European Journal of Pediatrics

https://doi.org/10.1007/s00431-021-04369-5

ORIGINAL ARTICLE

Spinal pain in childhood: prevalence, trajectories, and diagnoses

in children 6 to 17 years of age
Jeffrey J. Hébert1,2 · Amber M. Beynon 2,3 · Bobby L. Jones4 · Chinchin Wang5,6 · Ian Shrier 6 · Jan Hartvigsen 7,8 ·
Charlotte Leboeuf‑Yde9 · Lise Hestbæk7,8 · Michael S. Swain3 · Tina Junge7,10 · Claudia Franz11 · Niels Wedderkopp12

Received: 10 October 2021 / Revised: 6 December 2021 / Accepted: 29 December 2021

© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2022

Abstract
This study aimed to investigate the trajectories of spinal pain frequency from 6 to 17 years of age and describe the
prevalence and frequency of spinal pain and related diagnoses in children following different pain trajectories. First through
fifth-grade students from 13 primary schools were followed for 5.5 years. Occurrences of spinal pain were reported weekly
via text messages. Children reporting spinal pain were physically evaluated and classified using International Classification of
Disease criteria. Trajectories of spinal pain frequency were modeled from age 6 to 17 years with latent class growth analysis.
We included data from 1556 children (52.4% female, mean (SD) baseline age = 9.1 (1.9) years) and identified 10,554 weeks
of spinal pain in 329,756 weeks of observation. Sixty-three percent of children reported one or more occurrences of spinal
pain. We identified five trajectories of spinal pain frequency. Half the children (49.8%) were classified as members of a “no
pain” trajectory. The remaining children followed “rare” (27.9%), “rare, increasing” (14.5%), “moderate, increasing” (6.5%), or
“early-onset, decreasing” (1.3%) spinal pain trajectories. The most common diagnoses in all trajectory groups were non-specific
(e.g., “back pain”). Tissue-specific diagnoses (e.g., muscle strain) were less common and pathologies (e.g., fracture) were rare.
Conclusion: From childhood through adolescence, spinal pain was common and followed heterogeneous courses com-
prising stable, increasing, and early-onset trajectories. These findings accord with recommendations from adult back pain
guidelines that most children with spinal pain can be reassured that they do not have a serious disease and encouraged to
stay active.

What is Known:
• Spinal pain imposes a large burden on individuals and society.
• Although many people first experience the condition in childhood, little is known about the developmental trajectories of spinal pain from
childhood to adolescence.
What is New:
• Data from 1556 children and 329,756 participant weeks showed five unique spinal pain trajectories from 6 to 17 years: most children rarely
reported spinal pain, while one in five followed increasing or early-onset trajectories.
• Most pain occurrences were non-specific; pathological diagnoses were rare.

Keywords Low back pain · Neck pain · Diagnosis · Prevalence · Pediatric · Life course · Trajectory · Prognosis

Abbreviations Introduction
CHAMPS study-DK Childhood health, activity, and
motor performance school study Spinal pain imposes a large burden on individuals and society.
Denmark For many, spinal pain develops in childhood; for example, the
ICD International Classification of 12-month period prevalence of back pain in children ranges
Diseases from 17.4 to 60.3% [1]. Back pain experienced in childhood
tracks into adulthood [2], when it becomes the single largest
Communicated by Gregorio Paolo Milani source of years lived with disability [3].
 Jeffrey J. Hébert
Despite evidence of spinal pain’s burden, traditional clini-
j.hebert@unb.ca cal wisdom suggests that spinal pain in childhood is rare, and
Extended author information available on the last page of the article
when present, stems from a pathological etiology (e.g., tumor,

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infection) [4]. However, current evidence shows spinal pain
to be a common and usually benign condition in children,
even when pain is persistent [5]. Thus, it may be the nature of
symptoms and their developmental trajectories that distinguish
different types of spinal pain rather than etiology. Life-course
epidemiology emphasizes the importance of change in health-
related features over time (i.e., health trajectories) [6]. Trajec-
tory modeling has been used to understand the development
of spinal pain, with models identifying discrete subgroups of
adults who follow unique courses of pain over time [7]. Studies
to date have focused on the trajectories of spinal pain in adult
populations, leading researchers to highlight the development
of spinal pain in youth as a priority [7, 8].
However, few studies to date have investigated the occur-
rence of spinal pain from adolescence to early adulthood. One
study modeled the 3-year trajectories of low back pain in ado-
lescents from ages 11 to 14 [9]. While 78% of participants had
a very low probability of low back pain, the others followed
trajectories showing an increasing (8%), decreasing (10%),
early increase (2%), or persistently high (1%) probability of
pain [9]. Another prospective study of individuals aged 14
to 22 found that most participants experienced impactful low
back pain (i.e., pain resulting in care-seeking or interruption
in activities) that followed an increasing (44%) or decreasing
(10%) probability trajectory over the 8-year period [10].
There remains a lack of evidence regarding the develop-
mental patterns of spinal pain in childhood as well as other
fundamental aspects of pain, such as frequency and diagnostic
characteristics. This knowledge is necessary to understand the
development of spinal pain in the earlier life course. Therefore,
the first aim of this study was to describe the trajectories of
spinal pain frequency from 6 to 17 years of age. The second
aim was to describe the prevalence and frequency of spinal
pain and related diagnoses experienced by children following
different pain trajectories.
Methods
Study design and participants
We analyzed prospective spinal pain data from the Child-
hood Health, Activity and Motor Performance School
Study Denmark (CHAMPS Study-DK) collected between
October 2008 and April 2014. The CHAMPS Study is a
school-based health study; the study sample and proce-
dures have been described in detail previously [11, 12]. In
brief, CHAMPS Study-DK is a dynamic cohort in which
some schools and participants entered the study at differ-
ent times. In total, 19 public primary schools were invited,
and 10 schools agreed to participate. A central feature of
the original study design involved the comparison of out-
comes between students attending schools implementing
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European Journal of Pediatrics
either usual or supplemented physical education. Because
our study objectives were not concerned with the effects
of physical education curriculum, we combined all data
into a common cohort comprising students registered to
attend grades one through five. We excluded children with
serious chronic diseases and three children were excluded
based on this criterion: one child with a congenital heart
malformation, 1 child with cerebral palsy, and 1 child with
dwarfism.
The study protocol was approved by the Regional
Scientific Ethical Committee of Southern Denmark (ID S-
20080047) and registered with the Danish Data Pro-
tection Agency (J.nr. 2008–41-2240). All participating
children gave verbal assent and parents provided written
informed consent prior to enrollment.
Spinal pain measurements
Weekly pain data were collected via short-message-
service text messaging, except during the six-week summer
and one-week Christmas holiday periods. Each week, the
child’s parent or guardian was sent a text message inquir-
ing about any occurrence of pain experienced by the child
in different bodily regions over the preceding seven days:
“Has (child’s name) had pain for the last week?”. Potential
answers included “neck, back, or lumbar spine,” “shoulder,
arm, or hand,” “hip, leg, or foot,” and “no, my child has
not had any pain.” In this study, we limited our outcome
to neck, back, or lumbar pain (i.e., spinal pain).
When spinal pain was reported by text message, a
healthcare provider followed up with the parent by tel-
ephone within the week. If the pain continued to be present
at the time of telephone interview, the child was sched-
uled for physical evaluation within 7 days. If the pain had
resolved by the time of follow-up, the child continued to
be monitored by text messaging as before. The evaluation
comprised a standardized physical examination performed
by study investigators who were registered physiothera-
pists or chiropractors. An orthopedic surgeon trained the
examiners to ensure a standard examination approach, and
the procedures were piloted by co-evaluating the first 20
children examined. The examiners maintained close con-
tact with the orthopedic surgeon and each other through-
out the study, discussing challenging cases and reinforcing
examination procedures. When clinically indicated, chil-
dren were referred for additional diagnostic investigation
(e.g., blood tests, diagnostic imaging), orthopedic evalua-
tion, or both. When children received medical evaluation
or treatment outside of the study (e.g., emergency care),
we obtained information through linked medical records.
All children who underwent physical examination
with or without diagnostic testing were diagnosed using
European Journal of Pediatrics
International Classification of Diseases (ICD-10) cod-
ing [13]. When more than one code was assigned for the
same episode, we identified the primary diagnosis as the
one most likely to be directly responsible for the child’s
pain. Diagnostic codes were classified as either traumatic
or non-traumatic. We considered four spinal pain outcomes:
(i) self-reported spinal pain, (ii) diagnosed spinal pain, (iii)
non-traumatic spinal pain, and (iv) traumatic spinal pain.
Self-reported spinal pain included all pain reports. Diag-
nosed spinal pain was a subcategory of self-reported spinal
pain comprising pain episodes for which the child underwent
a physical evaluation and received a diagnosis. In this way,
reports of diagnosed spinal pain indicated episodes lasting
approximately 1 week or longer. Non-traumatic and trau-
matic spinal pain were subcategories of diagnosed pain and
determined by ICD codes.
Anthropometric measurements and pubertal
development
Height was measured to the nearest 0.5 cm with a portable
stadiometer (SECA 214, Seca Corporation, Hanover, MD,
USA) and weight to the nearest 0.1 kg using a calibrated
Tanita BWB-800S digital scale (Tanita Corporation, Tokyo,
Japan). Body mass index was calculated as weight(kg)/
height(m)2. We classified BMI outcomes as normal, over-
weight, or obese according to age- and sex-specific criteria
from the International Obesity Task Force [14].
Pubertal development was determined using Tanner
stages [15]. During a structured interview that included
explanatory text and visual diagrams of pubic hair develop-
ment in boys and breast development in girls, participants
self-assessed their Tanner stage on a 1 to 5 scale, with higher
scores indicating later pubertal stages [16]. Tanner stage 1
represents prepubertal status, stages 2 to 4 denote increas-
ing levels of adolescent development, and stage 5 indicates
adult development. We collapsed Tanner stages 4 and 5 into
a common category owing to their low prevalence in the
sample population.
Data analysis
Missing spinal pain data were imputed with random hot
deck multiple imputations [17] across five datasets. This
approach involved the matching of missing data with
observed records, generating probabilities for matched
records, and sampling records based on the probability of
each outcome. Covariates incorporated into the random hot
deck imputations were sex and pain for the individuals with
missing data in the surrounding weeks. Additional details
have been reported previously [18]. To support the modeling
procedure, the weekly pain data were collapsed into 11 six-
month study periods. To contribute data to a study period,
we required that participants were enrolled and responding
to the text messages for at least 60% of that period.
All analyses were conducted with Stata 16.1 software
(StataCorp, College Station, TX, USA). We described con-
tinuous variables as means and standard deviations (SD)
and categorical variables as counts and percentages for
the entire sample and stratified by trajectory subgroup. We
modeled trajectories of self-reported spinal pain frequency
(weeks with pain), as a function of age, with latent class
growth analysis. This approach is a specialized applica-
tion of finite mixture modeling used to identify meaning-
ful trajectory subgroups (latent classes) within otherwise
heterogeneous data [19; 20]. These models use maximum
likelihood estimation to approximate trajectory distributions
without assuming that trajectory classes comprise distinct
populations; features that distinguish this approach from
similar techniques such as growth mixture modeling [19].
We applied a zero-inflated Poisson distribution and applied
equal weights across the five imputed datasets to generate a
common model.
We first constructed a single-class model and then
increased the number of latent classes, the complexity of
the polynomial distributions (e.g., linear, quadratic, cubic)
and zero-inflation patterns until an optimal model was iden-
tified. We used several criteria to define the optimal model
as fit decisions should not hinge on a single metric [19].
Initial decisions were made using the Bayesian information
criterion and judgment to identify clinically meaningful sub-
groups. We subsequently tested models with four a priori
diagnostic criteria: (i) a minimum average posterior prob-
ability of group membership ≥ 0.7, (ii) minimum odds of
correct classification > 5, (iii) precision of confidence inter-
vals around estimates of group membership probabilities,
and (iv) close correspondence between the estimated group
membership probability and the proportion of participants
assigned to each group based on the posterior probability
[19, 20]. We explored for sex-specific differences in the spi-
nal pain trajectories by analyzing data from boys and girls
separately. The resulting models were very similar (data
not shown), and we therefore elected to report one common
model.
Results
In total, 1670 children were enrolled in the study. We
excluded 114 (6.8%) children as they only had spinal pain
data for one study period. Therefore, data from 1556 chil-
dren (baseline age = 9.1 (1.9) years, 52.4% female) com-
prising 329,756 weeks of observation were included in the
trajectory model (Fig. 1). The average weekly response rate
over the course of the study was greater than 96% [21, 22];
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 European Journal of Pediatrics

Fig. 1 Participant flow diagram

Total sample
N = 1670

0 study periods with valid pain data (N = 70)

1 study period with valid pain data (N = 44)

Valid spinal pain data: N = 1556

Missing anthropometric data (N = 19)

Missing pubertal development data (N = 30)

Anthropometric data: N = 1537

Pubertal development data: N = 1530

in total, valid responses were received for 94.8% of weeks
prior to imputation. The mean number of 6-month study
periods with valid spinal pain data was 8.0 (2.8). There-
fore, participating children contributed approximately four
years of weekly spinal pain data on average. Precise age data
were unavailable for 19 children (1.2%) who provided spinal
pain data via text messaging but did not participate in the
measurement sessions; we estimated their ages using average
values from children at the same grade level.
Over the course of the study, 63.2% of children reported
one or more occurrences of spinal pain and 27.5% of chil-
dren experienced one or more pain occurrences of sufficient
duration to allow for physical examination and diagnosis
(diagnosed spinal pain). In total, spinal pain was reported
in 10,554 participant weeks, among which 4,823 (45.7%)
were weeks with diagnosed spinal pain. The large majority
of diagnosed spinal pain weeks were categorized as non-
traumatic (4342 weeks; 90.0%).
Spinal pain trajectories
The final trajectory model identified a five-class solution
comprising zero-order, linear, and quadratic polynomials
(Fig. 2). All predefined diagnostic criteria were met: pos-
terior probabilities were 0.80 or greater, odds of correct
classification exceeded 5.0, confidence intervals were rela-
tively precise, and differences between the estimated group
membership probability and the proportion of participants
assigned to the group were small (Table 1).
Latent trajectory subgroups were labeled according to
the average frequency of weeks with spinal pain and the
shapes of their distributions. Approximately half the chil-
dren (49.8%) were classified as members of a trajectory
defined by the absence or minimal occurrence of spinal pain
(i.e., “no pain”). Although we received rare reports of pain
from approximately one-third of children following the “no
pain” trajectory (approximately 0.4 weeks per four years on

Fig. 2 Trajectories of self-

reported spinal pain and their
prevalence (N = 1556)1. 1Points
represent weeks with spinal
pain in each 6-month period.
Dotted lines represent 95%
confidence intervals

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European Journal of Pediatrics

Table 1 Latent class growth model diagnostics

Average posterior Odds of correct Assigned Estimated membership (95% CI)

probability1 classification2 membership 3

Trajectory subgroup
“No pain” 0.84 5.31 56.3% 49.8 (46.3 to 53.2)%
“Rare” 0.80 10.15 23.8% 27.9 (24.8 to 31.1)%
“Rare, increasing” 0.85 34.54 12.3% 14.5 (12.7 to 16.3)%
“Moderate, increasing” 0.91 141.15 6.2% 6.5 (5.6 to 7.4)%
“Early-onset, decreasing” 0.98 3535.60 1.3% 1.3 (1.0 to 1.6)%
1
Minimum threshold = .70
2
Minimum threshold = 5.0
3
Percentages do not total to 100 due to rounding

average), the pain was nearly always transient and resolved
prior to physical examination. Remaining children were
assigned to a “rare” (27.9%), “rare, increasing” (14.5%),
“moderate, increasing” (6.5%), or an “early-onset, decreas-
ing” (1.3%) spinal pain trajectory. Baseline demographic,
anthropometric, and pubertal development data for each
trajectory subgroup are presented in Table 2.
Spinal pain prevalence, frequency, and diagnoses
Table 3 and Fig. 3 report descriptive statistics for spinal pain
characteristics, stratified by trajectory subgroup. Primary
diagnoses, stratified by spinal pain trajectory subgroup, are
reported in Table 4. Back pain (non-specific) was the most
common diagnosis received by participants in four of five
trajectories groups, comprising 18 to 33% of all primary
diagnostic codes. Tissue-specific spinal pain diagnoses (e.g.,
muscle strain, facet syndrome) were less common, and path-
ological diagnoses (e.g., fracture) were rare.
Discussion
In this study, children were classified as following one of
five spinal pain trajectories from 6 to 17 years of age. Most
children were classified as never or rarely experiencing spi-
nal pain, while approximately 1 in 5 reported an increasing
frequency of spinal pain into adolescence. The increasing
trajectories are noteworthy as they may indicate children
who suffer for prolonged periods and may also be at risk of
developing more frequent or persistent spinal pain later in
life. Moreover, a small subgroup of children experienced
early-onset spinal pain. While children following the early-
onset trajectory improved after about age 13, they reported
the greatest number of weeks with pain overall. Most chil-
dren (63%) reported at least one episode of spinal pain in
approximately 4 years (including the few reports of usually
transient pain from children in the “no pain” subgroup), and
nearly 1 in 3 (28%) were diagnosed with at least one condi-
tion related to their pain, which were largely classified as

Table 2 Baseline demographic, anthropomorphic, and pubertal development statistics stratified by spinal pain trajectory subgroup1

n “No pain” “Rare” “Rare, increasing” “Moderate, increasing” “Early-onset,

decreasing”

Age (years) 1556 9.0 (1.9) 9.2 (1.7) 9.1 (2.1) 9.4 (2.1) 9.8 (2.1)
Height (cm) 1537 136.0 (12.8) 137.9 (11.8) 138.6 (13.3) 139.3 (13.9) 141.8 (14.7)
Weight (kg) 1536 31.7 (9.5) 32.6 (8.8) 33.4 (10.8) 34.4 (11.9) 36.8 (11.9)
BMI (kg/m2) 1536 16.8 (2.3) 16.9 (2.3) 17.0 (2.7) 17.2 (2.9) 17.6 (4.4)
Overweight (n(%)) 1536 93 (10.8%) 54 (14.8%) 21 (10.9%) 15 (15.5%) 2 (10.5%)
Obese (n(%)) 1536 20 (2.3%) 5 (1.4%) 5 (2.6%) 1 (1.0%) 1 (5.3%)
Female sex (n(%)) 1556 432 (49.3%) 182 (49.1%) 122 (63.5%) 69 (71.1%) 11 (55.0%)
Puberty stage (n(%)) 1530 526 (61.4%) 196 (53.7%) 105 (54.7%) 48 (50.0%) 12 (63.2%)
Tanner 1 229 (26.7%) 124 (34.0%) 58 (30.2%) 32 (33.0%) 5 (26.3%)
Tanner 2 75 (8.8%) 35 (9.6%) 22 (11.5%) 12 (12.4%) 2 (10.5%)
Tanner 3 27 (3.2%) 10 (2.7%) 7 (3.7%) 5 (5.2%) —
Tanner 4/5

BMI body mass index

1
Values are mean (SD) unless otherwise indicated

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 European Journal of Pediatrics

Table 3 Spinal pain outcomes stratified by spinal pain trajectory subgroup (N = 1556)

Total “No pain” “Rare” “Rare, increasing” “Moderate, increasing” “Early-onset,

decreasing”

Sample size 1556 876 371 192 97 20

Reporting periods1 8.0 (2.8) 7.8 (2.9) 8.1 (2.7) 8.4 (2.7) 7.9 (2.8) 7.5 (3.1)
Spinal pain prevalence2
Self-reported pain 984 (63.2%) 304 (34.7%) 371 (100.0%) 192 (100.0%) 97 (100.0%) 20 (100.0%)
Diagnosed pain 428 (27.5%) 34 (3.9%) 168 (45.3%) 140 (72.9%) 73 (75.3%) 13 (65.0%)
Non-traumatic pain 347 (22.3%) 23 (2.6%) 119 (32.1%) 123 (64.1%) 69 (71.1%) 13 (65.0%)
Traumatic pain 127 (8.2%) 12 (1.4%) 60 (16.2%) 41 (21.4%) 12 (12.4%) 2 (10.0%)
Spinal pain frequency3
Self-reported pain 6.8 (17.6) 0.4 (.6) 4.5 (3.1) 14.6 (9.1) 35.3 (22.8) 114.0 (52.3)
Diagnosed pain 3.1 (12.5) < 0.1 (.2) 1.3 (1.9) 6.7 (6.5) 17.7 (18.3) 66.1 (68.8)
Non-traumatic pain 2.8 (12.3) < 0.1 (0.2) 0.9 (1.8) 5.6 (6.5) 16.3 (18.1) 65.7 (68.7)
Traumatic pain 0.3 (1.6) < 0.1 (0.1) 0.4 (0.9) 1.0 (2.6) 1.4 (4.8) 0.4 (1.4)
1
Mean (SD) 6-month periods with valid spinal pain data
2
N (%) participants reporting ≥ 1 occurrence of spinal pain
3
Mean (SD) weeks with spinal pain

non-traumatic. The most common diagnoses were descrip-
tive and non-specific (e.g., “back pain”); tissue-specific and
pathological diagnoses were less frequent. This means that
spinal pain in children is common, often non-specific, and
follows a heterogeneous course of pain frequency.
We are unaware of other studies that have modeled the
developmental trajectories of spinal pain from childhood
through adolescence. However, previous studies have esti-
mated the probability of reporting low back pain during
early adolescence [9] or from adolescence to early adulthood
[10], with results that also suggest spinal pain to be com-
mon in those age groups. The primary differences between
the current and previous studies involve the populations and
methods of spinal pain measurement. We modeled the tra-
jectories of spinal pain (back and neck pain) frequency over
5.5 years in children aged 6 to 11 years at baseline and cov-
ered a larger age span. We measured spinal pain frequency
versus pain occurrences and applied shorter sampling win-
dows (1 week versus 3 to 12 months). Despite these meth-
odological differences, there were some similarities in the
pain trajectories identified by the different studies.
One prospective study modeled the 3-year trajectories of
low back pain experienced by 1336 11- to 14-year-old chil-
dren from the USA and identified six unique trajectories [9].
Comparable to our study, in which 78% of participants had
no pain or rare pain, approximately 3 in 4 participants in the

Fig. 3 Average weeks with (A) self-reported spinal pain1 and (B) for which the child underwent a physical evaluation and received a
diagnosed spinal pain2, stratified by trajectory subgroup. 1Self- diagnosis. Values are means and 95% confidence intervals (some
reported spinal pain includes all pain reports. 2Diagnosed spinal pain intervals too narrow to visualize). NP, no pain; R, rare; RI, rare,
is a subcategory of self-reported spinal pain comprising pain episodes increasing; MI, moderate, increasing; EOD, early-onset, decreasing

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European Journal of Pediatrics

Table 4 Diagnoses as a proportion of total diagnoses stratified by spinal pain trajectory subgroup1,2

“No pain” “Rare” “Rare, increasing” “Moderate, increasing” “Early-onset, decreasing”

(N = 876, 144 diagnoses) (N = 371, 325 diagnoses) (N = 192, 299 diagnoses) (N = 97, 152 diagnoses) (N = 20, 40 diagnoses)

Soft tissue pain 41% Back pain 18% Back pain 25% Back pain 30% Back pain 33%

Muscle strain 16% Soft tissue pain 17% Facet syndrome (L) 16% Facet syndrome 16% Neck pain 13%
(TL)
Enthesopathy 15% Muscle strain 13% Muscle strain 11% Neck pain 13% Muscle strain 10%
Back pain 12% Neck pain 10% Soft tissue pain 11% Muscle strain 7% Soft tissue pain 10%
Neck pain 3% Facet syndrome 10% Neck pain 8% Facet syndrome 7% Idiopathic scoliosis 5%
(TL) (C)
Contusion thorax 3% Contusion 8% Facet syndrome 5% Soft tissue pain 5% Enthesopathy 5%
(C)
Unspecified joint 2% Enthesopathy 7% SI syndrome 5% SI syndrome 5% Facet syndrome 5%
disorder (C)
Neck sprain/strain 2% Facet syndrome (C) 4% Contusion 5% Sprain/strain (C) 3% Facet syndrome 5%
(TL)
Facet syndrome (T) 1% Neck sprain/strain 4% Head pain 3% Head pain 3% Head pain 3%
SI syndrome 1% SI syndrome 2% Idiopathic scoliosis 2% Idiopathic scoliosis 3% Sprain/strain (C) 3%
Torticollis 1% Head pain 2% Enthesopathy 2% Disc protrusion (L) 2% Sprain /strain (T) 3%
Biomechanical 1% Idiopathic scoliosis 1% Neck sprain/strain 2% Contusion 2% Contusion pelvis 3%
lesion
Juvenile arthritis 1% Other joint disorder 1% Unspecified joint 1% Enthesopathy 1% SI syndrome 3%
disorder
Facet syndrome (C) 1% Biomechanical 1% Postural kyphosis 1% Postural kyphosis 1% Superficial injury 3%
lesion
Lumbar fracture 1% Sprain /strain (T) 1% Disc protrusion (L) 1% Spinal 1%
osteochondrosis
Postural kyphosis < 1% Facet syndrome (C) < 1% Spondylolysis 1%
Torticollis < 1% Lumbago with < 1% Coccygodynia 1%
sciatica
Disc degeneration < 1% Thoracic fracture < 1% Dorsopathy, 1%
(C) unspecified
Disc protrusion (L) < 1% Thoracic sprain / < 1% Biomechanical 1%
strain lesion
Muscle/tendon < 1% Sprain/dislocation < 1% Sprain/strain (T) 1%
injury(C) (L)
Coccyx fracture < 1% Soft tissue injury < 1%
Dislocation, sprain/ < 1%
strain (LP)
Sprain and strain < 1%
(SI)
Soft tissue injury < 1%

Bold-italics < 5% prevalence; bold 5 to 10% prevalence; italics > 10% prevalence
L lumbar, T thoracic and lumbar, C cervical, T thoracic, LP lumbopelvic, SI sacroiliac
1
Individuals could receive multiple primary diagnoses if more than 1 pain episode was reported
2
Percentages do not total to 100 due to rounding

other cohort had a very low probability of reporting pain.
The remaining participants in that study followed trajecto-
ries whose probabilities of pain increased (8%), decreased
(10%), peaked early (2%), or remained persistently high (1%)
over time. We identified a greater proportion of participants
who followed increasing spinal pain trajectories, which
may reflect the larger age range of our population and the
later stage of pubertal development for some participants, a
potential risk factor for spinal pain [23, 24]. However, the
early peak trajectory reported in that study included children
whose probability of pain increased until around age 13 and
sharply decreased thereafter, a pattern similar to the early-
onset, decreasing frequency trajectory experienced by 1.3%
of the participants in the current study. While most pain

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trajectories identified by the current and previous studies
followed a course of consistent or increasing pain frequency
or probability, this finding shows that some children with
early-onset pain do experience a favorable prognosis.
The current study adds to the evidence that spinal pain in
children rarely results from a pathological etiology. Of the
1556 participants enrolled in this study, we identified few
cases of pathological spinal pain such as idiopathic scoliosis
(12 cases; 0.8%), disc protrusion (6 cases; 0.4%), fractures
(3 cases; 0.2%), inflammatory arthritis (1 case; 0.1%), and
spondylolysis (1 case; 0.1%). In comparison, non-specific
diagnoses such as back pain (211 cases; 13.6%), soft tissue
pain (159 cases; 10.2%), and neck pain (86 cases; 5.5%)
were more common. This finding accords with evidence
from adult populations showing the vast majority (approxi-
mately 90%) of low back pain to be non-specific [25]. Given
the implications of overdiagnosis, clinicians are encouraged
to embrace non-specific labels when appropriate and avoid
potentially harmful diagnostic labels during a formative
period when one’s perceived vulnerability to spinal pain is
poorly understood [26].
The number of children meeting our criteria for diag-
nosed spinal pain (27.5%) was less than half that of those
with self-reported spinal pain (63.2%), indicating that many
pain occurrences resolved within one week. However, pre-
vious findings have shown spinal pain to be episodic and
recurrent for many [7, 27], and contemporary perspectives
view spinal pain as a long-term condition with a variable
course of symptoms and not a series of unrelated and self-
limiting pain events [28, 29].
Clinical decision-making for children with spinal pain
is a challenge. There have been few trials published on the
treatment of spinal pain in the pediatric population and
guideline recommendations are almost exclusively under-
pinned by evidence from adult studies of low back pain [30].
The current study results show concerning causes of spinal
pain to be rare. This finding accords with guideline recom-
mendations for clinicians to (1) reassure patients without
clinical “red flags” that they do not have a serious disease,
(2) encourage normal activities, and (3) avoid bed rest [31].
Study strengths and limitations
The strengths of this prospective study include the frequent
and repeated measurements of spinal pain in a representative
cohort of children from the general population. The 1-week
sampling window likely reduced the potential for recall bias,
and the integration of clinical examination and diagnostic
information advances our understanding of spinal pain clas-
sification in the pediatric population.
13
European Journal of Pediatrics
Trajectory modeling is a person-centered approach, and
our a priori statistical criteria suggested a high likelihood
that participants were correctly classified. However, statis-
tical models do not represent the individual experiences of
all participants. For example, longitudinal evaluations show
that some adults follow an episodic or “fluctuating” course
of back pain in which intervals with minimal symptoms are
separated by painful episodes that recur with time [7, 27].
These patterns are difficult to model, as the timing of the
episodes can be unpredictable. Trajectory model outcomes
“smooth” the course of symptoms and therefore represent
the average experience of people assigned to a particular
trajectory subgroup.
In the current study, participants contributed approxi-
mately 4 years of spinal pain data on average. Because we
sought to understand the development of spinal pain as a
function of age, we modeled pain trajectories from ages 6
to 17 years. This approach assumes that the participating
children would follow similar trajectories at a given age,
irrespective of their age at baseline and duration of partici-
pation. The validity of diagnostic criteria to identify spe-
cific pain-generating tissues such as joints, intervertebral
discs, or muscles is unclear. Therefore, some diagnoses
may be misclassified. Similarly, pain occurrences were
reported by parents, and surrogate reporting is a potential
source of bias, particularly with minor occurrences that
may not be communicated from children to their parents
[32]. The current study focused on the trajectories of spi-
nal pain frequency, which is key to understanding the bur-
den of this condition. However, investigating additional
person-centered and societal outcomes (e.g., pain inten-
sity, cost, school absenteeism, reduced physical activity
participation) in future studies could provide important
context to understanding the burden of spinal pain in chil-
dren. Finally, while we attempted to recruit all 19 regional
primary schools in Svendborg, nine schools elected not to
participate in this study. Although our study sample rep-
resents approximately half of all primary school students
in the region, there may be differences between the study
and target populations.
Data science tasks in epidemiology can be classified as
description, prediction, and causal inference [33], and future
research is needed to investigate these aspects of spinal pain
in children. For example, the trajectories described in this
study can be extended to see if they predict persistent pain
states in adulthood. Identifying baseline predictors of the
different pain trajectories will help identify those children
at risk of future spinal pain. Finally, the discovery of modifi-
able causes of spinal pain will be central to the development
and testing of future interventions.
European Journal of Pediatrics
Conclusion
Spinal pain is common, often non-specific, and follows a
heterogeneous course in children. Most children were clas-
sified as members of a no pain or rare spinal pain trajec-
tory subgroup. About 1 in 5 children followed trajectories
of increasing pain frequency, while a small subgroup of
followed an early-onset, decreasing spinal pain trajectory.
Children with early-onset pain reported the most weeks with
spinal pain overall, while those following an increasing tra-
jectory were tracking to experience the most pain in late ado-
lescence. Pathological diagnoses were rare in all subgroups.
Authors’ contributions Prof Hébert analyzed and interpreted the data,
drafted the initial manuscript, and critically reviewed the manuscript for
important intellectual content. Dr Beynon, Ms Wang, Dr Shrier, and Dr
Swain carried out initial analyses and interpreted the data, and critically
reviewed the manuscript for important intellectual content. Dr Jones
analyzed and interpreted the data and critically reviewed the manuscript
for important intellectual content. Prof Leboeuf-Yde, Prof Hartvigsen,
and Prof Hestbæk conceptualized and designed the study, and critically
reviewed the manuscript for important intellectual content. Dr Junge and
Dr Franz acquired data and critically reviewed the manuscript for impor-
tant intellectual content. Prof Wedderkopp conceptualized and designed
the study, coordinated and supervised data collection, interpreted the
data, and critically reviewed the manuscript for important intellectual
content. All authors approved the final manuscript as submitted and
agree to be accountable for all aspects of the work.
Funding The CHAMPS Study-DK was originally supported by grants
from The TRYG Foundation, University College Lillebaelt, Univer-
sity of Southern Denmark, The Nordea Foundation, The IMK founda-
tion, e.g., The Egmont Foundation, The A.J. Andersen Foundation,
The Danish Rheumatism Association, Østifternes Foundation, Brd.
Hartmann’s Foundation, TEAM Denmark, The Danish Chiropractor
Foundation, and The Nordic Institute of Chiropractic and Clinical Bio-
mechanics. No funding was secured for the current study. The funders
had no role in the design or conduct of the study.
Availability of data and material Data are available from the CHAMPS
Study Steering Committee upon reasonable request. Legal and ethical
restrictions apply. Interested parties may contact Dr. Niels Christian
Møller (nmoller@health.sdu.dk), and the following information will
be required at the time of application: a description of how the data will
be used, securely managed, and permanently deleted.
Code availability The code used in the analysis is available upon rea-
sonable request.
Declarations
Ethics approval The study protocol was approved by the Regional
Scientific Ethical Committee of Southern Denmark (ID S-20080047)
and registered with the Danish Data Protection Agency (J.nr. 2008–41-
2240).
Consent to participate All participating children gave verbal assent
and parents provided written informed consent prior to enrollment.
Consent for publication Not applicable.
Conflict of interest The authors declare no competing interests. Prof
Hébert receives salary and research support from the Canadian Chiro-
practic Research Foundation and the New Brunswick Health Research
Foundation.
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Authors and Affiliations
Jeffrey J. Hébert1,2 · Amber M. Beynon 2,3 · Bobby L. Jones4 · Chinchin Wang5,6 · Ian Shrier 6 · Jan Hartvigsen 7,8 ·
Charlotte Leboeuf‑Yde9 · Lise Hestbæk7,8 · Michael S. Swain3 · Tina Junge7,10 · Claudia Franz11 · Niels Wedderkopp12
1 7
Faculty of Kinesiology, University of New Brunswick,
Fredericton, New Brunswick, Canada
2 8
College of Science, Health, Engineering and Education,
Murdoch University, Perth, WA, Australia
3
Department of Chiropractic, Faculty of Medicine, Health
and Human Sciences, Macquarie University, Sydney, NSW,
Australia
4
Department of Psychiatry, University of Pittsburgh School
of Medicine, Pittsburgh, PA, USA
5 Department of Regional Health Research, Center of Research
Department of Epidemiology, Biostatistics and Occupational
Health, McGill University, Montreal, QC, Canada
6
Centre for Clinical Epidemiology, Lady Davis Institute,
McGill University, Montreal, QC, Canada
13
European Journal of Pediatrics
27. Axen I, Leboeuf-Yde C (2013) Trajectories of low back pain. Best
Pract Res Clin Rheumatol 27:601–612
28. Dunn KM, Hestbaek L, Cassidy JD (2013) Low back pain across
the life course. Best Pract Res Clin Rheumatol 27:591–600
29. Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML,
Genevay S, Hoy D, Karppinen J, Pransky G, Sieper J, Smeets RJ,
Underwood M, Working LLBPS G (2018) What low back pain is
and why we need to pay attention. Lancet 391:2356–2367
30. Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross
DP, Ferreira PH, Fritz JM, Koes BW, Peul W, Turner JA, Maher
CG, Working LLBPS, G, (2018) Prevention and treatment of low
back pain: evidence, challenges, and promising directions. Lancet
391:2368–2383
31. UK National Institute for Health and Care Excellence (2016) Low
back pain and sciatica in over 16s: assessment and management
32. Kamper SJ, Dissing KB, Hestbaek L (2016) Whose pain is it
anyway? Comparability of pain reports from children and their
parents. Chiropr Man Therap 24:24
33. Hernán MA, Hsu J, Healy B (2019) A second chance to get causal
inference right: a classification of data science tasks. Chance
32:42–49
Publisher's Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
Department of Sports Science and Clinical Biomechanics,
University of Southern Denmark, Odense, Denmark
Chiropractic Knowledge Hub, Odense, Denmark
9
Department of Regional Health Research, University
of Southern Denmark, Odense, Denmark
10
Health Sciences Research Centre, University College
Lillebaelt, Odense, Denmark
11
Private Practice, Haderslev, Denmark
12
in Childhood Health, University of Southern Denmark,
Odense, Denmark
European Journal of Pediatrics
Concluzii:
1. În acest studiu durerea de spate a
copiilor cu vârsta cuprinsă între
6-17 ani a fost încadrată în 5
stadii. Majoritatea copiilor nu au
experimentat niciodată sau rareori
durerea de spate în timp ce 1 din
5 copii au raportat o frecvență de
creștere a durerii de spate în
adolescență.
2. Cele mai frecvente diagnostice au
fost descriptive și nespecifice (de
exemplu, „dureri de spate”);
diagnosticele specifice țesuturilor
și patologice au fost mai puțin
frecvente. Aceasta înseamnă că
durereala nivelul coloanei
vertebrale la copii este frecventă,
adesea nespecifică și urmează un
curs eterogen de frecvență a
durerii.
3. Durerea coloanei vertebrale este
frecventă, adesea nespecifică, și
urmează un curs eterogen la
copii.
4. Acest studiu este o confirmare că
durerea la copii rezultă rareori
dintr-o etiologie patologică. Din
cei 1556 de participanți ai
studiului au fost identificate
puține cazuri de durere patologică
a coloanei, cum ar fi scolioză
idiopatică (12 cazuri/0,8%);
protruzia discală (6 cazuri/ 0,4%),
fracturi (3 cazuri/0,2%), artrita
inflamatorie (1 caz/0,1%) și spondiloliza
(1caz/0,1%). În comparație,
diagnosticele nespecifice, cum ar fi
durerea de spate (211 cazuri; 13,6%),
durerea de țesut moale (159 cazuri;
10,2%) și durerea de gât (86 cazuri;
5,5%) au fost mai frecvente.
5. Din copilărie și până la adolescență
durerea a fost frecventă și a urmat
cursuri eterogene cuprinzând traiectorii
stbile, în creștere și cu debut precoce.
Aceste constatări sunt în concordanță cu
recomandările din ghidurile specific
durerilor de spate ale adulților, conform
cărora majoritatea copiilor cu dureri de
spate pot fi asigurați că nu au un
diagnostic sau o deficiență gravă și
îndrumarea de a avea o viață activă.
6. Pe parcursul studiului, 63,2% dintre
copii au raportat una sau mai multe
apariții de durere de coloană vertebrală
și 27,5% au experimentat una sau mai
multe apariții de durere cu o durată
suficienă pentru a permite examinarea
fizică și diagnosticul (dureri spinale
diagnosticate). În total, durerea coloanei
vertebrale a fost raportată în 10554 de
săptămâni de participare, dintre care
4823 (45,7%) au fost săptămâni cu
dureri spinale diagnosticate. Marea
majoritate a săptămânilor de durere
spinală diagnosticată au fost clasificate
ca non-traumatic (4342 săptămâni;
90,0%).
13
European Journal of Pediatrics (2019) 178:695–706
https://doi.org/10.1007/s00431-019-03326-7

ORIGINAL ARTICLE

Epidemiology of spinal pain in children: a study

within the Danish National Birth Cohort
Anne Cathrine Joergensen 1 • Lise Hestbaek2 • Per Kragh Andersen3 • Anne-Marie Nybo Andersen 1

Received: 13 December 2018 / Revised: 9 January 2019 / Accepted: 16 January 2019 / Published online: 20 February 2019
Ⓒ The Author(s) 2019

Abstract
This study aims to describe the prevalence of spinal pain among Danish children, explore the differential nature of spinal pain,
and investigate socio-demographic factors predisposing spinal pain. A descriptive study of 46,726 11–14-year-olds participating
in the Danish National Birth Cohort was conducted. Self-reported spinal pain (neck, middle back, and low back pain) was
registered and classified according to severity. Socioeconomic data on children and their parents were identified in Statistics
Denmark registers. Associations between socio-demographic factors and aspects of spinal pain were estimated using multinomial
logistic regression models. To account for sample selection, inverse probability weighting (IPW) was applied. Almost 10% boys
and 14% girls reported severe spinal pain, whereas around 30% of all children reported moderate pain. Effect estimates indica ted
the risk to increase with increasing age. Further, children without biological full siblings, not living with both of their parents, or
children living in less-educated or lower-income families were more likely to experience spinal pain. The study conclusions were
essentially unaffected by IPW.
Conclusion: A considerable number of children suffer from spinal pain, and it is more common among children in more
disadvantaged families. Etiology of spinal pain needs to be explored further with the aim of informing efficient and targeted
prevention.

What is Known:
• Childhood spinal pain may cause marked discomfort and impairment in children’s everyday life, and is suggested as important predictor of later-in-life
spinal pain.
• Methodological heterogeneity in previous studies and complexity of measuring pain make inferences at a broader level inadequate.
What is New:
• Prevalence of severe spinal pain in 11–14-year-olds was estimated to almost 10% for boys and 14% for girls, and children in more disadvantaged
families were more likely to experience spinal pain.
• The results seemed unaffected by sample selection.

Keywords Spinal pain . Neck pain . Back pain . School children . Epidemiology . Socio-demographic risk factors

Communicated by Mario Bianchetti

Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s00431-019-03326-7) contains supplementary
material, which is available to authorized users.
1
* Anne Cathrine Joergensen Section of Epidemiology, Department of Public Health, Faculty of
acjo@sund.ku.dk Health and Medical Science, University of Copenhagen, Oster
Farimagsgade 5, bd. 24, DK-1014 Copenhagen K, Denmark
Lise Hestbaek
2
l.hestbaek@nikkb.dk Department of Sport Science and Clinical Biomechanics, University
of Southern Denmark, Campusvej 55, 5230 Odense, Denmark
Per Kragh Andersen
pka@biostat.ku.dk 3
Section of Biostatistics, Department of Public Health, Faculty of
Anne-Marie Nybo Andersen Health and Medical Science, University of Copenhagen, Oster
amny@sund.ku.dk Farimagsgade 5, 1014 Copenhagen K, Denmark
696
Abbreviations
DNBC The Danish National Birth Cohort
DNBC-11 The 11-year follow-up in the Danish
National Birth Cohort
IPW Inverse probability weighting
ISCED International Standard Classification
of Education
RRR Relative risk ratio
Spinal pain Neck pain, middle back pain, and/or low
back pain
YSQ The Young Spine Questionnaire
95% CI 95% confidence intervals
Introduction
Spinal pain (i.e., neck and back pain) constitutes a public
health concern worldwide [29]. Historically, spinal pain was
primarily studied in the working age population, but it has
become increasingly acknowledged that vulnerability to spi-
nal pain develops and becomes apparent already in childhood
[1, 9, 27]. Spinal pain has been framed Bas a long-term or
recurrent condition rather than a series of unrelated episodes^
[9], and epidemiological studies have characterized a prior
history of spinal pain as an important predictor of spinal pain
later in life [16, 24, 49]. In addition, spinal pain in children
may cause marked discomfort and impairment in children’s
everyday life and cause long-term problems. Research sug-
gests that children and adolescents reporting spinal pain expe-
rience increased healthcare utilization, absenteeism or impair-
ment in school, and restrictions in physical activity [27, 30,
42]. Likewise, children with spinal pain commonly experience
the co-existence of other health complaints, physically and
mentally [9, 13, 45, 48]. Therefore, studying spinal pain eti-
ology in its earliest onset may be of value, and likewise
targeting primary prevention towards the young population
rather than the working age population could be beneficial.
A growing body of evidence indicates spinal pain onset to
be around age 10–12, to increase in prevalence with age, and to
approach adult levels around age 18 [6, 9, 24, 31, 33].
However, spinal pain prevalence in the young population varies
considerably across studies with lifetime prevalence estimates
ranging between 4 and 74% [24, 27]. This wide discrepancy
can be explained by methodological limitations and heteroge-
neity as well as the complexity of measuring pain [11, 24, 27,
33, 48], resulting in imprecision and inadequacy to synthesize
findings and to make inferences at a broader level.
Familial and social factors are assumed to be of importance
for childhood health and pain experience [13, 41]. In spinal
pain research, a relationship has been indicated for risk factors
such as parental socioeconomic status [17, 36], biological vul-
nerability [10, 15], and parental pain behavior [7, 47]; however,
Eur J Pediatr (2019) 178:695–706
the evidence of risk factors predisposing to spinal pain is con-
flicting mainly due to methodological limitations [9].
Overall, findings from epidemiological studies of child-
hood spinal pain are ambiguous, and little is known about
the etiology of spinal pain, early life predictors, and specific
influence of timing and duration of spinal pain episodes [1, 9,
16, 24, 49]. Therefore, we aimed to describe the epidemiology
of spinal pain in 11–14-year-olds in the Danish National Birth
Cohort (DNBC) and to explore the differential nature of spinal
pain. Further, we aimed to provide a population-based preva-
lence estimate of spinal pain in Danish children using inverse
probability weighting (IPW).
Methods
Study population
For this descriptive cross-sectional study, we studied a cohort
of 46,726 children born in Denmark from 1996 through 2003
participating in DNBC. DNBC is a population-based birth co-
hort of mothers and their children with several follow-ups go-
ing from pregnancy and through childhood and young adult-
hood [37]. Pregnant women (n = 100,415) were recruited dur-
ing the period 1996 to 2002 by their general practitioner at their
first antenatal visit around gestational weeks 6–12. Further de-
tails of DNBC are described elsewhere [37]. For this study, we
used data from the 11-year follow-up (DNBC-11) for which
children received an electronic questionnaire around their 11th
birthday. Due to financial delay, DNBC-11 was carried out
from 2010 to 2014; thus, a minority of the children was 12–
14 years of age at completion. The unique individual personal
identification number assigned to all persons with a permanent
residence in Denmark allowed a complete linkage on individ-
ual level between DNBC data and Danish nationwide registries
containing comprehensive information on individual social
characteristics and furthermore linkage between children and
their parents [51]. We excluded participants with no informa-
tion on spinal pain variables (n = 2848), maternal education
(n = 47), equivalised household income (n = 182), siblings
(n = 4), and family type (n = 153) (Fig. 1).
Data were stored and processed at Statistics Denmark and
no personally identifiable data were accessible. Approval of
the study was obtained from the Danish Data Protection
Agency through the joint notification of the Faculty of
Health and Medical Sciences at the Uni versity of
Copenhagen and the DNBC Steering Committee.
Information on spinal pain
DNBC-11 included a sub-division of the Young Spine
Questionnaire (YSQ) (nine out of 19 questions), designed as
a standardized tool of measuring spinal pain in children age 9–
Eur J Pediatr (2019) 178:695–706
Fig. 1 The flow chart for the
selection of study participants
eligible for inclusion in the study
11 [32]. YSQ includes questions on pain frequency (often/
once in a while/once or twice/never), pain intensity (1 Bno
pain^ to 6 Bvery much pain^) of neck, middle back, and low
back pain (Fig. 2), and a variety of daily-life consequences
due to spinal pain [18, 32].
To distinguish between trivial and non-trivial pain [1, 16],
we combined pain frequency and intensity for each spinal
region into no pain, moderate pain, or severe pain. The opti-
mal cut-point for consequential spinal pain in children is pres-
ently unknown, but based on findings from a previous study
of children in this age group [1], also using the YSQ, severe
pain was defined as pain of four or more on the Faces Pain
Scale-Revised [18] and occurring at least Bonce in a while.^
This definition has been used before in analyses of the present
data [28]. Exact classification of pain groups appears from
Fig. 3. Subsequently, we constructed the main outcome of
interest overall spinal pain as a composite variable including
the three spinal regions. If the pain reported differed between
the three spinal locations, the location with the most severe
pain was used (Fig. 3).
Children were considered to have multiple spinal pain if
they reported severe pain in two or three spinal regions, and to
have one-sited pain if they reported severe pain in one spinal
region. Spinal pain-related daily-life consequences were a
composite measure reflecting the number of daily-life conse-
quences based on questions related to school absenteeism,
physical activity restrictions, and healthcare utilization.
7
A variety of additional case-definitions of spinal pain were
generated and applied in sensitivity analyses.
Socio-demographic factors
A priori, we selected child’s age, sex, and additional socio-
demographic factors as potential risk factors for spinal pain.
Biological full siblings (having biological full siblings or not)
and family type (living with both parents or not) were derived
upon questions from DNBC-11. Maternal age at childbirth (≤
25, 26–30, 31–35, > 35 years) was obtained from the Danish
Medical Birth Registry [5]. Information on maternal education
was obtained from the Danish Population’s Education
Register [25]. Educational level was operationalized as the
highest completed education attained the year of the child’s
11th birthday and was categorized into three groups according
to the International Standard Classification of Education
(ISCED) 2011: low (ISCED 0–2), medium (ISCED 3–4),
and high (ISCED 5–8) [22]. Equivalised disposable income
at the child’s 11th birthday was based on disposable house-
hold income extracted from the Income Statistics Register [3].
To enable comparison of family income across family size and
composition, we divided disposable household income by an
equivalence factor corresponding to the modified OECD
scale. This method is available on OECD’s website.
Equivalised disposable income was further categorized into
quartiles by year relative to all mothers giving birth in the
698
The following questions are about
neck and back pain
Have you suffered from neck pain?
o Yes, often
o Yes, once in a while
o Once or twice
o Never
How
much
pain?
Fig. 2 Illustration of original question for neck pain (frequency and
intensity) included in DNBC-11. Identical questions were asked for
middle back pain and low back pain. Rating of pain intensity was based
given year. All registries applied were available at Statistics
Denmark.
Statistical analyses
Descriptive statistics were reported using proportions and an-
alyzed for heterogeneity using the chi-squared test. To exam-
ine associations between socio-demographic factors and dif-
ferent aspects of spinal pain, we applied crude and adjusted
multinomial logistic regression models to estimate and report
relative risk ratio (RRR) and their corresponding 95% confi-
dence intervals (CI) [20] (for interpretation see Supplementary
File 1). In all analyses, children with no pain were considered
the reference outcome. The possibility of applying ordinal
logistic regression models was investigated, but the propor-
tional odds assumptions were not fulfilled [2].
To explore possible sex differences, we evaluated first-order
interactions with child’s age and additional socio-demographic
factors using a likelihood ratio test. The test showed no signs of
interaction with the familial and socioeconomic factors; how-
ever, a statistically significant interaction was found between
child’s sex and age. Hence, the regression analyses were ad-
justed for this interaction as well as for the main effects of the
familial and socioeconomic factors. The dependency between
Fig. 3 Illustration of composition
of frequency and pain intensity for
neck, middle back, and low back
pain as well as the main outcome
definition overall spinal pain
Eur J Pediatr (2019) 178:695–706
How much did it hurt at its worst?
1 is
on the Faces Pain Scale-Revised originally validated among 5–12-year-
olds
siblings in the sample (n = 6416) was taken into account by
applying a robust standard error estimator [53].
To account for sample selection (into the cohort and attri-
tion) [23], we applied IPW in sub-analyses using all children
born in Denmark from 1996 to 2003 as reference population
(n = 505,690) [43]. The probability of participating in the
study was estimated for each individual using the logistic re-
gression model. For this purpose, we applied a given set of
predictor variables for participation in DNBC-11. These fac-
tors included maternal education at childbirth, equivalised
household income the year before birth, maternal parity, and
urbanization, all obtained from Statistics Denmark and there-
fore available for participants as well as non-participants.
Subsequently, the weight (i.e., the inverse of the probability
of selection) was computed and included in the models. Thus,
intuitively, each participant accounted for him/herself as well
as for non-participants with similar characteristics [35].
The primary analyses were performed as complete case
analyses and, subsequently, we performed a sensitivity analy-
sis in which we accounted for missingness in DNBC-11 by
applying multiple imputations on missing data for the includ-
ed risk factors: family type, maternal education, and
equivalised household income. The results remained essen-
tially unchanged; hence, imputation was not applied in the
Eur J Pediatr (2019) 178:695–706 9

study [38]. Finally, we conducted several additional sensitivity Table 1 Distribution of variables related to spinal pain available in the
11-year follow-up of the Danish National Birth Cohort, stratified by
analyses to examine the robustness of the results.
child’s sex (N = 46,726)
All statistical analyses were performed using STATA V.15.
Total Boys Girls
N (%) N (%) N (%)
Results Neck paina
No pain 31,837 (68.1) 15,692 (70.4) 16,145 (66.0)
Characteristics of children with spinal pain Moderate pain 11,399 (24.4) 5174 (23.2) 6225 (25.5)
Severe pain 3490 (7.5) 1421 (6.4) 2069 (8.5)
Neck pain was the most frequent spinal region in which
Middle back paina
both girls and boys reported pain. Low back pain was the
No pain 38,354 (82.1) 18,640 (83.6) 19,714 (80.7)
least frequent, but estimates were close to those of middle
Moderate pain 6399 (13.7) 2906 (13.1) 3493 (14.3)
back pain (Table 1). Table 2 shows the composite defini-
Severe pain 1973 (4.2) 411 (3.3) 1232 (5.0)
tions of spinal pain used to estimate the prevalence among
Low back paina
children in DNBC-11 and the weighted prevalence rela-
No pain 40,154 (86.0) 19,769 (88.7) 20,385 (83.4)
tive to Danish children born from 1996 to 2003. In total,
Moderate pain 4847 (10.4) 1949 (8.8) 2898 (11.9)
severe spinal pain (intensity 4–6) was reported in 9.8% of
Severe pain 1725 (3.7) 569 (2.6) 1156 (4.8)
boys and 14.0% of girls, and moderate spinal pain in
approximately 30% of all children. Intriguingly, the prev- School absenteeismb
alence of spinal pain varied widely according to the ap- Never 43,476 (93.0) 20,892 (93.7) 22,584 (92.4)
plied case-definition of spinal pain. Including intensity 3 1–2 times 2752 (5.9) 1180 (5.3) 1572 (6.5)
in the definition of severe spinal pain, the prevalence al- More than 2 times 487 (1.0) 209 (0.9) 278 (1.1)
most doubled, whereas an intensity of 5–6 reduced the Missing 11 (0.02) 6 (0.03) 5 (0.02)
estimates by half compared with the main outcome defi- Refrainment of physical activityb
nition (data not shown). Most of the children only report- Never 39,809 (85.2) 19,181 (86.1) 20,628 (84.4)
ed severe spinal pain in one spinal region. Approximately 1–2 times 5668 (12.1) 2604 (11.7) 3064 (12.5)
23% of girls and 20% of boys had experienced at least More than 2 times 1237 (2.7) 496 (2.2) 741 (3.0)
one daily-life consequence due to spinal pain (Table 2) of Missing 12 (0.03) 6 (0.03) 6 (0.02)
which most cases were attributed to refrainment of phys- Care-seeking behaviorb
ical activity (Table 1). Never 42,262 (90.5) 20,311 (91.2) 21,951 (89.8)
All selected socio-demographic factors were related to spi- 1–2 times 2911 (6.2) 1346 (6.0) 1565 (6.4)
nal pain (Table 3). Our findings indicated moderate and severe More than 2 times 1541 (3.3) 624 (2.8) 917 (3.8)
spinal pain to be more frequent among girls and the preva- Missing 12 (0.03) 6 (0.03) 6 (0.02)
lence to increase rapidly with increasing age. Additionally, a
Composite measure of pain frequency and intensity (see Figs. 2 and 3
children with no biological siblings or children not living with for details)
both parents more often reported moderate and severe spinal b
All variables are due to spinal pain and only available for children
pain. Likewise, children in less-educated and lower-income reporting pain in at least one spinal region
families were more likely to report severe spinal pain com-
pared with those in high-status families. Similar patterns were
observed for neck, middle back, and low back pain, separately stronger for severe pain than for moderate pain. In analyses
(Supplementary File 2). of multiple spinal pain (i.e., pain in two or more regions) and
Applying IPW to account for selection, we observed a neg- daily-life consequences, we observed similar patterns to those
ligible increase in prevalence estimates, suggesting that results of overall spinal pain (Table 5). The same applied when using
from DNBC may be applicable to estimate a population-based alternative case-definitions (Supplementary Files 4–5).
prevalence of spinal pain among children in Denmark (Table 2 Despite small alterations, the overall findings on risk factors
and Supplementary File 3). were unaffected by IPW (Supplementary Files 6–8).
In sensitivity analyses, we examined the robustness of the
The association between risk factors and spinal pain associations using maternal education at childbirth and house-
hold income the year before birth instead of at the year of the
The adjusted effect estimates of experiencing moderate or child’s 11th birthday, for which the same effect estimates were
severe spinal pain confirmed the findings described above observed. The same applied when using parental education
(Table 4). We observed, however, no clear association for (i.e., the highest attained education of the parents) instead of
maternal age at childbirth. Generally, the associations were maternal education.
700 Eur J Pediatr (2019) 178:695–706

Table 2 Prevalence of spinal pain under different case-definitions (chi-squared tests of heterogeneity between boys and girls were statisti-
among 46,726 Danish children from the Danish National Birth Cohort, cally significant for all case-definitions) (N = 46,726)
11–14 years of age, born between 1996 and 2003, stratified by child’s sex

Case-definitions of spinal pain Original data (unweighted data) Weighted dataa

Total Boys Girls Total (%) Boys (%) Girls (%)

N (%) N (%) N (%)

Overall spinal painb

No pain 27,256 (58.3) 13,667 (61.3) 13,589 (55.6) 57.3 60.1 54.7
Moderate pain 13,877 (29.7) 6446 (28.9) 7431 (30.4) 30.0 29.4 30.4
Severe pain 5593 (12.0) 2174 (9.8) 3419 (14.0) 12.8 10.4 14.9
Multiple spinal pain
No pain 41,133 (88.0) 20,113 (90.2) 21,020 (86.0) 87.2 89.6 85.1
One-sited pain 4266 (9.1) 1705 (7.7) 2561 (10.5) 9.7 8.0 11.2
Multi-sited pain 1327 (2.9) 469 (2.1) 858 (3.5) 3.1 2.4 3.7
Spinal pain-related daily-life consequencesc
Never 36,541 (78.2) 17,736 (79.6) 18,805 (77.0) 77.6 79.1 76.2
1–2 times 7561 (16.2) 3471 (15.6) 4090 (16.8) 16.4 15.8 17.0
More than 2 times 2613 (5.6) 1074 (4.8) 1539 (6.3) 6.0 5.0 6.9
Missing 11 (0.02) 6 (0.03) 5 (0.02) 0.02 0.03 0.02
a
Inverse probability weights relative to all children born in Denmark from 1996 to 2003
b
Main outcome of interest based on neck, middle back, and low back pain (see Fig. 3)
c
Defined as follows: BNever^ if no experience of any of the daily-life consequences, B1–2 times^ if they responded Bonce or twice^ to only one of the
daily-life consequences, and the remaining were categorized as BMore than 2 times^

Discussion associated with the co-occurrence of other symptoms, physi-

In this descriptive paper using data from 46,726 children in
DNBC, we demonstrated that a sizeable number of children
aged 11 to 14 suffered from moderate or severe spinal pain.
Spinal pain was more common in girls and increased with age.
Further, the results displayed a clear social gradient in the
experience of spinal pain. The findings were confirmed after
IPW, taking selection into account.
The results emphasize spinal pain to be a common problem
among children; however, the exact extent of the problem
depends highly on the case-definition and nature of spinal pain
as well as the age of study participants. We found prevalence
estimates of severe spinal pain in 11–14 year-olds to be almost
10% for boys and 14% for girls with a rapid increase with
increasing age. Previous studies included individuals up to
age 23 [27] (i.e., allowing the prevalence to increase with
age), and thereby complicating comparison of estimates. The
differential nature of spinal pain implies a need for careful
application of case-definitions, interpretation of results, and
in the planning of preventive strategies. Studies have sug-
gested that having pain often or once in a while can be
interpreted as an indicator of recurrent pain, which may cause
marked discomfort and impairment in children’s everyday life
and reduce their quality of life as well as causing lifelong
problems with pain [42, 46]. Persistent pain has been
cally and psychological [44], and in a Danish twin study ad-
olescents with persistent low back pain were 3.5 times more
likely to have persistent low back pain as adults [16].
Alongside, co-occurrence of other musculoskeletal symptoms
is hypothesized as a risk indicator for a more persistent course
(i.e., multiple spinal pain) [44]. Oppositely, having experi-
enced a single episode of pain can either be due to a sudden
trauma or injury, or the beginning of a pain trajectory with
insidious pain onset [9]. The latter is especially interesting
for the age group included in our study, since this age has been
suggested as spinal pain onset. We grouped infrequent pain
with low intensity as no pain. It is possible that these children
were in the beginning of a pain trajectory, thus, may belong to
the group of children that may benefit from appropriate sup-
port to prevent spinal pain later in life.
Socioeconomic status is associated with parents’ ability to
affect their children’s health and well-being in a positive man-
ner due to lifestyle, health behavior, and knowledge [14].
Thus, children growing up in disadvantaged families are
predisposed to health adversities [8, 41]. We found children
from less-educated and lower-income families to be more
likely to experience spinal pain compared with children in
well-off families. These findings are in accordance with two
Nordic studies suggesting a similar social gradient in somatic
complaints, including back pain [13, 41], and with a recent
Eur J Pediatr (2019) 178:695–706 701

Table 3 Distribution of spinal

pain according to selected N Overall spinal painab
characteristics of the 46,726
children participating in the 11- No pain (%) Moderate pain (%) Severe pain (%)
year follow-up in the Danish
National Birth Cohort Total population 46,726 58.3 29.7 12.0
Sex
Boys 22,287 61.3 28.9 9.8
Girls 24,439 55.6 30.4 14.0
Age
11 years 38,303 59.4 29.3 11.3
12 years 7226 54.0 31.3 14.7
13–14 yearsc 1197 49.7 32.9 17.6
Sibling position
Biological full siblings 41,185 58.9 29.4 11.7
Only biological child 5541 53.9 31.7 14.4
Family type
Child lives with both parents 36,533 59.9 29.1 11.0
Child not living with (both) parentsd 10,193 52.7 32.0 15.3
Maternal educational level
High 26,886 59.3 29.7 11.0
Medium 17,217 57.6 29.6 12.8
Low 2623 54.0 29.7 16.3
Equivalised household income
4th quartile (highest) 16,698 60.3 28.9 10.9
3rd quartile 14,331 58.6 29.8 11.6
2nd quartile 10,542 57.0 30.3 12.7
1st quartile (lowest) 5,155 54.1 30.8 15.1
Maternal age at childbirth
≤ 25 years 5417 55.6 30.8 13.6
26–30 years 19,972 58.4 29.6 12.0
31–35 years 16,043 58.7 29.7 12.0
> 35 years 5294 59.8 28.8 11.4
a
Variables were analyzed with the chi-squared test of heterogeneity. Chi-squared tests were statistical significant
for all variables
b
For inverse probability weighted estimates see Supplementary File 3
c
130 individuals were 14 years old, most of them just turned 14 years at time of follow-up
d
Parents not living together due to divorce, separation, they never lived together, or only one parent alive

systematic review suggesting low socioeconomic status to be
a risk factor for onset of musculoskeletal pain in studies with
long-term follow-up [21].
We also found children with no biological full siblings
and children in separated families to be more likely to expe-
rience spinal pain. The family situation may affect the vul-
nerability and well-being of the child. In line with our find-
ings, studies have shown that children in single-parent fam-
ilies, in stepfamilies, or only children were more vulnerable
and had worse health outcomes than children in traditional
families or children with siblings, and further that health
adversities hereof psychosomatic symptoms were more com-
mon among these children [41, 52]. When familial and so-
cioeconomic variables were introduced in the models, the
effect estimates were only slightly reduced and remained
statistically significant, indicating that familial determinants
were still affecting childhood spinal pain when adjusting for
socioeconomic factors, and vice versa. Thus, it is likely that
some of the underlying mechanisms may be found within the
family environment of the child (i.e., affecting vulnerability
and well-being of the child) such as in parental pain behavior
[7, 47], chronic pain, parental mental health and behavioral
problems (i.e., depression, anxiety, and substance use) [19,
40], or in other psychosocial and lifestyle factors [12, 26].
These conditions might impact psychological symptoms in
the child such as sleep difficulties, feeling low, nervousness,
general well-being, and loneliness which have previously
been associated with spinal pain in children [4, 45].
702 Eur J Pediatr (2019) 178:695–706

Table 4 Relative risk ratio (RRR) of overall spinal pain according to potential risk factors among the 46,726 children participated in the 11-year follow-
up in the Danish National Birth Cohort

Characteristics Overall spinal pain

Modelab Model 2ac

Moderate pain Severe pain Moderate pain Severe pain

RRR (95% CI) RRR (95% CI) RRR (95% CI) RRR (95% CI)

Sex, age
Boys, 11 years Ref. Ref. Ref. Ref.
Boys, 12 years 1.12 (1.03–1.21) 1.16 (1.03–1.31) 1.12 (1.03–1.21) 1.15 (1.02–1.30)
Boys, 13+ years 1.41 (1.18–1.69) 1.29 (0.98–1.70) 1.41 (1.17–1.69) 1.26 (0.96–1.66)
Girls, 11 years 1.15 (1.10–1.20) 1.46 (1.37–1.56) 1.14 (1.09–1.19) 1.44 (1.35–1.54)
Girls, 12 years 1.41 (1.31–1.53) 2.39 (2.16–2.64) 1.41 (1.30–1.52) 2.34 (2.12–2.59)
Girls, 13+ years 1.49 (1.23–1.80) 3.47 (2.83–4.26) 1.48(1.23–1.79) 3.40 (2.77–4.18)
Sibling position
Biological full siblings Ref. Ref. Ref. Ref.
Biological only child 1.18 (1.10–1.25) 1.35 (1.24–1.47) 1.12 (1.05–1.20) 1.18 (1.08–1.30)
Family type
Child lives with both parents Ref. Ref. Ref. Ref.
Child not living with (both) parentsd 1.25 (1.19–1.31) 1.57 (1.47–1.68) 1.18 (1.12–1.25) 1.39 (1.29–1.50)
Maternal educational level
High Ref. Ref. Ref. Ref.
Medium 1.02 (0.98–1.07) 1.18 (1.13–1.27) 0.99 (0.94–1.03) 1.11 (1.05–1.19)
Low 1.08 (1.00–1.20) 1.62 (1.45–1.82) 1.01 (0.92–1.11) 1.37 (1.21–1.55)
Equivalised household income
4th quartile (highest) Ref. Ref. Ref. Ref.
3rd quartile 1.06 (1.01–1.12) 1.10 (1.02–1.18) 1.05 (1.00–1.11) 1.06 (0.98–1.14)
2nd quartile 1.11 (1.05–1.17) 1.23 (1.14–1.33) 1.07 (1.01–1.13) 1.09 (1.00–1.18)
1st quartile (lowest) 1.19 (1.10–1.27) 1.55 (1.46–1.70) 1.10 (1.02–1.18) 1.23 (1.11–1.36)
Maternal age at childbirth
≤ 25 years Ref. Ref. Ref. Ref.
26–30 years 0.92 (0.86–0.98) 0.84 (0.77–0.92) 0.96 (0.89–1.02) 0.95 (0.86–1.04)
31–35 years 0.91 (0.85–0.98) 0.81 (0.74–0.89) 0.95 (0.89–1.02) 0.91 (0.83–1.01)
> 35 years 0.87 (0.80–0.95) 0.78 (0.69–0.88) 0.90 (0.83–0.98) 0.87 (0.77–0.98)
a
Reference category: not having reported moderate or severe spinal pain (no pain)
b
Crude model
c
Adjusted for additional variables in the model, as well as the interaction between child’s age and sex (P < 0.001)
d
Parents not living together due to divorce, separation, they never lived together, or only one parent alive

Strengths and limitations
As one of the few, DNBC facilitates large-scale life-course
studies of spinal pain etiology and prevention due to the great
inclusion of validated self-reported spinal pain questions on
more than 46,000 11–14-year-olds as well as rich data on ex-
posures from conception and onwards, i.e., potential familial
risk factors for spinal pain. Since DNBC is nested within the
Danish population, it allows individual linkage of data on
health and (parental) social issues from Danish nationwide reg-
istries, permitting analyses of, e.g., any social interactions in the
disease production. For this study, linkage to Danish registries
made it possible to provide a population-based estimate of spi-
nal pain prevalence using inverse probability weights relative
to all children born in Denmark from 1996 to 2003.
Some limitations of the study are worth mentioning to
ensure accurate interpretation of the results. Generally, the
cross-sectional design impedes causal conclusions.
However, sensitivity analyses on risk factors occurring
before spinal pain onset as well as knowledge upon spinal
pain onset to occur around age 10–12 [6, 9, 24, 31, 33]
strengthen the study temporality.
 Eur J Pediatr (2019) 178:695–706
Table 5 Relative risk ratio (RRR) of multiple spinal pain and daily-life consequences due to spinal pain, respectively, according to potential risk factors among the 46,726 children participated in the 11 -
year follow-up in the Danish National Birth Cohort

Characteristics No. of cases Multiple spinal painac No. of cases Daily-life consequencesbc
(One-sited/Multi-sited) (1–2 times/More than two times)
One-sited Multi-sited 1–2 times More than two times
RRR (95% CI) RRR (95% CI) RRR (95% CI) RRR (95% CI)

Sex, age
Boys, 11 years 1377/376 Ref. Ref. 2714/863 Ref. Ref.
Boys, 12 years 283/75 1.12 (0.98–1.28) 1.08 (0.84–1.39) 639/189 1.36 (1.23–1.50) 1.26 (1.07–1.48)
Boys, 13+ years 45/18 1.02 (0.75–1.39) 1.47 (0.91–2.38) 118/22 1.44 (1.17–1.78) 0.83 (0.54–1.27)
Girls, 11 years 1963/606 1.34 (1.25–1.45) 1.51 (1.33–1.73) 3176/1167 1.10 (1.04–1.16) 1.26 (1.15–1.39)
Girls, 12 years 496/206 1.87 (1.67–2.09) 2.81 (2.36–3.35) 779/303 1.53 (1.40–1.67) 1.84 (1.60–2.11)
Girls, 13+ years 102/46 2.60 (2.08–3.24) 4.21 (3.05-5.82) 135/69 1.79 (1.47–2.18) 2.81 (2.15–3.68)
Sibling position
Biological full siblings 3656/1140 Ref. Ref. 6598/2221 Ref. Ref.
Biological only child 610/187 1.15 (1.04–1.26) 1.10 (0.93–1.31) 963/392 1.08 (1.00–1.17) 1.24 (1.10–1.40)
Family type
Child lives with both parents 3087/948 Ref. Ref. 5709/1918 Ref. Ref.
Child not living with (both) parentsd 1179/379 1.31 (1.21–1.42) 1.32 (1.15–1.51) 1852/695 1.17 (1.10–1.25) 1.20 (1.09–1.33)
Maternal educational level
High 2308/652 Ref. Ref. 4415/1364 Ref. Ref.
Medium 1636/570 1.07 (1.00–1.14) 1.30 (1.15–1.46) 2708/1035 0.92 (0.87–0.97) 1.13 (1.03–1.23)
Low 322/105 1.33 (1.17–1.52) 1.47 (1.18–1.84) 438/214 0.96 (0.86–1.08) 1.47 (1.25–1.72)
Equivalised household income
4th quartile (highest) 1398/416 Ref. Ref. 2566/884 Ref. Ref.
3rd quartile 1281/382 1.04 (0.96–1.13) 1.03 (0.89–1.18) 2357/736 1.09 (1.02–1.16) 0.96 (0.86–1.06)
2nd quartile 1015/321 1.06 (0.97–1.16) 1.08 (0.93–1.26) 1738/616 1.07 (1.00–1.15) 1.03 (0.92–1.15)
1st quartile (lowest) 572/208 1.15 (1.02–1.28) 1.32 (1.10–1.) 900/377 1.13 (1.03–1.24) 1.22 (1.06–1.40)
Maternal age at childbirth
≤ 25 years 565/170 Ref. Ref. 945/320 Ref. Ref.
26–30 years 1833/564 0.95 (0.85–1.05) 1.01 (0.85–1.21) 3205/1107 0.93 (0.86–1.01) 1.02 (0.89–1.16)
31–35 years 1408/451 0.90 (0.81–1.00) 1.01 (0.84–1.22) 2560/890 0.92 (0.85–1.00) 1.02 (0.89–1.16)
> 35 years 460/142 0.88 (0.77–1.00) 0.97 (0.76–1.22) 851/296 0.93 (0.84–1.03) 1.00 (0.85–1.19)

a
Reference category: not having reported in any of the spinal regions
b
Reference category: not having experienced daily-life consequences due to spinal pain
c
Adjusted for additional variables in the model, as well as the interaction between child’s age and sex (P < 0.001)
d
Parents not living together due to divorce, separation, they never lived together, or only one parent alive

703
704
In DNBC-11, information on spinal pain was based on
children’s self-report. Children’s perception of pain is subjec-
tive and self-reported data are prone to induce misclassifica-
tion; however, children’s self-report has previously been de-
fined as a reliable approach to measuring pain in children [50].
It should, however, be taken into account that the child’s vul-
nerability, health and well-being, age, sex, cognitive level, and
familial background may affect their pain reports [34, 50].
Among the children that participated in DNBC-11, 5.7%
were excluded due to incomplete data on spinal pain variables.
Imputation of an outcome measure is inadequate, and further,
we cannot rule out that data are missing not at random; thus,
the estimates may be biased [38]. Nonetheless, applying IPW
is a method to reduce bias from complete case analyses [43].
DNBC participants are a selected sample of the source popu-
lation with participation strongly related to familial and socioeco-
nomic factors [23]. When accounting for sample selection by
applying IPW [35, 43], we found the impact on the estimates
to be negligible. This is in accordance with methodological find-
ings by Jacobsen et al. and Pizzi et al. investigating the impact of
selection in birth cohort studies [23, 39]. However, since IPW
does not address unknown or unmeasured factors that influence
selection, fully representative estimates for the Danish population
cannot be concluded [35]. Despite potential selection problems,
the advantages of using detailed birth cohort data should be
balanced against issues of study validity, selection, and being
the only possible approach to perform large-scale life-course
studies on childhood spinal pain.
Conclusion
A considerable number of children suffer from spinal pain.
Spinal pain is more common in girls and the prevalence increases
with increasing age. In addition, children in more disadvantaged
families are more likely to experience spinal pain. Awareness of
the consequences of applying different case-definitions is essen-
tial in the assessment of spinal pain. Our findings provide a basis
for further in-depth examination of spinal pain etiology with the
aim of informing efficient and targeted prevention of spinal pain.
Acknowledgements The Danish National Birth Cohort was established
with a significant grant from the Danish National Research Foundation.
Additional support was obtained from the Danish Regional Committees,
the Pharmacy Foundation, the Egmont Foundation, the March of Dimes
Birth Defects Foundation, the Health Foundation, and other minor grants.
The DNBC Biobank has been supported by the Novo Nordisk
Foundation and the Lundbeck Foundation. Follow-ups of mothers and
children have been supported by the Danish Medical Research Council
(SSVF 0646, 271-08-0839/06-066023, O602-01042B, 0602-02738B),
the Lundbeck Foundation (195/04, R100-A9193), the Innovation Fund
Denmark 0603-00294B (09-067124), the Nordea Foundation (02-2013-
2014), the Aarhus Ideas (AU R9-A959-13-S804), the University of
Copenhagen Strategic Grant (IFSV 2012), and the Danish Council for
Independent Research (DFF 4183-00594 and DFF 4183-00152).
Eur J Pediatr (2019) 178:695–706
Funding source The study was supported by the Danish Council for
Independent Research (DFF-7016-00344).
Authors’ contributions MSc Joergensen conceptualized and designed the
study, carried out data management and analyses, and drafted the
manuscript.
Prof Nybo Andersen and Dr Hestbaek conceptualized and designed
the study and contributed to interpretation of results and critical revision
of the manuscript.
Prof Kragh Andersen supervised in statistical methods and analyses
and contributed in interpretation of results and critical revision of the
manuscript.
All authors approved the final manuscript as submitted, and agree to
be accountable for all aspects of this article.
Compliance with ethical standards
Approval of the study was obtained from the Danish Data Protection
Agency through the joint notification of the Faculty of Health and
Medical Sciences at the University of Copenhagen and the DNBC
Steering Committee.
Conflict of interest The authors declare that they have no conflicts of
interest.
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Concluzii:

1. Un număr considerabil de copii suferă de

dureri de coloană.

2. Durerea coloanei vertebrale este mai frecventă

la fete, iar prevalența crește odată cu creșterea
vârstei.

3. În plus, copiii sunt mai defavorizați, familiile

sunt mai susceptibile de a experimenta dureri
spinale.

4. Conștientizarea consecințele aplicării

diferitelor definiții de caz sunt esențiale în
evaluarea durerii spinale.

5. Descoperirile noastre oferă o bază pentru o

examinare suplimentară aprofundată a etiologiei
durerii spinale cu scopul de a informa prevenirea
eficientă și direcționată a durerilor de coloană.
European Journal of Pediatrics (2018) 177:1803–1810
https://doi.org/10.1007/s00431-018-3235-6

ORIGINAL ARTICLE

Does lower extremity pain precede spinal pain? A longitudinal study

Signe Fuglkjær 1 • Werner Vach2,3 • Jan Hartvigsen1,4 • Niels Wedderkopp 5,6 • Tina Junge 1,7 • Lise Hestbæk1,4

Received: 9 February 2018 / Revised: 23 August 2018 / Accepted: 24 August 2018 / Published online: 19 September 2018
Ⓒ The Author(s) 2018

Abstract
The main objective was to investigate whether children aged 9–15 years at baseline were more likely to experience an incident
event of spinal pain after experiencing lower extremity pain. Children’s musculoskeletal pain was monitored by weekly mobile
phone text message responses from parents, indicating whether the child had spinal pain, lower extremity pain, or upper extremity
pain the preceding week. Data were analyzed using mixed effect logistic regression models and cox regression models. The
association between an incident event of spinal pain and LE pain the preceding weeks increased with increasing observation
period and was statistically significant for 12 and 20 weeks (OR = 1.34 (95% CI 1.05 to 1.70) and OR = 1.39 (95% CI 1.11 to
1.75), respectively). We found that the likelihood increased in children with more frequent or longer duration of lower extremity
pain. The reversed relationship was investigated as well, and we also found a positive association between spinal pain and a
subsequent incidence event of lower extremity pain, but less pronounced.
Conclusion: Children were more likely to experience an incident event of spinal pain after experiencing lower extremity pain.
The likelihood increased in children with more frequent or longer duration of lower extremity pain.

What is Known:
• Both spinal pain and lower extremity pain often start early in life and is common already in adolescence.
What is New:
• Children were more likely to experience an incident event of spinal pain after experiencing LE pain.
• The likelihood increased in children with more frequent or longer duration of LE pain

Keywords Predictor . Risk factor . Low back pain . Epidemiology . Childhood . Kinetic chain

Communicated by Mario Bianchetti

Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s00431-018-3235-6) contains supplementary
material, which is available to authorized users.
1
* Signe Fuglkjær Department of Sports Science and Clinical Biomechanics, Faculty of
sfuglkjaer@health.sdu.dk Health Sciences, University of Southern Denmark, Campusvej 55,
5230 Odense M, Denmark
Werner Vach 2
Department of Orthopaedics and Traumatoloy, University Hospital
werner.vach@usb.ch Basel, Spitalstr 21, CH-4031 Basel, Switzerland
3
Institute for Medical Biometry and Statistics, Medical Faculty and
Jan Hartvigsen
Medical Center, University of Freiburg, Freiburg, Germany
jhartvigsen@health.sdu.dk
4
Nordic Institute of Chiropractic and Clinical Biomechanics,
Niels Wedderkopp Campusvej 55, 5230 Odense M, Denmark
NWedderkopp@health.sdu.dk 5
Institute of Regional Health Services Research, University of
Southern Denmark, Winsloewparken 193, 5000 Odense C, Denmark
Tina Junge 6
tiju@ucl.dk Sports Medicine Clinic, Orthopaedic Department, Hospital
Lillebaelt, Østre Hougvej 55, 5500 Middelfart, Denmark
7
Lise Hestbæk Health Sciences Research Centre, University College Lillebaelt,
l.hestbaek@nikkb.dk Vestre Engvej 51C, 7100 Vejle, Denmark
1804
Introduction
Spinal pain often starts early and is common already in ado-
lescence [1, 6, 20], and therefore knowledge about risk factors
and predictors should be explored in childhood. Spinal pain
has been associated with physical activity [2], overweight
[24], widespread pain [18], and most of all, a previous episode
of spinal pain [27, 30].
In children, lower extremity (LE) pain is more common
than spinal pain [9, 25] with ankle and foot pain being the
most common pain sites in young children [12, 16, 31], while
knee problems become more prevalent during adolescence
[21, 25]. Recently, it has been shown that the prevalence of
LE pain decreases from the age of 11 [13], whereas the prev-
alence of spinal pain increases from about the same age [6,
20]. We therefore hypothesize that LE pain in young children
may predispose the child for subsequent spinal pain. This
might be due to pain-induced changes in movement patterns,
which could lead to altered biomechanical loading in other
regions and thereby cause compensatory pain. Thus potential-
ly, a change in the kinetic chain between the LEs and the spine
could lead to spinal pain, and indeed indications of an associ-
ation between LE pain and later spinal pain have been found
previously [23, 26].
However, the presence of co-occurring musculoskeletal
pain is fairly common, also in children [8, 14, 15, 25], and
it is well known that pain in one site is a strong predictor
for pain elsewhere. Several theories have been explored to
explain this phenomenon. A relationship between physical
factors, such as overweight or physical activity, and de-
velopment of spinal pain has high face validity, but the
exact nature of such associations remains unclear [19].
Other possible explanations have been proposed, and
some examples are (1) central sensitization caused by
long-term pain in which altered signaling in the central
nervous system amplifies the overall pain perception
[22]; (2) several psychological factors have been shown
to predict musculoskeletal pain in children [5, 7, 28]; and
(3) hypermobility has been proposed as an explanation for
spreading of pain sites in girls [8]. However, common for
these potential explanations is that they would be expect-
ed to affect a potential relationship between pain sites
equally in both directions.
To test the hypothesis that LE may increase the risk of
subsequent spinal pain, we investigated whether children were
more likely to experience an incident event of spinal pain after
experiencing LE pain in the preceding weeks and to which
degree a potential association depended on the frequency of
LE pain prior to the spinal pain. Furthermore, to test whether a
potential association was bidirectional, we also estimated the
reverse relationship: whether spinal pain would lead to subse-
quent LE pain and to which degree a potential association
depended on the frequency of prior spinal pain.
Eur J Pediatr (2018) 177:1803–1810
Materials and methods
Setting
This was a prospective school-based cohort study nested with-
in the Childhood Health, Activity and Motor Performance
School Study (CHAMPS study-DK). The CHAMPS study-
DK was a dynamic cohort study; thus, children could enter
and leave the study at any time during the study period. The
main purpose of the CHAMPS study-DK was to evaluate the
effect of extra physical education on general childhood health.
Schools were divided into two groups: intervention schools
received six lessons of physical education per week, whereas
control schools received two lessons per week. The CHAMPS
study-DK is described in detail elsewhere [32]. In this paper,
only information with regard to spinal and lower extremity
pain will be analyzed.
Study population
There is evidence that the frequency of spinal pain increase
with age [4, 6, 10, 20]. To obtain a satisfying frequency of
spinal pain, only data from the last 2 years of the study period
(from August 2012 to June 2014) was used in this study. In
August 2012, the included pupils attended fourth to eighth
grades in 13 out of 17 public primary schools in the munici-
pality of Svendborg, Denmark. This municipality has 58,000
inhabitants and is comparable to the rest of Denmark in terms
of age, sex, and income, but has a slightly higher unemploy-
ment rate (5.3% versus 4.5%) [29]. In Svendborg, 84% of the
children attend public schools, which therefore represent all
socioeconomic levels.
Data collection
Registration of MSK pain was conducted by weekly mobile
phone text message responses (SMS responses) from parents.
Every week, parents received the following mobile phone text
message question (SMS question): BHas [name of the child]
had any pain during the past week in: 1-Neck or back; 2-
Shoulder, arm or hand; 3-Hip, leg or foot; 4-No, [name of
the child] did not have any pain.^ It was possible to report
more than one pain area. If parents did not reply, they received
reminders twice with an interval of 48 h. The SMS question
was sent out every week except for 6 weeks during the sum-
mer holidays (July and August) and 1 week during the
Christmas holidays. If parents texted a B1,^ B2,^ and/or B3^
for the MSK pain question, they were telephoned within
5 days by a member of the clinical team, consisting of licensed
and experienced chiropractors and physiotherapists. A stan-
dardized interview was performed about the nature of their
child’s pain, including information about location and dura-
tion of pain and mode of onset.
Eur J Pediatr (2018) 177:1803–1810
Variables of interest
Explanatory variables were LE pain the preceding weeks de-
fined as at least one episode with LE pain within the preceding
1, 2, 4, 8, 12, or 20 weeks, and spinal pain the preceding
weeks defined as at least one episode with spinal pain within
the preceding 1, 2, 4, 8, 12, or 20 weeks.
Outcome variables were an incident event of spinal pain
defined as spinal pain after at least 20 weeks without spinal
pain, and an incident event of LE pain defined as LE pain after
at least 20 weeks without LE pain. Confounders were age
(August 2012) and sex.
Statistical analyses
Children were included in the final analyses, if SMS responses
were available in at least 85% of the weeks from August 2012
to June 2014, excluding the summer holiday of 2013.
Potential differences in demographics were tested both be-
tween participants and non-participants (children that either
refused to participate or never answered the invitation), and
between the study sample and children excluded due to low
response rate. For non-participants, sex could be determined
from the names, but no other information was available.
Analyses were performed at the level of the single
weeks. The outcome measurement used in the primary
analysis was an incident event of spinal pain, defined as
spinal pain after at least 20 weeks without spinal pain.
Data included in the analyses were collected from August
2012 until June 2014, and included outcome measurements
from January 2013 to June 2013, and from January 2014 to
June 2014, to ensure that history of spinal pain of the last
20 weeks in each child was not disrupted by the summer
holiday period. Thus, from January 2013 to June 2013 and
from January 2014 to June 2014, we considered the prob-
ability to experience an incident event of spinal pain in
dependence of LE pain within the preceding 1, 2, 4, 8,
12, or 20 weeks. The association between this exposure
and the occurrence of an incident event of spinal pain was
described by odds ratios (ORs) with 95% confidence inter-
val (CI), obtained from a mixed effect logistic regression
with child as a random effect, adjusted for age and sex.
Next, we explored the proportion of weeks with LE pain as
a risk factor for incident events of spinal pain using two ap-
proaches. First, information about the proportion of weeks
with LE pain during the preceding 20 weeks was calculated,
and for each week, children were categorized into three
groups: No LE pain within the preceding 20 weeks, LE pain
1–50% of the weeks, LE pain > 50% of the weeks. Again,
associations were expressed by OR with 95% CI obtained
from a mixed effect logistic regression model with child as a
random effect. Trends were assessed by considering the three
categories as a continuous covariate coded as 1, 2, and 3.
1805
We then performed a time-to-event analysis to investigate
whether the time to experience an incident event of spinal pain
(event of interest) depended on the proportion of weeks with
LE pain prior to the beginning of analysis. We considered two
starting times: January 1, 2013, and January 1, 2014, and
combined the analyses. Children with spinal pain within
20 weeks prior to each start date were excluded from the
analysis. Children were categorized into three groups based
on proportion of weeks with LE pain 20 weeks prior to the
start date: No LE pain within the preceding 20 weeks LE pain
1–50% of the weeks, LE pain > 50% of the weeks. Kaplan–
Meier curves were used to visualize the time until an incident
event of spinal pain. Differences between the curves were
expressed as Hazard ratios with 95% CIs based on a Cox
model, adjusted for sex and age. Again, test for trend was
included. Clustering due to using children potentially
experiencing more than one event was taken into account by
using robust standard errors.
All analyses were repeated stratified by sex.
Missing SMS responses were imputed as Bno pain.^ To
estimate the impact of this decision, we performed a sensitiv-
ity analysis. Missing SMS responses were imputed as the
same value as the previous week’s SMS response.
Finally, all analyses were repeated in an identical way, but
in the reversed direction. Here, we explored whether the prob-
ability to experience an incident event of LE pain, depended
on the presence of spinal pain or the proportion of weeks with
spinal pain the preceding weeks. Difference in effect estimates
between the primary and reversed analyses was assessed by
fitting the two models simultaneously and using robust stan-
dard errors taking the clustering within children into account.
STATA 15.0 (StataCorp, College Station, TX, USA) was
used for analyses, significance level was set at 0.05.
Availability of data and materials Data are available only upon
request from the CHAMPS study-DK Steering Committee
due to legal and ethical restrictions. Interested parties may
contact Dr. Niels Wedderkopp (nwedderkopp@health.sdu.dk)
Table 1 Overview of participants from a cohort of Danish school
children; CHAMPS study-DK
Age, August 2012 Boys, n (%) Girls, n (%) Total n (%)
490 (48.0) 530 (52.0) 1020 (100.0)
9 29 (41.4) 41 (58.6) 70 (6.9)
10 90 (41.5) 127 (58.5) 217 (21.3)
11 114 (49.1) 118 (50.9) 232 (22.8)
12 120 (55.0) 98 (45.0) 218 (21.4)
13 86 (46.2) 100 (53.8) 186 (18.2)
14–15 51 (52.6) 46 (47.4) 97 (9.5)
Mean age (SD) 11.6 (SD 1.4) 11.4 (SD 1.4) 11.5 (SD 1.4)
1806 Eur J Pediatr (2018) 177:1803–1810

Table 2 Age- and sex-adjusted

associations, including Primary analyses: outcome spinal pain1 Reversed analyses: outcome lower p value for the difference
confidence intervals (CI), extremity pain2 between primary and
between incident events of spinal reversed analyses
pain and lower extremity pain the Lower extremity Odds ratio (95% Spinal pain Odds ratio (95%
preceding weeks, and the pain within the CI) within the CI)
reversed association; from a preceding preceding:
cohort of Danish school children.
Reference is children without 1 week 0.87 (0.58 to 1.31) 1 week 1.26 (0.84 to 1.87) 0.19
lower extremity1 or spinal pain2 2 weeks 0.93 (0.65 to 1.33) 2 weeks 1.14 (0.79 to 1.65) 0.41
4 weeks 1.11 (0.82 to 1.49) 4 weeks 1.18 (0.86 to 1.62) 0.75
8 weeks 1.23 (0.94 to 1.59) 8 weeks 1.09 (0.82 to 1.44) 0.50
12 weeks 1.34 (1.05 to 1.70) 12 weeks 1.15 (0.89 to 1.47) 0.34
20 weeks 1.39 (1.11 to 1.75) 20 weeks 1.12 (0.89 to 1.40) 0.14

1
Is lower extremity pain within the preceding weeks associated with an incident event of spinal pain?
2
Is spinal pain within the preceding weeks associated with an incident event of lower extremity pain?

and the following information will be required at the time of
application: a description of how the data will be used, secure-
ly managed, and permanently deleted.
Results
In total, parents of the 1020 children delivered 99,856 SMS
responses from August 2012 to June 2014. The majority of the
SMS responses was Bno pain^ (76.0%), 9.2% was missing, of
which 6.1% represented the summer holiday. The most com-
monly reported pain site was ‘LE pain,^ which was reported
9548 times (9.6%).

Study sample Is LE pain within the preceding weeks associated

From 2011 to 2014, 1917 children were invited to the
CHAMPS study-DK and 1465 (76%) accepted participation.
From August 2012 to June 2014, 1346 children were included
in the study; however, 326 were subsequently excluded due to
low SMS compliance, which left 1020 children for the final
analyses. There was no significant difference in relation to
sex, neither between participants and non-participants nor be-
tween compliers and non-compliers. Non-compliers were
slightly older than compliers (11.7 years of age versus
11.5 years of age, p = 0.03).
Children were 9–15 years (mean age 11.5 years). The ma-
jority were girls (Table 1).
with an incident event of spinal pain?
In the primary analysis, the total number of incident events of
spinal pain was 301. The association between an incident event
of spinal pain and LE pain the preceding weeks increased with
increasing observation period and was statistically significant
for 12 and 20 weeks (OR = 1.34 (95% CI 1.05 to 1.70) and
OR = 1.39 (95% CI 1.11 to 1.75), respectively) (Table 2).
Using information about the proportion of weeks with LE
pain during the preceding 20 weeks, we found that children
with more frequent or longer duration of LE pain were more
likely to experience an incident event of spinal pain than chil-
dren with less LE pain (Table 3).

Table 3 Age- and sex-adjusted associations, including confidence intervals (CI), between incident events of spinal pain and proportion of weeks with
lower extremity pain within the preceding 20 weeks, and the reversed association; from a cohort of Danish school children

Primary analyses: outcome spinal pain1 Reversed analyses: outcome p value for the difference between
lower extremity pain2 primary and reversed analyses

Proportion of weeks with Odds ratio Proportion of weeks Odds ratio

lower extremity pain (95% CI) with spinal pain (95% CI)

0% 1.00 0% 1.00
1–50% 1.35 (1.06 to 1.72) 1–50% 1.15 (0.90 to 1.45) 0.29
51–100% 1.59 (1.04 to 2.43) 51–100% 0.94 (0.51 to 1.72) 0.11
Trend 1.30 (1.10 to 1.54) 1.07 (0.91–1.26) 0.09

1
Is lower extremity pain within the preceding weeks associated with an incident event of spinal pain?
2
Is spinal pain within the preceding weeks associated with an incident event of lower extremity pain?
Eur J Pediatr (2018) 177:1803–1810 1807

In the time-to-event analysis, 198 and 197 children were
excluded due to report of spinal pain from August 2012 to
December 2012 and from August 2013 to December 2013,
respectively. In total, 822 children for 2013 and 823 for 2014
were used in the time-to-event analysis representing 251 inci-
dent events of spinal pain in 234 children. The Kaplan–Meyer
plot illustrated that the probability to experience an incident
event of spinal pain was higher for the children with LE pain
than in the children without LE pain (Fig. 1a).
In the Cox regression analyses, children with LE pain
were 1.70 times (95% CI 1.33 to 2.19) more likely to ex-
perience an incident event of spinal pain than children
without LE pain. Children with a more frequent or longer
duration of LE pain were more likely to experience an
incident event of spinal pain than children without LE pain
(Table 4). Thus, also the time-to-event analysis indicated
that the likelihood increased in children with more frequent
or longer duration of LE pain.

Fig. 1 Kaplan–Meier plot

illustrating the a probability to
experience an incident event of
spinal pain in dependence of
proportion of weeks with lower
extremity pain 20 weeks prior to
the start of analysis and b
probability to experience an
incident event of LE pain in
dependence of proportion of
weeks with spinal pain 20 weeks
prior to the start of analysis. LE
lower extremity
1808 Eur J Pediatr (2018) 177:1803–1810

Table 4 Age- and sex-adjusted associations, including confidence intervals (CI), between incident events of spinal pain and proportion of reported
lower extremity pain 20 weeks prior to analyses, and the reversed association. From a cohort of Danish school children

Primary analysis: outcome spinal pain 1 Reversed analysis: outcome lower extremity pain2 p value for the difference between
primary and reversed analyses
Proportion of weeks with n Hazard ratio Proportion of weeks with n Hazard ratio
lower extremity pain1 (95% CI) lower extremity pain 2 (95% CI)

0% 1008 1.00 0% 1006 1.00

1–50% 515 1.62 (1.24 to 2.11) 1–50% 168 1.42 (1.06 to 1.92) 0.51
51–100% 122 2.07 (1.34 to 3.20) 51–100% 34 1.51 (0.82 to 1.78) 0.40
Trend 1645 1.48 (1.24 to 1.89) 1208 1.32 (1.06 to 1.65) 0.38

1
Is lower extremity pain within the preceding weeks associated with an incident event of spinal pain?
2
Is spinal pain within the preceding weeks associated with an incident event of lower extremity pain?

Is spinal pain within the preceding weeks associated Discussion

with an incident event of LE pain?
In the reversed analysis, the total number of incident events of
LE pain was 458. We found a positive, but not statistically
significant, association between spinal pain the preceding
20 weeks and the likelihood to experience an incident event
of LE pain (Table 2). The number of weeks with spinal pain
during the preceding 20 weeks did not seem to influence the
risk of an incident event of LE pain (Table 3).
The time-to-event analysis included 590 children for 2013
and 618 children for 2014, representing 308 incident events of
LE pain in 282 children. The Kaplan–Meyer plot illustrated
that children with spinal pain experienced more incident
events of LE pain than children without spinal pain (Fig. 1b).
Children with spinal pain were 1.44 (95% CI 1.09 to 1.90)
times more likely to experience an incident event of LE pain than
children without spinal pain; however, we did not find that chil-
dren with more frequent or longer duration of spinal pain were
more likely to experience an incident event of LE pain (Table 4).
None of the differences between the primary and the re-
versed analyses were significant.
Sex differences
When the primary analyses were stratified for sex, the patterns
and associations were accentuated for the girls. In the stratified
reversed analyses, there was no evidence of associations for
the girls, and some associations for the boys, but without
trends in relation to time or frequency of spinal pain.
However, it should be noted that the cell sizes for children
with pain in more than half of the weeks were small, and the
estimates therefore potentially imprecise (Table 5).
Sensitivity analysis
Similar results were found, when missing SMS responses
were imputed as the same value as the previous week’s SMS
response (Supplementary File 1).
We found that children were more likely to experience an
incident event of spinal pain after experiencing LE pain 12
or 20 weeks prior to the spinal pain and this likelihood in-
creased in children with more frequent or longer duration of
LE pain. In the reverse analysis, we also found a positive
association between spinal pain and the likelihood to experi-
ence an incident event of LE pain, but this was less pro-
nounced and there were no patterns in relation to timing or
amount of prior spinal pain. The association was more pro-
nounced in girls than in boys. Several factors could explain
this finding, e.g., higher muscle strength and endurance in
boys than girls [11], or sex-related differences in types of
physical activity or in psychological reactions to pain.
However, it could be a chance finding since cell sizes are small
in the reversed analysis. This is supported by the fact that there
was no evidence of association in the reversed analysis, which
does not correlate with existing literature showing that more
girls than boys experience multisite pain [14, 25].
The primary analysis showed that the risk of spinal pain in-
creased with the amount of LE pain preceding spinal pain.
Likewise, significant associations with spinal pain were only seen
after more than eight weeks indicating a certain latency period.
Since this was not the case in the reversed analysis, this may
support the hypothesis of alterations of loading in the development
of spinal pain, e.g., certain duration of LE pain may lead to com-
pensatory pain in the spine, possibly due to changes in the kinetic
chain. Recently, a similar pattern (increased risk of low back pain
in case of LE pain) was found in American soldiers [26].
These findings highlight the importance of a clinical histo-
ry and examination of the complete MSK system, i.e., chil-
dren with spinal pain should also receive a thorough exami-
nation of the LEs and vice versa.
Mobile phone text messages are known to be a practical
and user-friendly method of data collection [3, 17]. In this
study, few responded with pain in more than one region. It is
unknown if parents were reluctant to report more than one
pain site, in which case, the SMS responses may not illustrate
Eur J Pediatr (2018) 177:1803–1810 1809

1.53 (1.02 to 2.31)

0.38 (0.05 to 2.73)
1.50 (0.81 to 2.76)
1.41 (0.82 to 2.44)
1.43 (0.90 to 2.27)
1.18 (0.78 to 1.79)
1.37 (0.95 to 1.95)
1.38 (1.00 to 1.90)

1.45 (1.05 to 2.00)

0.67 (0.17 to 2.72)
Table 5 Associations stratified by sex and adjusted for age, including confidence intervals (CI), between incident events of spinal pain and lower extremity pain the preceding weeks, and the reversed the complete picture of MSK pain. Likewise, parents may
have been reluctant to report a shift in region of pain and

Odds ratio
therefore observe the child for a week or two before reporting
a new pain episode, and this could add to the lack of associ-

1.00
1.00
ation when considering LE pain in the past few weeks.
Major strengths include the large prospective population-
Boys

166
169
178
189
199
218

482
214

328
21

70
based cohort, the high response rate and the short recall period.
n

8
This study confirms that some individuals are more prone to
Odds ratio (95% CI)
1.11 (0.66 to 1.88)

1.33 (0.85 to 2.05)

0.98 (0.59 to 1.61)
1.01 (0.66 to 1.57)
1.02 (0.70 to 1.49)
0.98 (0.69 to 1.40)
0.92 (0.67 to 1.27)

0.91 (0.64 to 1.29)

0.98 (0.50 to 1.92)

2.10 (1.08 to 4.09)

experience MSK pain than others, and that pain might spread to
other areas of the body, but not in a completely haphazard way.
Furthermore, these pain patterns tend to start early in life, and
thus highlights the importance of development of prevention
1.00

1.00
strategies and effective treatment for MSK pain early in life.
Girls

198
201
209
229
242
262

507
257

349
58

84
21
n

Proportion of weeks with spinal pain

Conclusion
Spinal pain within the preceding:

Children were more likely to experience an incident event of

Reversed analyses: outcome lower extremity pain2

spinal pain after experiencing LE pain. The likelihood in-

Hazard ratio (95% CI)

creased in children with more frequent or longer duration of

LE pain, and was more pronounced in girls than in boys. In the
reversed analyses, we also found a positive association be-
12 weeks
20 weeks
2 weeks
4 weeks
8 weeks

tween spinal pain and incidence events of lower extremity

1 week

1–50%

1–50%
> 50%

> 50%

pain, but this was less pronounced. This paper confirms that
0%

0%

attention to the entire musculoskeletal system is required to

understand the course and development of spinal pain.
Odds ratio (95% CI)
0.96 (0.53 to 1.73)
0.97 (0.58 to 1.62)
1.07 (0.69 to 1.66)
1.14 (0.78 to 1.65)
1.23 (0.87 to 1.73)
1.23 (0.90 to 1.70)

1.18 (0.84 to 1.66)

1.61 (0.84 to 1.65)

1.42 (0.99 to 2.04)

1.54 (0.77 to 3.09)

Is lower extremity pain within the preceding weeks associated with an incident event of spinal pain?
Is spinal pain within the preceding weeks associated with an incident event of lower extremity pain?

Acknowledgments We acknowledge the participants and their parents,

the participating schools, and the BSport & Uddannelse Svendborg
Kommune.^ Finally, we would like to thank all members of the
1.00

1.00

CHAMPS study-DK and Eleanor Boyle for assistance in the initial phase
of the statistical analyses.
Boys

276
281
293
314
325
353

457
347

328
221
association; from a cohort of Danish school children (530 girls and 490 boys)

71

39

Authors’ contributions NW was responsible for the concept and design

n

of the CHAMPS study-DK. SF and TJ participated in the collection of

Odds ratio (95% CI)

data. LH, JH, WV, and SF conceived the idea for the present study. SF
0.80 (0.45 to 1.41)
0.89 (0.54 to 1.46)
1.13 (0.75 to 1.72)
1.32 (0.92 to 1.89)
1.46 (1.04 to 2.04)
1.58 (1.14 to 2.18)

1.61 (0.92 to 2.81)

1.88 (1.27 to 2.80)

2.54 (1.27 to 2.80)
1.57 (1.11 to 2.22)

prepared the data for the statistical analyses and conducted those in col-
laboration with WV. SF, LH, JH, and WV participated in the interpreta-
tion of the results and for the first draft of the manuscript. All authors
revised the manuscript critically for intellectual content and approved the
1.00

1.00

final version. All authors agree to be accountable for all aspects of the
work in ensuring that questions related to the accuracy or integrity of any
part of the work are appropriate investigated and resolved.
Girls

291
299
310
325
336
360

486
347
104

551
195
63
n

Funding The following organizations funded individual researchers and

Proportion of weeks with lower extremity pain

the CHAMPS study Denmark part II: the Nordea Foundation, the TRYG
Lower extremity pain within the preceding:
Primary analyses: outcome spinal pain1

Foundation, the IMK Foundation, the Region of Southern Denmark, the

University of Southern Denmark, the University College Lillebaelt’s
Department of Physiotherapy, the Danish Chiropractic Research
Foundation, the Svendborg Project, the Municipality of Svendborg, as
well as the Nordic Institute of Chiropractic and Clinical Biomechanics.
No funding bodies were involved in the analysis of data, interpretation of
Hazard ratio (95% CI)

the data or publication decisions.

Compliance with ethical standards

12 weeks
20 weeks
2 weeks
4 weeks
8 weeks
1 week

1–50%

1–50%
> 50%

> 50%

Conflict of interest The authors declare that they have no conflict of

0%

0%

interest.
1

2
1810
Ethical approval Approval was obtained from the Regional Health
Research Ethics Committee before start (ID: S20080047) and the study
was registered with the Danish Data Protection Agency (J.nr. 2008-41-
2240). Written informed consent was obtained from the parents. Prior to
clinical examinations, both child and parent gave verbal acceptance. All
participation was voluntary with the option to withdraw at any time.
Abbreviations CHAMPS study-DK, Childhood Health, Activity and
Motor Performance School Study; LE, Lower extremity; MSK,
Musculoskeletal; SMS, Mobile phone text message; UE, Upper extremity
Open Access This article is distributed under the terms of the Creative
Co m m o n s A t tr i b u t i o n 4 .0 I n t e r n a t i o n a l Li c e ns e ( ht t p:/ /
creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
distribution, and reproduction in any medium, provided you give
appropriate credit to the original author(s) and the source, provide a link
to the Creative Commons license, and indicate if changes were made.
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 Svendborg, as precum și Institutul Nordic de
Concluzii: Chiropractică și Biomecanică Clinică.

1. Copiii au avut mai multe șanse de a 11.Nu au fost implicate organisme de finanțare în
experimenta un eveniment de durere a coloanei analiza datelor, interpretarea acestora.
vertebrale după ce au avut dureri LE.

2. Probabilitatea a crescut la copiii cu o durată

mai frecventă sau mai lungă de durere LE și a
fost mai pronunțată la fete decât la băieți.

3. În analizele inversate, am găsit o asociere

pozitivă între durerea coloanei vertebrale și
incidenta evenimentelor la nivelul extremităților
inferioare.

4. Această lucrare confirmă faptul că se impune

atenție la întregul sistem musculo-scheletic pentru
a înțeleage cursul și dezvoltarea durerii coloanei
vertebrale.

5. Contribuțiile autorilor NW a fost responsabil

pentru concept și design a studiului CHAMPS-
DK. SF și TJ au participat la colecția de date. LH,
JH, WV și SF au conceput ideea pentru acest
studiu.

6. SFa pregătit datele pentru analizele statistice și

le-a efectuat în colaborare cu WV. SF, LH, JH și
WV au participat la interpretarea rezultatelor și la
prima schiță a manuscrisului.

7. Toți autorii a revizuit manuscrisul în mod critic

pentru conținutul intelectual și a aprobat
versiunea finala.

8. Toți autorii sunt de acord să răspundă pentru

toate aspectele.

9. O parte a lucrării sunt investigate și rezolvate

corespunzător.

10.Următoarele organizații au finanțat cercetători

individuali și studiul CHAMPS Danemarca partea
II: Fundația Nordea, TRYG Fundația, Fundația
IMK, Regiunea Danemarcei de Sud,
Universitatea Danemarcei de Sud, Colegiul
Universitar Lillebaelt Departamentul de
Fizioterapie, Danish Chiropractic Research
Fundația, Proiectul Svendborg, Municipiul