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Lower-Back Pain in Kids and Teens

Research, implications and solutions to a growing problem.

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It is estimated that 60%–80% of the population will suffer from lower-back pain (LBP) at some time during their lifespan (Hamill et al. 1995). The causes are poorly defined because of the multiple risk factors, which include degenerative changes; repeated incorrect lifting technique; excessive static sitting and standing postures; bending; twisting; and falling.

One specific population that has
received recent attention in regard to LBP is children and teenagers. LBP in kids and teens, you ask? What could be contributing to LBP in such a young population? Too much sitting? Heavy backpacks? The research may surprise you.

Anatomy Review

The spine’s ligaments, muscles, fasciae and intervertebral disks provide the body with both static and dynamic support. An
intervertebral disk consists of two layers: the annulus fibrosus and nucleus pulposus. The fibers making up the annulus fibrosus consist of 50%-60% collagen, providing the disk’s tensile strength. Collagen is less abundant in the lateral and posterior portions of disks, particularly in the lower back’s L4–S1 region, making this area vulnerable to injury because of reduced tensile strength (Hamill et al. 1995).

Disks absorb the load and distribute the forces applied to the vertebral column. The annular fibers are thicker and more numerous anteriorly (in the front) than posteriorly (in the back). The thinner posterior longitudinal ligament runs down the posterior surface of the vertebral bodies, inside the spinal canal, and connects to the rim of the vertebral bodies and the center of the disks, making the posterolateral aspect vulnerable for disk protrusion (Jensen 1980).

Postural and
Phasic Muscles

Muscles enable our limbs to move and perform simple functional tasks, such as reaching into a cupboard, putting on a shirt, lifting a bag and so on. However, all muscles are not the same.

Certain muscles tend to tighten, while others tend to “weaken.” Vladimir Janda, MD, DSc, a respected physician, researcher and clinician, discovered over a 50-year
career that dysfunction in our joints, muscles and nervous system is a result of motor dysfunction. By focusing specifically on anatomy and kinesiology and their interrelationship, he discovered characteristic patterns of muscle hyper- and hypo-activity, which he called “muscle imbalances.” This led to the labeling of “postural syndromes,” which he termed upper and lower crossed syndromes. Through his
research, he noticed patterns and syndromes of muscle imbalances (Morris et al. 2006).

Janda categorized the muscles of the upper and lower body into two groups: postural and phasic. Postural muscles
respond to dysfunction by tightening, whereas phasic muscles respond by weakening (see Table 1). He concluded that in order to prevent motor dysfunction—which can ultimately lead to pain—in adults and teenagers it was necessary first to stretch the tighter postural muscles and then to strengthen the weaker phasic muscles (see Figure 1).

Current Research

Several studies have examined the causes of kids’ and teenagers’ back pain.

An observational study by Young, Haig and Yamakawa (2006) of 184 middle-school children investigated a possible relationship between back pain and backpack weight. The study did not find a correlation between backpacks and
incidence of LBP, but 35.9% of all of the students surveyed reported having back pain in the cervical, thoracic or lumbar region. The researchers acknowledged that for children with back pain, wearing a backpack could make the condition more uncomfortable, and that a strategy of reducing the frequency of wearing a backpack or the load carried might be a viable option in such cases.

Ippolito, Versari and Lezzerani (2006) reviewed the literature concerning clinical aspects and rehabilitation of different types of juvenile LBP disorders. The most common causes of LBP in children were found to result from mechanical, developmental, inflammatory, neoplastic and psychosomatic factors. Under mechanical cause, the literature found that in some cases faulty posture develops in older children with exaggerated lumbar lordosis. Poor postural habits may be linked to prolonged television watching or inappropriate school furniture. Strategies such as stretching and strengthening exercises may improve postural abnormalities.

In a study by Petersen, Bergström and Brulin (2003), a random sample of 1,155 children completed a questionnaire. Recurrent monthly backache was reported by 18% of the children, with approximately half of them having weekly complaints. The prevalence of recurrent backache showed a large variation by grade, not by gender. The results suggested a need for preventive efforts addressing these complaints at an early age.

Geldhof and associates (2007) studied classroom postures of 41 children, aged 8–12. Data revealed that 55% of the children complained of neck region pain and 45% reported pain in the thoraco-lumbar region. Analysis showed that children who spent more time sitting with the trunk flexed over 45 degrees reported significantly more thoraco-lumbar pain. Prolonged static sitting with poor posture is common in schoolchildren, according to this study, and the findings suggest a need to implement movement breaks and alterations of class organization.

Marketing Your Services for Practical Application

Based on the research, LBP affects children across the age gamut. Poor posture can be a common cause. Educating clients and parents of young teenagers about neutral spine can be a positive first step toward reversing LBP in kids and teens. It can also be a specialty profit center for your business.

An excellent way to educate both parents and youth about postural issues is to deliver a simple presentation at a school function or sporting event. Design a flier that lets people know you’ll be giving postural screenings plus fitness and muscular endurance tests (i.e., sit-ups and push-ups). After your presentation, you can offer to assess core strength using the four-point plank and side plank. You can also perform basic human movement sport assessments on kids doing activities such as kicking/throwing a ball or pushing a medicine ball from chest level.

Also consider using a plumb line for postural assessment. For standing posture, a plumb line—a cord with a plumb bob attached to provide an absolute vertical-line standard for measuring deviations—functions as a point of reference. Ideal spinal alignment depicted with a plumb line would show the line passing through the lobe of the ear, the shoulder joint and the greater trochanter of the
femur, and then passing slightly anterior to midline of the knee and the lateral malleolus (at the ankle). Use of a plumb line will not only help you show postural
deficiencies but also give you a perfect
opportunity to explain that faulty alignment leads to undue stress and strain on bones, joints, ligaments and muscles.

From all the information obtained in various assessments, you can then design a structured exercise program that addresses postural imbalances, resulting in improved postural strength, health and wellness.

Another effective way to create awareness is to hold an open house at a local high school and invite parents, athletes and teenagers. Stimulate a forum for both awareness and discussion by explaining “weak links” in the human body and inviting the audience to ask questions. Then lead an audience participation program, during which attendees try common core strength exercises (on a mat), followed by a few simple tube exercises that act to strengthen weaker phasic muscles.

Distribute handouts with clear
imagery and evidence-based literature to the audience. This will strengthen your presentation and demonstrate your professionalism and dedication to safe, researched exercise programs. Most important, it will make people aware of your services and how you can help clients exercise the right way.

Table 1. Janda’s Postural and Phasic Muscles Classification

Postural Muscles (tighten)

upper trapezius
pectoralis major/minor
erector spinae
tensor fasciae latae
hip adductors

Phasic Muscles (weaken)

middle and lower trapezius
gluteus maximus
gluteus medius
anterior tibialis

Source: Morris, C., et al. 2006.

Figure 1. Upper and Lower Crossed Syndromes

Postural Education: Strengthening the Core

Your clients will typically possess one of the following common postures: lumbar lordosis, thoracic kyphosis or swayback. By explaining posture based on science/biomechanics and the related research, you can initiate informative discussions during postural assessments.

Educating clients about the core is paramount. Anatomically, the core runs from the chest to the pubic symphysis (anteriorly) and from the scapulae to the top of the iliac crests (posteriorly). Stressing the role of the core and its effect on everyday human movement (including sport activities) is fundamental. Demonstrating simple static (in-place) ways of strengthening the core is key (see “Alternate Arm and Leg Lift” as an example).

Alternate Arm and Leg Lift

Practical Application
After you have discussed posture assessment and goals with clients, share information about the ways that posture can be changed through awareness (cognitive), practice (psychomotor) and behavior. Repetition results in motor learning and the acquisition of new skills.

Also demonstrate simple exercises that stretch the postural muscles. Using pictures is ideal, as images will help clients retain the information. Do the same for strengthening the phasic muscles.

Make exercise fun for young children and teenagers. Begin with basic exercises, such as plank, then progress to walking push-ups with a large stability ball. Use light, progressive resistance exercises targeting the weaker rhomboids and lower trapezius. This is functional for sitting in a chair all day at school.

Four-Point Plank

Lower Trapezius Strengthening

Anatomically and biomechanically, the human spine is weakest in the lower lumbar region. Pioneering research by Vladimir Janda, MD, DSc, proved that dysfunctions in the joints, muscles and nervous system are a result of motor dysfunctions that lead to muscle imbalances. The sooner we educate our clients about these weak links and work to correct imbalances, the more likely it will be that they can avoid (or reduce) lower-back pain.


Geldhof, E., et al. 2007. Classroom postures of 8–12 year old children. Ergonomics, 50 (10), 1571–81.
Hamill, J., & Knutzen, K.M. 1995. Biomechanical Basis of Human Movement. Philadelphia: Lippincott Williams & Wilkins.
Ippolito, E., Versari, P., & Lezzerini, S. 2006. The role of rehabilitation in juvenile low back disorders. Pediatric Rehabilitation, 9 (3), 174–84.
Jensen, G.M. 1980.Biomechanics of the lumbar intervertebral disk: A review. Physical Therapy, 60 (6), 765–73.
Morris, C., et al. 2006. Vladimir Janda, MD, DSc: Tribute to a master of rehabilitation. Spine, 31 (9), 1060–64.
Petersen, S., Bergström, E., & Brulin, C. 2003. High prevalence of tiredness and pain in young school children. Scandinavian Journal of Public Health, 31, 367–74.
Young, I.A., Haig, A.J., & Yamakawa, K.S. 2006. The association between backpack weight and low back pain in children. Journal of Back and Musculoskeletal Rehabilitation, 19, 25–33.


Concerned about your place in the new fitness industry? We have 40 years of experience supporting pros just like you! Let’s create a new wellness paradigm together—IDEAfit+ is the extra edge you need. Once you team up with IDEA, be sure to take full advantage of all the benefits of membership.

Chris Gellert, MPT

Chris Gellert, MPT, CSCS, CPT, is a licensed physical therapist, personal trainer, national presenter and author. He is the president of Pinnacle Training & Consulting Systems, an educational company that creates evidenced-based material for personal trainers. He can be reached at [email protected] or www.pinnacle-tcs.com.

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