of MSK pain in 13-year-old children and assessed associations with physical and psychosocial factors. Data from the Generation R Study, a population-based birth cohort, was used. Prevalence and characteristics of MSK pain were assessed, using a pain mannequin, at 13 years of age (N = 3062). Demographics and data on physical activity, sedentary behaviors, previous reported MSK pain, and behavioral problems were extracted from questionnaires. The body mass index (BMI) SD-score was calculated from objectively measured weight and height. A prevalence of 23.3% was found for MSK pain in children of which 87.2% persisted for more than 3 months (ie, chronic), 45.5% experienced pain daily. More physically active children and children with a higher BMI reported MSK pain more frequently compared with non-MSK pain and no pain. The knee was the most often reported location. Children with MSK pain were more likely to have reported MSK pain at 6 years. Multivariable analyses showed significant associations for male sex (OR 0.74, 95% CI 0.56-0.98), high maternal educational (OR 0.69, 95% CI 0.49-0.96), higher BMI (OR 1.19, 95% CI 1.05-1.35), being physically active (OR 1.41, 95% CI 1.03-1.91), and behavioral problems (OR 1.85, 95% CI 1.33-2.59) with the presence of MSK pain. The chronic nature of MSK pain in combination with the relatively high prevalence of MSK pain in this study shows that MSK pain is already an important problem at a young age.
1. Introduction
Musculoskeletal (MSK) pain is one of the most common health problems in children and adolescents and is associated with significant individual, social, and financial burden worldwide and is one of the leading causes of years lived with disability.12 Musculoskeletal problems can already have extensive influence on their normal daily routine of school, social, and sports participation.13,17,37,38 Research has reported prevalence rates of MSK pain in children aged 9 to 18 years ranging from 4% to 40%24 and that 1 in 3 adolescents have MSK pain monthly.22 Knee, back, and neck pain are the most common sites of musculoskeletal pain.24
Many factors, both physical and psychosocial, are suggested to influence the presence of MSK pain in children. Physical factors as skeletal growth and maturation are believed to be main reasons for MSK problems to arise in childhood and adolescence.15 Nontraumatic knee complaints, such as Osgood–Schlatter disease (OSD) and patellofemoral pain (PFP), are typical knee problems that emerge during puberty.7,23,39 Furthermore, research suggests a possible association between MSK problems during childhood and development and the chronic character of MSK problems in adults.3,40 A history of MSK pain at 11-year olds is a very strong risk factor for MSK pain at age 14 years.34 Some studies have investigated possible associations between various physical, joint loading factors and the development of MSK problems in children and adolescents. For example, being overweight is significantly associated with the presence of MSK pain in childhood,31 and taller children seem more likely to develop MSK problems than shorter peers,18 possibly because of increased joint loading and dysfunction.27 Some research indicates a relation between another joint loading factor as physical activity and exercise and the onset of low back pain and spinal pain in children.10,18 However, in another study in 14-year-old children, no associations were found between physical activity and MSK pain.34 Furthermore some research has shown a possible association between sedentary behavior and MSK pain in children and adolescents,21 whereas other studies did not find this association.18,34 The association between psychosocial factors and MSK pain in children has been studied, with associations found between negative emotional symptoms,18 worrying, sleeping problems,34 and externalizing problems.16 These results are similar to what has been found in adults.30,47 Nevertheless, for most of the aforementioned factors, there is an absence of high-quality prospective studies and thus the evidence for their proposed potential as risk factors remains conflicting. In the Generation R study,25 it was found that MSK pain at the age of 36 months and behavioral problems are independently associated with the presence of MSK pain in 6-year-old children.45 Currently, similar studies in 13-year-old children have not been performed yet, although it is known that MSK complaints often develop during adolescence.33,48 Therefore, the aim of this study is to describe the prevalence and characteristics of MSK pain in 13-year-old children in a large population-based birth cohort and identify physical and psychosocial factors associated with MSK pain.
2. Methods
2.1. Study population
This study was performed within in the Generation R Study, a population-based prospective cohort study, focusing on growth, development, and health from fetal life until young adulthood. Eligible participants were women with an expected delivery date between April 2002 and January 2006, living in Rotterdam, the Netherlands. At the start of the study, 9749 children of the pregnant mothers were included in the cohort. At regular time points during infancy, childhood, and puberty, questionnaires were send out, and physical examination was performed. Detailed information on the Generation R study cohort has been described elsewhere.25 The Medial Ethical Committee of the Erasmus Medical Center, Rotterdam, approved the study, and written informed consent was obtained from the parents of all participants.
2.2. Procedures
For this study, data from the follow-up phases at the age of 6 and 13 years were used. In total, 7968 children still participated in the study at the age of 13 years, 82% of the original cohort. Data were derived from physical examinations at the research center and from self-reported and parent-reported questionnaires. Questions on pain were asked with a self-reported questionnaire during a second visit at the research center, which was arranged for the purpose of magnetic resonance imaging (MRI). Children who took part in the regular first visit regular measurements at 13 years received an invitation to participate in the MRI study. Children who did not participate in the first visit or declined to participate in the MRI study were excluded for this study purpose. This resulted in a final study sample of 3062 children with data on the presence of pain and pain locations. Additional questions on pain characteristics were added to the questionnaire in a later stage after delayed ethical approval procedures and are therefore only available in 325 children. Reporting in this study is in accordance with STROBE reporting guidelines.
2.3. Measurements—questionnaires
2.3.1. Demographics
Information on child's sex was obtained from midwife and hospital records at birth. Maternal and paternal educational level was categorized to high (higher education, master's degree), intermediate (higher education, bachelor's degree), and low (no education finished, primary school, or secondary school). Country of birth of both parents was assessed by prenatal questionnaires and, if necessary, supplemented and corrected according to follow-up questionnaires. Based on the average income in the Netherlands, the net household income was dichotomized into less or more than €1600 per month. The Tanner stage, a scale that defines physical measurements of development based on external primary and secondary sex characteristics in children,28,29 derived from the questionnaire was used to define puberty. Puberty was defined as Tanner stage 3 or higher.
2.3.2. Musculoskeletal pain
To assess the presence of pain, children were asked whether they had pain in the past 6 weeks. If so, the location was checked on a pain mannequin46 with 61 possible locations, both at the front and back side of the body. In this study, MSK pain was defined as pain in neck, back, or upper and lower limbs (Supplementary Figure 1, available at http://links.lww.com/PAIN/B999). Additional questions on pain characteristics included the frequency of occurrence (constant/daily/multiple days per week/weekly/monthly/less than monthly), pain duration (number of weeks or months), onset of pain (sudden/gradual), relation to sports (yes/no), and pain intensity (numeric rating scale 0-10).
For the history of MSK pain, data from the parent-reported questionnaire at the age of 6 years, based on the pain list,32 was used. In that questionnaire, parents were asked whether their children had any pain in the past 3 months, defined as pain recurring or lasting for longer periods and not a result of falling or bumping. If present, they were asked to choose the pain location from a list of 9 locations. Musculoskeletal pain at the age of 6 years was defined as back pain, neck pain, or limb pain from that list.
2.3.3. Physical activity and sedentary behaviors
Questionnaire data were used to evaluate physical activity and sedentary behaviors. Various physical activity behaviors were evaluated, namely, physical activity (ie, being physically active), sports participation (yes or no), and active transport to/from school. Physical activity was derived from the number of days per week with at least 1 hour of physical activity. The cutoff for a child being physical active was defined as at least 1 hour per day for at least 4 days per week (ie, more than half of the week). Active transport to/from school was defined as having at least 1 trip of walking or cycling to school per week.
Television viewing (including video/DVD) and computer use (including video games) were used to measure sedentary behaviors. The number of days and minutes per week and weekend days that children viewed television or used the computer were asked. The mean daily television viewing and computer use were calculated by dividing the sum of mean hours per day by 7. Daily television viewing was dichotomized into ≥1 hour/day vs <1 hour/day and daily computer use into ≥2 hour/day vs <2 hour/day.
2.3.4. Child behavior
Among the Generation R participants The Child Behavior Checklist (CBCL) was used to assess behavioral problems.2 The CBCL is known for having good reliability, validity, and generalizability and is widely used to asses behavioral and emotional problems in children.2,19 The CBCL questionnaire consists of 99 items divided in 7 subscales: Emotionally Reactive, Anxious/Depressed, Somatic Complaints (without medical cause), Withdrawn behavior (from social contacts), Sleep Problems, Attention Problems, and Aggressive Behavior. For the analyses, the total CBCL problem score, and the sum scores on internalizing problems (Emotionally Reactive, Anxious/Depressed, Somatic Complaints, and Withdrawn scales) and externalizing problems (Attention Problems and Aggressive Behavior scales) were calculated.2 Besides the continuous scores, where a higher score indicates more behavioral problems, the number of children with (sub)clinical problems was calculated following the cutoff scores from a Dutch reference group. Total score, internalizing score, and externalizing score were based on the 84th percentile and somatic complaints on the 93rd percentile. These cutoff scores are the standard for defining borderline/clinical problems, which includes enough problems to be of concern (borderline ranges), and so many problems that a child clearly deviates from norms for the child's sex and age range (clinical ranges).2,44
2.4. Measurements—physical examination
2.4.1. Anthropometry
Child height was measured in standing position using a Harpenden stadiometer (Holtain Limited, Crymych, United Kingdom), and weight was measured without heavy clothing and shoes using a mechanical personal scale (SECA). Height and weight were used to calculate the body mass index (BMI) (kilograms/square meter). Body mass index SD scores account for child age and sex and were calculated based on the Dutch reference growth curves, where a BMI SD score of 0 correlates with a child being on the 50th percentile.11 Weight status was categorized according to the cutoffs by Cole and Lobstein5 and dichotomized to underweight or normal weight vs overweight or obesity. Overweight was defined as being on the 90th percentile, which correlates with a BMI SD score of roughly 1.3.
2.5. Statistical analyses
Child characteristics and prevalence of pain were described using descriptive statistics. To analyze the differences between children with MSK pain, children with pain at other sites (ie, “other pain”), and children without pain (ie, “no pain”), the χ2 and analysis of variance (normally distributed) were used for categorical variables and Mann–Whitney U (2 groups) and Kruskal–Wallis (>2 groups) tests were used for continuous variables. Post hoc analyses were performed to assess which of the 3 subgroups significantly differed from each other. Furthermore, an exploratory analysis into the differences between the children who did and did not participate in the MRI study was performed. In addition, multinomial logistic regression, both univariate and multivariable, expressed in odds ratios (ORs) with 95% CIs was performed to test associations between demographics, physical, and psychosocial factors with the presence of MSK pain compared with children with no pain. The regression analyses were performed in a sample of 1612 children with complete data on all predictors. Redundant variables were removed from the multivariable regression model in case of collinearity, assessed by correlation coefficients with a cutoff of 0.7. All analyses were conducted with nonimputed data. Depending on the number of missing values in the predictor, the sample size for the univariate analyses differed per analysis (ranging from 0% missing data for sex and age to 29.6% for active transport to/from school). SPSS software (IBM Corp. Released 2016. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBMCorp) was used for all analyses, and the level of statistical significance was set at P < 0.05.
3. Results
3.1. Participants characteristics
Almost half (49.7%) of the 3062 included children were boys (Table 1). The children had a median age of 13.8 years (interquartile range 13.6-14.4 years), with a BMI SD score of 0.44 (SD 1.19) and Dutch born parents in 61.8%. In 38.7% of the children, the maternal educational level was low. Compared with the excluded participants, participants in this study (N = 3062) were significantly less often boys, had an older age, more often had a Dutch ethnicity, and had a higher maternal education (Supplementary Table 1, available at http://links.lww.com/PAIN/B999).
Table 1.
Participant characteristics.
| Total (n = 3062) | MSK pain (n = 575) | Other pain (n = 139) | No pain (n = 2348) | P | |
|---|---|---|---|---|---|
| Demographics | |||||
| Sex | 0.034 | ||||
| Girl | 1594 (52.1%) | 321 (55.8%)a | 78 (56.1%) | 1195 (50.9%)a | |
| Boy | 1468 (47.9) | 254 (44.2)a | 61 (43.9) | 1153 (49.1)a | |
| Age, y | 13.81 (13.58-14.36) | 13.84 (13.58-14.48) | 13.93 (13.65-14.57)a | 13.80 (13.58-14.33)a | 0.048 |
| Birth country of parents | |||||
| Dutch | 1853 (61.8) | 339 (60.0) | 68 (50.0)a | 1446 (62.9)a | 0.019 |
| Other Western | 270 (9.0) | 55 (9.7) | 12 (8.8) | 203 (8.8) | |
| Non-Western | 877 (29.2) | 1771 (30.3) | 56 (41.2)a | 650 (28.3)a | |
| Maternal educational level | |||||
| High | 852 (32.1) | 138 (27.8)a | 23 (19.7)b | 691 (33.8)a,b | 0.001 |
| Intermediate | 778 (29.3) | 147 (29.6) | 34 (29.1) | 597 (29.2) | |
| Low | 1028 (38.7) | 212 (42.7)a | 60 (51.3)b | 756 (37.0)a,b | |
| Paternal educational level | |||||
| High | 925 (38.0) | 146 (33.0)a | 30 (29.1)b | 749 (39.7)a,b | 0.010 |
| Intermediate | 583 (24.0) | 105 (23.7) | 25 (24.3) | 453 (24.0) | |
| Low | 925 (38.0) | 192 (43.3)a | 48 (46.6)b | 685 (36.3)a,b | |
| Household income, <€1600/mo | 339 (13.4) | 73 (15.7) | 23 (20.0)a | 243 (12.4)a | 0.019 |
| Single parenthood, yes | 337 (12.8) | 77 (15.6)a | 18 (15.3) | 242 (11.9)a | 0.066 |
| Physical factors | |||||
| BMI, SD score | 0.44 (1.19) | 0.58 (1.18)a | 0.57 (1.23) | 0.39 (1.19)a | 0.001 |
| Overweight, yes | 486 (15.9) | 115 (20.0)a | 31 (22.3)b | 340 (14.5)a,b | 0.001 |
| Height, SD score | 0.01 (1.01) | 0.05 (0.99)a | −0.20 (0.98)a,b | 0.01 (1.02)b | 0.033 |
| Puberty | |||||
| Tanner stage ≥3, yes | 1479 (61.3) | 286 (64.3) | 63 (63.6) | 1130 (60.4) | 0.289 |
| Physical activity behaviors | |||||
| Physical activity | |||||
| Minimum 1 h/d ≥ 4 d/wk, yes | 1487 (66.8) | 291 (72.0)a,b | 52 (55.3)a,c | 1144 (66.2)b,c | 0.004 |
| Sports participation, yes | 2160 (84.8) | 417 (88.3)a,b | 86 (80.4)a | 1657 (84.2)b | 0.035 |
| Active transport, ≥ 1 trip/wk | 1909 (88.6) | 342 (87.0) | 72 (84.7) | 1495 (89.1) | 0.254 |
| Sedentary behaviors | |||||
| Television viewing, h/d | 0.79 (0.50-1.79) | 0.79 (0.50-1.79) | 1.21 (0.50-1.79) | 0.79 (0.50-1.79) | 0.118 |
| Television viewing, ≥1 h/d | 1037 (47.1) | 197 (49.6) | 49 (52.7) | 791 (46.2) | 0.251 |
| Computer game use, h/d | 3.00 (2.00-4.43) | 3.29 (2.00-4.71) | 3.43 (2.00-5.00) | 3.00 (1.93-4.43) | 0.091 |
| Computer game use, ≥2 h/d | 1631 (75.4) | 314 (78.9) | 70 (76.9) | 1247 (74.4) | 0.170 |
| Previous MSK pain | |||||
| MSK pain at 6 y | 276 (10.5) | 66 (13.3)a | 16 (14.3) | 194 (9.6)a | 0.022 |
| Psychosocial factors | |||||
| Child behavioral problems (CBCL) | |||||
| Total problems, score | 13.11 (6.05-26.00) | 15.00 (7.78-29.37)a | 18.58 (9.75-32.21)b | 13.00 (6.00-24.20)a,b | <0.001 |
| (Sub)clinical total problems, yes | 459 (17.0) | 111 (22.3)a | 28 (23.7)b | 320 (15.3)a,b | <0.001 |
| Internalizing problems, score | 4.00 (1.00-8.00) | 4.00 (2.00-8.00)a,b | 6.00 (2.82-11.00)a,c | 4.00 (1.00-7.47)b,c | <0.001 |
| (Sub)clinical internalizing problems, yes | 492 (18.2) | 101 (20.3)a | 35 (29.7)a,b | 356 (17.0)b | 0.001 |
| Externalizing problems, score | 2.00 (0.00-6.00) | 3.00 (1.00-7.00)a | 4.00 (1.00-7.21)b | 2.00 (0.00-6.00)a,b | <0.001 |
| (Sub)clinical externalizing problems, yes | 416 (15.4) | 95 (19.1)a | 26 (22.4)b | 295 (14.2)a,b | 0.002 |
| Somatic problems, score | 1.00 (0.00-3.00) | 1.00 (0.00-3.00)a,b | 2.00 (1.00-4.00)a,c | 1.00 (0.00-2.86)b,c | <0.001 |
| (Sub)clinical somatic problems, yes | 308 (11.4) | 74 (14.9)a | 24 (20.7)b | 210 (10.1)a,b | <0.001 |
Values presented as number (%) for categorical factors, or median (interquartile range) or mean (SD) for continuous factors. Bold values represent statistically significant P values (P < 0.05).
This table is based on nonimputed data. Missing values were 0 for sex, 0 for age, 62 (2.0%) for ethnicity, 404 (13.2%) for maternal educational level, 629 (20.5%) for paternal educational level, 530 (17.3%) for household income, 422 (13.8%) for single parenthood, 2 (0.1%) for BMI, overweight and height, 648 (21.2%) for puberty, 835 (27.3%) for physical activity, 516 (16.9%) for sports participation, 907 (29,6%) for active transport, 859 (28.1%) for television viewing, 898 (29.3%) for computer use, 426 (13.9%) for MSK pain at 6 years, 357 (11.7%) for the Child Behavior Checklist (CBCL) total score, 355 (11.6%) for the CBCL internalizing problems score, 365 (11.9%) for the CBCL externalizing problems score, and 366 (12.0%) for the CBCL somatic complaints score.
a,b,cSubgroups that significantly differ from each other, based on post hoc analyses.
3.2. Reporting of pain
In the previous 6 weeks, 714 children (23.3%) reported that they experienced any type of pain and 575 children reported MSK pain (18.8%). Of the sample of children that reported MSK pain, lower limb pain was most often reported (75.5%), followed by back pain (17.2%) and upper limb pain (16.0%). Knee pain was the most reported location of MSK pain (43.7%) followed by ankle/foot pain (26.6%). Girls reported more back pain than boys (21.2% vs 12.2%), whereas lower limb pain was reported more in boys than in girls (81.1% vs 71.0%) (Table 2).
Table 2.
Frequencies of musculoskeletal pain locations within the group of children with musculoskeletal pain and differences between boys and girls.
| Total (n = 575) | Boys (n = 254) | Girls (n = 321) | P | |
|---|---|---|---|---|
| Back pain | 99 (17.2) | 31 (12.2) | 68 (21.2) | 0.005 |
| Neck pain | 16 (2.8) | 5 (2.0) | 11 (3.4) | 0.291 |
| Upper limb pain | 92 (16.0) | 36 (14.2) | 56 (17.4) | 0.288 |
| Shoulder | 36 (6.3) | 13 (5.1) | 23 (7.2) | 0.314 |
| Elbow | 11 (1.9) | 7 (2.8) | 4 (1.2) | 0.189 |
| Wrist/hand | 45 (7.8) | 17 (6.7) | 28 (8.7) | 0.368 |
| Lower limb pain | 434 (75.5) | 206 (81.1) | 228 (71.0) | 0.005 |
| Hip | 35 (6.1) | 14 (5.5) | 21 (6.5) | 0.608 |
| Knee | 251 (43.7) | 110 (43.3) | 141 (43.9) | 0.882 |
| Ankle/foot | 153 (26.6) | 74 (29.1) | 79 (24.6) | 0.223 |
Values presented as number (%).
Bold indicates significant P values.
Most children experienced pain at only 1 pain location (83.7%), and almost half (45.8%) of the children experienced pain daily. Moreover, more than half of the children indicated that the MSK pain was related to sports (60.2%). In nearly 10% of the children with MSK pain, the pain was also experienced at other sites (8.9%), most often in the abdomen (4.5%) or the head (4.3%). Girls more frequently had MSK pain in multiple locations than boys (17.6% vs 6.0%, respectively) and reported more pain at other sites, particularly the abdomen, than boys (12.1% vs 4.7%, respectively). In boys, the pain was more often related to sports than in girls (70.0% vs 53.0% resp). Musculoskeletal pain was classified as chronic, ie, the pain existed for more than 3 months, in 87.2% of the children with pain (Table 3).
Table 3.
Pain characteristics in musculoskeletal pain group.
| Total (n = 575) | Boys (n = 254) | Girls (n = 321) | P | |
|---|---|---|---|---|
| No. of MSK pain locations | <0.001 | |||
| 1 | 447 (83.7) | 209 (89.7) | 238 (79.1) | |
| 2 | 67 (12.5) | 14 (6.0) | 53 (17.6) | |
| >2 | 20 (3.7) | 10 (4.3) | 10 (3.3) | |
| Frequency of occurrence | 0.630 | |||
| <1 x/mo | 30 (11.5) | 13 (11.8) | 17 (11.3) | |
| ≥1 x/mo, <1 x/wk | 6 (2.3) | 1 (0.9) | 5 (3.3) | |
| ≥1 x/wk | 105 (40.4) | 46 (41.8) | 59 (39.3) | |
| Every day | 119 (45.8) | 50 (45.5) | 69 (46.0) | |
| Pain intensity, NRS | 5.75 (1.60) | 5.81 (1.50) | 5.70 (1.67) | 0.587 |
| Pain duration, > 3 mo | 157 (87.2) | 57 (82.6) | 100 (90.1) | 0.144 |
| Pain onset | 0.467 | |||
| Sudden | 162 (62.5) | 66 (60.0) | 96 (64.4) | |
| Gradual | 97 (37.5) | 44 (40.0) | 53 (35.6) | |
| Pain related to sports, yes | 157 (60.2) | 77 (70.0) | 80 (53.0) | 0.006 |
| Pain at other sites | ||||
| Yes | 51 (8.9) | 12 (4.7) | 39 (12.1) | 0.002 |
| Head | 25 (4.3) | 7 (2.8) | 18 (5.6) | 0.096 |
| Chest | 9 (1.6) | 2 (0.8) | 7 (2.2) | 0.181 |
| Abdomen | 26 (4.5) | 5 (2.0) | 21 (6.5) | 0.009 |
Values presented as number (%) for categorical factors, or mean (SD) for continuous factors.
This table is based on nonimputed data. Missing values were 41 (7.1%) for locations of pain, 315 (54.8%) for frequency of occurrence, 315 (54.8%) for pain intensity, 395 (68.7%) for pain duration, 316 (55.0%) for pain onset, 314 (54.6%) for pain related to sports, and 0 for pain at other sites.
Bold indicates significant P values.
NRS, numeric rating scale.
3.3. Differences between children with musculoskeletal pain, pain at other sites, or without pain
In Table 1, differences in demographics, physical factors, and psychosocial factors between the groups of children with MSK pain, pain at other sites, and without pain are presented. There were less parents with a high educational level in the MSK pain and other pain groups compared with the no pain group (maternal educational level: 27.8%, 19.7%, and 33.8% and paternal educational level: 33.0%, 29.1%, and 39.7% respectively).
A higher BMI SD score (0.58 [SD 1.18] vs 0.39 [SD 1.19], P = 0.001) and more children with overweight (20.0% vs 14.5%, P = 0.001) were seen in the MSK pain group compared with the no pain group. Regarding physical activity behaviors, the MSK pain group had a higher amount of physical activity compared with the other and no pain groups (72.0%, 55.3%, and 66.2%, respectively) and participated more frequently in sport (88.3%, 80.4%, and 84.2%, respectively). However, there were no differences between the groups in sedentary behaviors. Children with MSK pain at 13 years more often had MSK pain at 6 years than in those without pain (13.3% vs 9.6%).
Significant differences between the 3 pain groups were found for all CBCL (sub)scores. In general, the children with MSK or other pain had more behavioral problems compared with children with no pain.
3.4. Multivariable regression analyses on the presence of musculoskeletal pain in complete cases
In the group of 1612 children with complete data on all predictors, univariate analyses showed significant associations with the presence of MSK pain compared with no pain for high maternal educational level, BMI, and behavioral problems. In multivariable analyses, significant negative associations for the prevalence of MSK pain were seen for male sex (OR 0.74, 95% CI 0.56-0.98) and higher maternal education (OR 0.69, 95% CI 0.49-0.96), although significant positive associations were seen for BMI (OR 1.19, 95% CI 1.05-1.35), being physically active (OR 1.41, 95% CI 1.03-1.91), and behavioral problems (OR 1.85, 95% CI 1.33-2.59) (Table 4).
Table 4.
Logistic regression analysis for musculoskeletal pain compared with no pain in complete cases (n = 1612).
| Univariate analyses, OR (95% CI) | Multivariable analyses, OR (95% CI) | |
|---|---|---|
| Demographics | ||
| Sex, boy | 0.79 (0.61-1.02) | 0.74 (0.56-0.98) |
| Age, y | 1.05 (0.85-1.30) | 1.03 (0.83-1.29) |
| Ethnicity | ||
| Dutch | Reference | Reference |
| Other Western | 1.16 (0.78-1.76) | 1.20 (0.78-1.85) |
| Non-Western | 1.05 (0.74-1.48) | 1.00 (0.69-1.45) |
| Maternal educational level | ||
| High | 0.68 (0.50-0.93) | 0.69 (0.49-0.96) |
| Intermediate | 0.87 (0.64-1.19) | 0.86 (0.62-1.19) |
| Low | Reference | Reference |
| Physical factors | ||
| BMI, SD score | 1.21 (1.07-1.36) | 1.19 (1.05-1.35) |
| Height, SD score | 1.01 (0.89-1.15) | 0.95 (0.83-1.09) |
| Puberty, yes | 1.22 (0.94-1.59) | 1.04 (0.77-1.41) |
| Physical activity, minimum 1 h/d ≥ 4 d/wk, yes | 1.30 (0.97-1.74) | 1.41 (1.03-1.91) |
| Sports participation, yes | 1.32 (0.86-2.04) | 1.56 (0.98-2.49) |
| Computer game use, ≥2 h/d | 1.18 (0.87-1.60) | 1.24 (0.91-1.69) |
| MSK pain at 6 y, yes | 1.46 (1.00-2.14) | 1.42 (0.96-2.10) |
| Psychosocial factors | ||
| CBCL—(Sub)clinical total problems, yes | 1.82 (1.31-2.51) | 1.85 (1.33-2.59) |
Odds ratios (OR) and 95% confidence intervals (CIs) resulting from multinomial logistic regression, including 1612 participants (nonimputed data). Bold values represent statistically significant ORs (P < 0.05).
4. Discussion
In this study, a 6-week prevalence of 18.8% was found for MSK pain in 13-year-old children, of which almost 90% was chronic and almost half of the children experienced pain daily. The most reported location of MSK pain was the lower limbs with boys reporting more lower limb pain than girls, whereas girls reported more back pain than boys. Children who previously reported MSK pain at 6 years reported MSK pain more frequently compared with no pain. Multivariable analysis showed significant associations with the presence of MSK pain in girls, low maternal educational level, a higher BMI, higher physical activity level, and presence of behavioral problems.
This study reported a 23% 6-week prevalence for pain, which is lower than the reported prevalence rates of 40% to 60% in previous research performed in children and adolescents.14,24,32,43 Comparing the prevalence in this study with the prevalence in 6-year-old children, the prevalence of MSK pain rose from 10% to almost 19%.45 This increase is likely due to physical changes, growth spurts, increased skeletal maturation, and changes in psychosocial factors at this age.6,15 Moreover, the increased prevalence could be due to more detailed pain questions in the questionnaire at 13 years compared with the questions at 6 years, such as a pain mannequin and specific questions about frequency, duration, and intensity. Knee pain being the most reported location of MSK pain is in line with the most research into MSK pain in adolescents.7,43 However, more research specifically in children with knee pain and possible associated factors is needed because current research into knee pain in children is limited and most research is performed in adults.
Almost 90% of children with MSK pain in this study, which had available data on duration, reported chronic pain. This is substantially higher than the percentage of chronic MSK pain in children with MSK pain at 6 years of age within the same study population, namely, 35.6%.45 This shows that aside from the rising prevalence, MSK pain becomes more chronic with increasing age. Only 10% of chronic MSK pain children also reported MSK pain at 6 years old. This seems to imply that chronic MSK pain most children during puberty is not related to the presence of MSK pain at a younger age. Because the knee was the most frequently reported location, a possible explanation for chronic MSK pain could be specific MSK complaints that are known to arise during puberty and persist long term such as nontraumatic knee complaints as PFP or OSD.7,23,26 Another explanation for chronic MSK pain could be back pain, which approximately 1 in 5 children in this study reported, and previous research has shown that back pain often also is a chronic complaint in children and adolescents.1,8 However, in this study, no differences were seen between MSK pain location and the amount of chronic pain (data not presented). The chronic nature of MSK pain in combination with the relatively high prevalence of MSK pain in this study and known burden of disease12 show that MSK pain is an important problem that already warrants attention starting at puberty.
In concordance with the literature,31 a higher BMI SD score and more children with overweight were seen in children with MSK pain vs children without pain. It is known that being overweight or obese can impact joint health and cause joint dysfunction, which leads to more ankle, foot, and knee problems than being normal weight.27 It is believed that joint dysfunction in children with overweight or obesity is caused by increased joint loading resulting in structural changes as malalignment.4,9 Thus, more attention should be given to children with overweight and MSK complaints because this could play an important role in the treatment of MSK pain and prevent future problems.
Physically active children seem to experience more MSK pain. This finding may be due to injuries that occur during sports participation. However, at this moment, there is no clear evidence from the literature for the relation between MSK pain and physical activity level in children, as both positive and negative associations have been reported.41 Furthermore, details about the character and intensity of the physical activity and precise origins of pain were not available in this study, although these factors could certainly play a role in the development and presence of MSK pain. These factors should be included in future research to get a better insight in the relation between physical activity level and MSK pain. Although evidence on the association between physical activity and knee pain is inconclusive due to heterogeneity in study populations14,32,36,43 and absence of high-quality prospective studies, there should be more awareness for children who are physically active because of the possible higher risk on MSK pain, maybe due to injury or overloading. However, it is also not desirable for children to refrain from physical activity because of the aforementioned negative effect of sedentary behavior.21 Attention should be paid to both preventing injury or overloading due to physical activity and to the possible long-term nature and impact of MSK pain during rehabilitation.
Finally, the presence of MSK pain and pain in general was associated with more behavioral problems, both in univariate and multivariable analyses. This is in line with current widespread belief that psychosocial problems are an important risk factor for the onset and poorer prognosis of MSK pain in adolescents and adults.16,30,47 The increased presence of MSK pain could stem from increased behavioral problems due to psychosocial factors, such as depressive feelings, negative pain beliefs, cognitions, and behaviors because they are associated with the development and persistence of chronic pain.35,42,47 However, studies have also indicated that chronic pain leads to changes in the central nervous system and various pain modulating neural areas and can induce negative affective states, such as depression, anger, and anxiety.49 Because of the cross-sectional nature of this study, we are unable to determine whether more behavioral problems lead to (chronic) MSK pain or the other way around. Nevertheless, both factors, psychosocial and biological, appear to influence each other and seem to be part of a vicious circle leading to persisting MSK pain. Thus, attention should be paid to depressive feelings, pain beliefs, cognition, and behaviors when treating MSK pain.
4.1. Strengths and limitations
This study has several strengths, namely, the large sample size with the prospective population-based design and availability of information on several factors studied within the same study sample. Because of the study design, we could include data from questionnaires at different time points, including the assessment of history of MSK pain. Presence of MSK pain was also assessed at 6 year olds and not retrospectively, increasing the reliability of data and diminishing the risk on recall bias. Another strength is that at age 13 years, in the Generation R study, children themselves filled out the questionnaires, thus providing reliable data directly from the target population. The questionnaires for children were adjusted to be as understandable for their age and make their answers as objectively as possible.25 However, the reliability of the MSK pain data at the age of 6 years could be debated because this questionnaire was reported by parents, and young children may have difficulty describing the presence and nature of pain to their parents, and the parents may have difficulties with objectively reporting the nature of the pain.
There are some other limitations present in this study. First, as known in the general follow-up of the Generation R Study,20 selection bias toward a more healthy and Western population and higher socioeconomic status (SES) might have occurred and seen in the nonresponse analysis of the selected study sample. As a result of this selection, there may be an underestimation of pain because those of lower SES are more likely to report pain.
Moreover, because there were selective (ie, not random) missing values in the multivariable analysis, imputation was not possible. Nevertheless, univariate ORs in the total study sample (n = 3062) were similar (similar size and direction) but had smaller confidence intervals compared with the univariate ORs in the small study sample (n = 1612) in which the multivariable analyses were performed. Finally, because of the cross-sectional approach of the analyses, no inferences could be made on causality. Results should be interpreted with caution because multiple factors were tested without correction for multiple testing.
5. Conclusion
This study shows that MSK pain is already a frequent problem in 13-year-old children that often occurs daily and frequently has a chronic character. Moreover, female sex, lower maternal education, a higher BMI, being physically active, and behavioral problems were associated with an increased presence of MSK pain. To assess the causation of the associations and gain insight into underlying mechanisms, further research is needed. Especially longitudinal analyses into associations between different physical and psychosocial factors, particularly physical activity, BMI and behavioral problems, and the presence of MSK pain. These analyses could possibly lead to early interventions strategies and targeted approaches to address risk factors in children with MSK pain.
Conflict of interest statement
S.B.-Z. reports grants from the Dutch Arthritis Association, the European Commission, ZonMw and reports personal fees from and consulting for Pfizer Infirst Healthcare outside of the submitted work. The remaining authors have no conflicts of interest to declare.
Appendix A. Supplemental digital content
Supplemental digital content associated with this article can be found online at http://links.lww.com/PAIN/B999.
Supplementary Material
Acknowledgements
The Generation R Study is conducted by the Erasmus Medical Center in close collaboration with the Faculty of Social Sciences of the Erasmus University Rotterdam, the Municipal Health Service Rotterdam area, Rotterdam, and the Stichting Trombosedienst & Artsenlaboratorium Rijnmond (STAR-MDC), Rotterdam. The authors gratefully acknowledge the contribution of children and parents, general practitioners, hospitals, midwives, and pharmacies in Rotterdam. The general design of the Generation R Study is made possible by financial support from the Erasmus Medical Center, Rotterdam, the Erasmus University Rotterdam, ZonMw, the Netherlands Organisation for Scientific Research (NWO), and the Ministry of Health, Welfare and Sport. The work of MH was financially supported by a EUR Fellowship grant from the Erasmus University Rotterdam.
Data availability statement: Data not publicly available.
Footnotes
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.painjournalonline.com).
Contributor Information
Marleen M. van den Heuvel, Email: m.m.vandenheuvel@erasmusmc.nl.
Patrick J. E. Bindels, Email: p.bindels@erasmusmc.nl.
Sita M. A. Bierma-Zeinstra, Email: s.bierma-zeinstra@erasmusmc.nl.
Marienke van Middelkoop, Email: m.vanmiddelkoop@erasmusmc.nl.
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