Show Nav


ICPA Responds to USA Today

An Orthopedic Surgeon on behalf of USA Today commented that children's spines were not subject to injury. Read ICPA's response below. 

“There's no evidence that the active lifestyles of childhood make kids vulnerable to poor spine development.”

First, from a chiropractic perspective, it must be clarified that chiropractic care of children promotes an active lifestyle. Chiropractors have long promoted proper nutrition, diet and an active physical lifestyle in their adult and pediatric patients. This approach to patient care is so much more given the epidemiology of obesity in children in this country. However, a consequence of an active lifestyle for children is the exposure to microtrauma (i.e., repetitive low grade trauma) and macrotraumatic events (i.e., the occurrence of a single major injury involving large forces). Macrotrauma is something well understood and appreciated by all – a child plays football or hockey and incur an injury as a result of “being hit.” Microtrauma are those forces that are not as large as the forces involved in a tackle or “hip check to the boards” but due to their cumulative effect, eventually lead to trauma. So where’s the evidence that this occurs.  Consider that poor spine development is reflected in the pathophysiological consequence of  low back pain (LBP). It has been well established that LBP is a common condition in adults but in recent years, it has also been frequently reported by children and adolescents. 1 The incidence of LBP in children has steadily increased in the past 20-30 years with the greatest increase in the last decade.2 The cumulative annual prevalence of LBP in 14-year old French schoolchildren was 82.9% with 57.7% reporting recurrent LBP and 8.9% chronic LBP.3 The annual prevalence of LBP in 5, 000 Iranian children aged 11- and 14-years was 17.4%. 4 Twenty-two percent of English schoolchildren and 18% of Finnish children aged 14-16-year-old reported having LBP.5,6 

A number of risk factors have been reported for LBP in children such as gender (i.e., more common in girls and rises with age)7, poor physical condition8, inadequate strength in back-stabilizing muscles 9,10, impaired flexibility in the hamstring muscles11and family history of LBP 12.

What about physical activity? 

A recent publication in the European Spine Journal examined just this topic. In a cross-sectional survey of 15-16-year old  schoolchildren, 
Skoffer and colleagues 13 examined children’s physical activity and occurrence and severity of LBP. After correcting for body height and weight and for anthropometric and school furniture parameters, more than half of the children reported pain or discomfort in the low-back region during the preceding 3 months, and 1/4 experienced decreased functioning or need of care because of LBP. LBP correlated with physical inactivity (i.e., time spent on homework and hours watching TV or video) and with a series of physical activities such as jogging, handball playing and gymnastics. Among sports activities, only swimming and the number of hours per week participating in soccer were associated with a decreased LBP prevalence. According to the authors, with the exception of swimming and soccer, the types of activities reported by this schoolchild population do not offer themselves for consideration as tools for LBP prevention.  
Other studies have also reported “physical activity” as a risk factor for LBP in children. Lundin and colleagues reported intense exercise as a risk factor for LBP in children 14, Bockowski and colleauges15 cite physical activity as a risk factors for LBP in children. In examing LBP in Tunisian schoolchildren, Bejia and colleagues 16 found that two factors associated with chronic LBP were  dissatisfaction with the school chair and football playing. Kujala and colleagues 17 investigated the occurrence of low-back pain and anatomic changes in the low back in relation to loading and injuries among 98 adolescents: 33 were non-athletes (16 boys, 17 girls), 34 boy-athletes (17 ice hockey, 17 soccer players), and 31 girl-athletes (17 figure skaters, 14 gymnasts). During the 3-yr follow-up, low-back pain lasting longer than 1 wk was reported by 29 athletes and by 6 nonathletes. Acute back injury was reported by 17 of 19 subjects who also reported low-back pain and by 2 of 63 of those without prolonged low-back pain. What’s even more disturbing is that among the 43 girls participating in baseline and follow-up MRI examinations of the lumbar spine, new MRI abnormalities were found in 6 of 8 reporting acute back injury and in 8 of the remaining 35 girls. The authors concluded that children experience excessive loading during the growth spurt that involves a risk for acute low-back injuries. 

Lastly, poor spine development as seen on imaging studies (i.e., magnetic resonance imaging) demonstrating degenerative joint disease in young children is well documented 18,19. Chiropractors, with a holistic and vitalistic approach to patient care are best to care for such patients as demonstrated by their continued popularity among parents and children 20, 21. The chiropractic adjustment has been demonstrated effective for patients with low back pain 22. The chiropractor’s focus and specific attention to posture and pelvic and spinal alignment is conducive to the normal development of a child’s spine. The growing child needs constant adaptations in the morphology and orientation of the pelvis to maintain an adequate sagittal balance and appropriate configuration in terms of skeletal loads, muscle fatigue, and energy expenditure. Specific biomechanical parameters such as the sacral slope and pelvic tilt are important for the “normal” development of spinal configurations 23. Chiropractors pay a lot of attention to these variables in the growing child 

“The spinal column is very well designed to absorb physiologic loads and that the everyday activity of children doesn’t even approach the kind of stress needed to cause an injury.”

The epidemiology of low back pain in children as discussed above would seem to counter this statement by the orthopedic surgeon. Let’s examine an everyday activity in children that requires their spinal column to absorb physiologic loads. Let’s examine the contribution of backpacks and the development of back pain in children. Korrevessis and colleagues 24 investigated the  correlation between backpack carrying, spinal curvatures, and athletic activities on 3, 441 schoolchildren's (aged 9-15 years) dorsal and low back pain. Korrevessis and colleagues found that dorsal pain increased with increasing backpack use. Sports exposure seemed to increase LBP more in girls more than in boys.  Korosvessis and colleagues 25 also found that backpack carrying, particularly that favoring one side, resulted in shift of upper trunk and shoulder and cervical lordosis, which seemed to increase back pain in school period and holidays. Skoffer26 also demonstrated that an everyday activity for children such as carrying a school bag may be associated with LBP as did Cattalorda and colleagues27.

“He also said that children’s spines are more flexible and have more capacity to bend and stretch than adult spines, which are not as flexible.”

Flexibility or more appropriately, hypermobility is a characteristic unique to the pediatric spine. This unique biomechanical feature of pediatric spines cannot be considered in isolation to that of the other unique features of the pediatric spine such as growth, malleability, adaptability, a changing spinal contour, changing applied forces and overall, an immature neuromusculoskeletal system. All these variables are considered by the chiropractor in the context of applying a spinal adjustment and in the development of spinal lesions. Specific to flexibility, in a study of 958 individuals aged 10-84 years, Burton and colleagues28 found that at the extremes of  back surface curvature, both hypomobility and hypermobility “were identified as risk indicators for low-back trouble.”  Under the characteristic of a growing spine, the height of the occipital condyles is approximately 50% compared to the adult with a flatter axial angle at C0-C1 functional spinal. This allows for greater mobility (hypermobility) and the development of upper cervical spine segmental dysfunction in such situations as in a low impact motor vehicle collision. In biomechanics, hypermobility has an inverse relationship with stability. Instability of the upper cervical spine has been associated with unexpected death in children29.


  1. Leboeuf-Yde C, Ohm Kyvik K. At what age does low back pain become a common problem? Spine 1998;23:228–34
  2. Hakala P, Rimpelä A, Salminen J, et al. Back, neck and shoulder pain in Finnish adolescents: national cross sectional surveys. BMJ 2002;325:743
  3. Viry P, Creveuil C, Marcelli C. Nonspecific back pain in children. A search for associated factors in 14-year-old schoolchildren. Rev Rhum Engl Ed, 1999; 66: 381-8
  4. Mohseni-Bandpei MA, Bagheri-Nesami M, Shayesteh-Azar M. Nonspecific low back pain in 5 000 iranian school-age children. J Pediatr Orthop, 2007; 27: 126-9.
  5. Murphy S, Buckle P, Stubbs D. A cross-sectional study of selfreported back and neck pain among English schoolchildren and associated physical and psychological risk factors. Appl Ergon, 2006; 18: 18.
  6. Taimela S, Kujala UM, Salminen JJ, Viljanen T. The prevalence of low back pain among children and adolescents. A nationwide, cohort-based questionaire survey in Finland. Spine, 1997; 22: 1132-6.
  7. Leboeuf-Yde C, Ohm Kyvik K. At what age does low back pain become a common problem? Spine 1998;23:228–34
  8. Harreby M, Nygaard B, Jessen T, et al. Risk factors for low back pain in a cohort of 1389 Danish school children: an epidemiologic study. Eur Spine J 1999;8:444–50
  9. Sjolie A, Ljunggren A. The significance of high lumbar mobility and low lumbar strength for current and future low back pain in adolescents. Spine 2001;26:2629–36.
  10. Salminen J, Erkintalo M, Laine M, et al. Low back pain in the young. Spine 1995;20:2101–8.
  11. Sjolie A. Low-back pain in adolescents is associated with poor hip mobility and high body mass index. Scand J Med Sci Sports 2004;14:168–75
  12. Gunzburg R, Balague´ F, Nordin M, et al. Low back pain in a population of school children. Eur Spine J 1999;8:439–43
  13. Skoffer B, Foldspang A. Physical activity and low-back pain in schoolchildren. Eur Spine J 2008;17(3):373-9
  14. Lundin O, Hellström M, Nilsson I, et al. Back pain and radiological changes in the thoraco-lumbar spine of athletes. A long-term follow-up. Scand J Med Sci Sports 2001;11:103–9
  15. Bockowski L, Sobaniec W, Kulac W, Smigielska-Kuzia J, Sendrowski K, Roszkowska M. Low back pain in school-age children: risk factors, clinical features and diagnostic managment. Adv Med Sci 2007;52 Suppl 1:221-3
  16. Bejia I, Abid N, Ben Salem K, Letaief M, Younes M, Touzi M, Bergaoui N. Low back pain in a cohort of 622 Tunisian schoolchildren and adolescents: an epidemiological study. Eur Spine J 2005;14(4):331-6
  17. Kujala UM, Taimela S, Erkintalo M, Salminen JJ, Kaprio J. Low-back pain in adolescent athletes. Med Sci Sports Exerc 1996;28(2):165-70
  18. Erkintalo MO, Salminen JJ, Alanen AM, Paajanen HE, Kormano MJ. Development of degenerative changes in the lumbar intervertebral disk: results of a prospective MR imaging study in adolescents with and without low-back pain. Radiology 1995 Aug;196(2):529-33
  19. Harreby M, Neergaard K, Hesselsoe G, Kjer J. Are radiologic changes in the thoracic and lumbar spine of adolescents risk factors for low back pain in adults? A 25-year prospective cohort study of 640 school children. Spine 1995 Nov 1;20(21):2298-302           
  20. Lee A, Li H, Kemper KJ. Chiropractic care for children. Arch Pediatr Adolesc Med. 2000;154(4):401–407
  21.  Sawni-Sikand, Schubiner H, Thomas RL. Use of complementary/alternative therapies among children in primary care pediatrics. Ambul Pediatr. 2002;2(2):99–103.
  22. Lawrence DJ, Meeker W, Banson R, Bronfort G, Cates JR, Haas M, Haneline M, Micozzi M, Updyke W, Mootz R, Triano JJ, hawk C. Chiropractic management of low back pain and low back-related leg complaints: a literature synthesis. J Manipulative Physiol Ther 2008;31(9):659-74
  23. Mac-Thiong JM, Labelle H, Berthonnaud E, Betz RR, Roussouly P. Sagittal spinopelvic balance in normal children and adolescents. Eur Spine J 2007;16(2):227-34
  24. Korovessis P, Koureas G, Papazisis Z. Correlation between backpack weight and way of carrying, sagittal and frontal spinal curvatures, athletic activity, and dorsal and low back pain in schoolchildren and adolescents. J Spinal Disord Tech 2004;17(1):33-40
  25. Korovessis P, Koureas G, Zacharatos S, Papazisis Z. Backpacks, back pain, sagittal spinal curves and trunk alignment in adolescents: a logistic and multinomial logistic analysis. Spine 2005;30(2):247-55.
  26. Skoffer B. Low back pain in 15- to 16-year-old children in relation to school furniture and carrying of the school bag. Spine 2007;32(24):E713-7
  27. Cattalorda J, Bourelle S, Gautheron V. Effects of backpack carrying in children. Orthopedics 2004;27(11):1172-5
  28. Burton AK, Tillotson KM, Troup JD. Variation in lumbar sagittal mobility with low-back trouble. Spine 1989;14(6):584-90
  29. Gilles FH, Bina M, Sotrel A. Infantile atlantooccipital instability. The potential danger of extreme extension. Am J Dis Child 1979;133(1):30-7