Rehabilitation of back pain in the pediatric population: a mixed studies systematic review

Our review included studies that: 1) enrolled children and adolescents (aged 19 years or younger) with non-specific LBP or TSP; 2) investigated rehabilitation interventions (Table 1); 3) compared the intervention of interest with other conservative interventions, placebo or sham, wait list, standard care, and no intervention (including intervention of interest as an addition to active comparison interventions where the attributable effect of the comparison interventions can be isolated); and 4) reported patient-important outcomes related to functioning as described by the International Classification of Functioning, Disability and Health (ICF) framework [11] domains body functions and structures (to describe a child’s impairment such as pain), and activities and participation (to describe a child’s functional status and involvement in life situations), adverse events, cost measures or qualitative outcomes (Table 2). We used the Convention on the Rights of the Child and the WHO definitions of children (< 18 years of age) and adolescents (10–19 years of age) [12, 13].

The rehabilitation process is designed to assist individuals in regaining, improving, or maximizing functioning and quality of life after experiencing injuries, surgeries, diseases, or other health-related issues [14]. It encompasses a diverse range of interventions (single or in combination) and clinical disciplines, tailored to the specific needs of each individual. The ultimate goal of a rehabilitation process is to facilitate the highest level of independence and participation in daily life, school, work, and leisure activities, adapting to limitations when necessary and enhancing overall well-being. For instance, a person recovering from a low back injury might engage in a rehabilitation process that includes education on back care, targeted exercises, spinal manipulation, and psychological support to manage pain and promote re-engagement in daily activities, exemplifying a holistic approach to recovery.

Given the comprehensive nature of the rehabilitation process, our systematic review remains open to the inclusion of studies that might focus on specific aspects of the rehabilitation process, including those that emphasize pain relief as a primary outcome. Recognizing pain as a significant barrier to participation and engagement in rehabilitation activities, studies dedicated to understanding and managing pain are considered valuable. Effective pain management is not only critical for the immediate relief of symptoms but also plays a crucial role in enabling individuals to actively participate in their rehabilitation journey and achieve long-term goals of independence and improved quality of life. Such an approach is aligned with the World Health Organization's person-centered perspective on rehabilitation, which emphasizes addressing the most pressing needs of individuals undergoing rehabilitation, including pain management [11].

We included randomized controlled trials (RCT), cohort studies, case–control studies, and mixed-methods studies (quantitative component) for effectiveness and safety of interventions; qualitative and mixed-methods studies (qualitative component) for users’ experiences, preferences, expectations, and valued outcomes of interventions; and trial- and model-based full economic evaluations for cost-effectiveness of interventions (Table 2).

A health sciences librarian developed search strategies reviewed by a second health sciences librarian, using the Peer Review of Electronic Search Strategies (PRESS) checklist [15, 16]. The searches included a combination of subject headings specific to databases (e.g., MeSH in MEDLINE) and free text words to capture the key concepts of rehabilitative management of back pain in children and adolescents (Additional file 2).

We searched the following databases from inception to June 16, 2023: MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), CINAHL (EBSCOhost), the Index to Chiropractic Literature (Chiropractic Library Collaboration), the Cochrane Controlled Register of Trials (Ovid), and EconLit (EBSCOhost).

To mitigate the potential impact of publication bias, we further searched: 1) reference lists of included studies and relevant systematic reviews; 2) three websites (the Canadian Paediatric Society, the American Academy of Pediatrics, the European Paediatric Association); and 3) the WHO International Clinical Trials Registry Platform [17]. We included studies in any language.

We conducted training exercises prior to initiating the screening process. Reviewers screened a random sample of 50 titles/abstracts and 25 full-text articles. Paired reviewers reached ≥ 90% agreement before starting screening [18].

Pairs of reviewers independently screened titles and abstracts retrieved from electronic databases, and subsequently the full text of each selected article to confirm inclusion. Paired reviewers discussed disagreements to reach consensus, involving a third reviewer, if necessary.

Furthermore, one reviewer screened reference lists of included studies and relevant systematic reviews, the three websites, and protocols retrieved from the WHO International Clinical Trials Registry Platform. A second reviewer reviewed the screening performed by the first reviewer. Disagreements were resolved through discussion.

We assessed the quality of studies using the Cochrane Risk of Bias (ROB) 1 tool [19] for RCTs; the risk of bias tool for nonrandomised studies for interventions (ROBINS-I) for cohort studies [20]; and the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for qualitative studies [21]. We categorized the validity or credibility of each study as either low risk of bias, unclear or high risk of bias. Paired reviewers independently assessed the eligible studies for quality. We contacted one author to request additional data for clarification [22]. Any disagreements between reviewers were resolved through discussion or with a third reviewer.

Paired reviewers independently extracted the data from all eligible studies and solved disagreements through discussion or a third reviewer. For the quantitative studies, we extracted data on the study and participant characteristics; intervention and comparator intervention characteristics using the Template for Intervention Description and Replication (TIDieR) checklist [23]; outcomes according to the ICF categories [24‐26]; adverse events; key findings; and methodological quality. We used the PerSPecTIF question formulation framework to guide data extraction for the qualitative studies regarding the items: perspective, setting, phenomenon of interest, environment, timing, and findings (e.g., themes) [27].

We used a sequential approach at the review level to synthesize and integrate the data [28]. This involved separate quantitative and qualitative findings synthesis followed by integration of the resultant quantitative and qualitative evidence.

We screened 8461 citations and 307 full-text articles, and included 11 studies (Fig. 1). Of these 11 studies, the effectiveness of rehabilitation interventions were investigated in 10 quantitative studies including eight RCTs (518 participants) [22, 32‐39] and two non-randomized clinical trials (40 participants) [40, 41] (Table 5), and one qualitative study investigated patients’ experience of physiotherapy (14 Participants) [42] (Table 6). We did not identify studies on cost-effectiveness of rehabilitation interventions. One RCT was reported in two full text articles [35, 36]. Two hundred ninety-five articles were excluded based on full text screening due to: 1) ineligible research question (8 articles); 2) ineligible population (238 articles); 3) ineligible intervention (2 articles); 4) ineligible outcome (3 articles); 5) ineligible study designs (36 articles); 6) duplicates (7 articles); and 7) cannot retrieve (1 article) (Additional file 3).

Among eight RCTs, one was rated as overall unclear risk of bias [33] and seven were rated as high risk of bias [22, 32, 34‐39] (Table 7, Risk of Bias Assessment of Included Studies). The two non-randomized clinical trials were rated as overall serious risk of bias (Table 8, Risk of Bias Assessment of Included Studies) [40, 41]. One qualitative study was rated as overall low risk of bias (Table 9) [42].

This systematic review has strengths. First, this review included comprehensive and peer-reviewed literature search strategies and examined all non-surgical rehabilitation interventions without language restrictions. Second, this review used a definition of rehabilitation as proposed by Cochrane Rehabilitation, which allowed us to capture what can be considered components of broader rehabilitation interventions that are provided within the rehabilitation process.

Due to limited number of relevant studies and clinical heterogeneity, a meta-analysis could not be conducted. Second, it was challenging to apply GRADE to the included studies to examine rehabilitation interventions due to clinical heterogeneity and blinding issues caused by the nature of rehabilitation interventions. Therefore, we adapted the GRADE approach and tailored it to rehabilitation studies.

There are three systematic reviews identified in evaluating rehabilitation interventions for the management of LBP in pediatric population published between 2014 and 2019 [6‐8]. Our review agreed with the systematic review by Michaleff et al. (2014) [8] suggesting that a supervised exercise program was better than no treatment. We augmented this conclusion by adding one non-randomized clinical trial [40]. However, we do not agree that a supervised exercise program reduces absences from physical activity due to a non-clinical important change [35, 36]. The systematic review by Driehuis et al. (2019) [6] suggested spinal manipulation did not bring adverse events; however, our review found the certainty of evidence is very low. Further studies are needed before making a conclusion about adverse events associated with spinal manipulation. Driehuis et al. did not identify studies on the effectiveness of spinal manipulation for LBP. Last, both Prevost et al. (2019) [7] and our review found that spinal manipulation reduced LBP intensity. Our review further clarified that spinal manipulation (1–2 sessions/week over 12 weeks) combined with exercise is probably associated with a greater likelihood of experiencing clinically important pain reduction immediately following the intervention and over the short-term versus exercise alone [33]. In addition to all the three reviews, we identified studies on the effectiveness of cognitive functional therapy, whole-body vibration and multimodal care.

The findings in our review have important implications for clinical practice. First, as evident in the included qualitative study, the patient-doctor relationship should be highlighted, providing a foundation for a positive interaction that may facilitate increased compliance with treatment towards the goal of recovery (i.e., subcategories 2 and 3: coaching from care providers, compliance with treatment) [42]. Second, information provided via education/advice should be considered as part of care program [44]. Third, spinal manipulation and group-based exercise may be considered through shared decision-making to reduce pain intensity in adolescents with LBP based on low to moderate certainty evidence [33‐36].

Compared to previous reviews, evidence is expanding. However, future studies with rigorous methodological quality are still needed. Two previous systematic reviews only identified four studies (including one case series and one cohort study without a control group) [7] and one study [6], respectively. Our review identified 10 quantitative studies (i.e., 8 RCTs, 2 non-randomized clinical trials) and one qualitative study. Of those, nine quantitative studies had high risk of bias. Specifically, blinding of participants, treatment providers and outcome assessors (e.g., participants for self-reported outcomes) are the main challenge in the included RCTs. This challenge is due to the nature of rehabilitation interventions. To minimize potential biases caused by these issues, future RCTs can be restricted to participants who are naïve to the studies interventions [31]. Alternatively, future RCTs can consider measuring treatment credibility/expectancy and blinding, and consider these in the analysis and interpretation of potential biases and the implications on intervention effect estimates [31]. Furthermore, apart from RCTs, future studies can consider various study designs (e.g., quasi-experimental design, qualitative, mixed methods, and implementation studies) depending on the research question [31]. These study designs can complement the evidence obtained from RCTs, therefore contributing to a more holistic perspective on the evaluation of benefits and harms, specifically for a context-sensitive condition (e.g., LBP). For example, qualitative studies can explore patients’ lived experiences and assist better understanding of evidence from RCTs regarding treatment effects, compliance etc.