Musculoskeletal disorders among children and young people: prevalence, risk factors, preventive measures

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Kerstin Schmidt and Paul Schmidt, BioMath GmbH, Thomas Tischer, Universität Rostock

Introduction

Existing statistics show a high prevalence of musculoskeletal disorders (MSDs) already among children and young people. Prevalence of MSDs among young people / workers (under 25) is not as high as for older age groups but it remains quite high.

In many cases, MSD problems begin in childhood, when inappropriate postures are combined with little sports activity[1]. Suffering from musculoskeletal pain in childhood or adolescence increases the risk of having it as an adult[2], possibly through the development of maladaptive beliefs, behaviours, and attitudes related to the earlier pain events[3]. If MSDs in children can be prevented, entry into a cycle of recurring episodes may be delayed and adult MSD prevalence decreased[4].

Figure 1: Percentages of children and young people with MSDs before and after entering the labour market (data published between 2010 and 2021) grouped by gender.Note “female” and “male” are subgroups of “all”, but the latter additionally includes prevalence values from studies that did not differentiate between genders. For each Gender – Labour market combination (i) the number of extracted prevalence estimates is shown at the top and (ii) the rounded median is written besides the boxplot’s median.
Figure 1: Percentages of children and young people with MSDs before and after entering the labour market (data published between 2010 and 2021) grouped by gender.
Note “female” and “male” are subgroups of “all”, but the latter additionally includes prevalence values from studies that did not differentiate between genders. For each Gender – Labour market combination (i) the number of extracted prevalence estimates is shown at the top and (ii) the rounded median is written besides the boxplot’s median.

This article shows how important it is to adopt a ‘life-course’ approach for studying musculoskeletal conditions and musculoskeletal health. This approach gives potential for a better understanding of how and why musculoskeletal conditions occur over the life course and how musculoskeletal health can be promoted. The adoption of such an approach “improves prevention for all workers (young and older), and reduces the damage to workers’ health while limiting early exit from work and improving the sustainability of work in jobs that have high physical demands”[5]. In this context, the lifelong impact of musculoskeletal pain needs to be considered. This raises the issue of young workers coming into the workplace with pre-existing musculoskeletal problems that have the potential to be exacerbated by work[6][7].

This article is based on a scoping review carried out in 2021 where studies published after 2009 were screened to identify prevalence of MSDs and main risk factors as well as main preventive measures or intervention strategies[8].

Prevalence of MSDs among children and young people

Eurostat Labour Force Survey[9] found the prevalence of work-related MSDs in workers in the European Union who are 15-34 years old to be 46.7% in 2007 and 57.2% in 2013.

In the EUOSHA report[8] the prevalence of musculoskeletal diseases (MSD) was found to be quite high already in schoolchildren and young people (7 to 26,5 years old) with ~30% on average. However, apprentices and young workers or students (15 to ~30 years old) even show a slightly higher average prevalence of ~34%. The estimates vary greatly between individual studies (0.5% - 91.0%).

The average prevalence for females is slightly higher compared to males and all – especially for young people before entering the labour market (Figure 1).

The average prevalence of back pain (29%), unspecified musculoskeletal complaints (31%); and upper or lower limb complaints (26%; 13%) in people before entering the labour market is high. The average prevalence in young workers is higher for unspecified and lower limbs disorders, but comparable or even lower for back and upper limb complaints” (medians after vs. before: unspecified: 52% > 31%, lower limbs 23% > 13%; back 27% < 29%; upper limbs 17% < 26%, Figure 2).

Figure 2: Percentages of children and young people with MSDs before and after entering the labour market (data published between 2010 and 2021) grouped by MSD locations.
Each dot represents a prevalence extracted from a publication. For each MSD location – Labour market combination (i) the number of extracted prevalence estimates is shown at the top and (ii) the rounded median is written besides the boxplot’s median

Risk factors for MSDs in children and young people

Generally, MSDs can be caused by acquired, individual or congenital risk factors, or by other diseases. Acquired risk factors are those which are largely preventable: physical, psychological, socioeconomic and environmental risk factors (Figure 3). Acquired risks are preventable since they are connected to too little, tensed or excessive use of the musculoskeletal system. Congenital factors relate to family history and genetically determined MSDs. MSDs also may be triggered by infections or tumours.

Figure 3: Risk factors for MSDs in children and young people

MSD risk factors in children and adolescents before entering the labour market

Studies indicate that already children and young people are experiencing MSDs. Unspecific pain of the back or limbs was previously believed to be uncommon in children[10] [11]. Details on the reasons and the associated factors are subject of current research. Many factors have been suggested to be associated with a higher risk of MSDs, including physical (e.g., reduced as well as excessive levels of physical activity, sedentary lifestyle, excess body weight/obesity, school back load) or psychological (mental problems) variables. Notions that e.g., excessive schoolbag weights or permanent uneven body postures can trigger MSDs, make clinical sense. However, studies reflect inconsistent results and for many suspected factors, the available evidence often does not support the notions.

Physical factors

Nutrition and weight

Nutrition: A direct association between vitamin D deficiency and fracture risk in children could not be shown. Dairy calcium and protein intakes seem to have limited effects on bone mineral density or fractures[12][13][14][15][16].

Body weight: Overall, the evidence suggests that an increased body mass index (BMI) is correlated with a higher risk of developing MSDs in children and adolescents[17][18]. Overweight and obese children have a higher risk particularly for lower extremity injuries or pain. Estimates on the association between BMI and back or neck pain are inconsistent. There is weak evidence for overweight and obese children to have a higher risk for back or neck pain[10][19]. Incorrect body postures are more frequently among children and adolescents with overweight and obesity[20][21].

Lifestyle

Physical (in)activity: In general, both extremes of activity levels (i.e., very low and very high levels of physical activity) are associated with back pain or increased injury risk in children and adolescents, while moderate physical activity might be protective[10][22]. There also were positive correlations between activity, bone health and self-esteem[23].

Leisure activities: Playground-related injuries and leisure activities still lead to high numbers of injuries to children[24][25].

Smoking: The association between lower back pain in adolescents and tobacco consumption is controversial. There is a definite link, but rather pain is causing smoking than vice versa. Adolescents suffering from back pain are more likely to smoke[10][26].

Alcohol consumption: No association was found between alcohol consumption and back pain[27].

Lack of sleep: There is a positive association between lack of sleep and back pain in children and adolescents. Quality of sleep seems to predict neck, lower back, and shoulder pain[10][28].

Bad or incorrect postures

Extended sitting: Prolonged sedentary position, especially with incorrect posture, seems to be associated with lower back pain in children and adolescents, with a dose-response relation between increased sedentary behaviour and unfavourable health outcomes[10][29].

Use of electronic devices: There seems to be an association between computer or smartphone use and musculoskeletal pain in children and adolescents. Though only heavy computer use is significantly associated with neck, shoulder, hand/wrist or back pain. In reviews the association between moderate screen time and neck/shoulder or lower back pain was assessed to be insufficient[10][19][30].

Backpack load: The association between carrying schoolbags and back pain is debatable and seems to be weak. Schoolbag load, schoolbag carrying time and the way a backpack is carried show inconsistent impact on back pain[11][27].

Playing an instrument: Musculoskeletal pain is highly prevalent among children and students intensively playing instruments[31][32].

Mental health/ psychosocial factors

Depression, anxiety, and distress may be important determinants in adolescent musculoskeletal pain[10][33].

Socioeconomic factors

The connections found between socioeconomic factors (higher social class, education, residence) and MSDs in children and adolescents are inconsistent. It appears that in the long run a low socioeconomic status might be a risk factor for onset of musculoskeletal pain although clearly the relationship is complex[10][34].

Environmental factors

One study demonstrated that warm temperatures could increase the fracture risk in children[35].

Individual factors

Gender: On average, musculoskeletal pain is more common in girls than in boys. Generally, there is a positive association between female gender and back pain[10][36].

Age: Prevalence increases from childhood to adolescence, with further growth in young adulthood[10][27][36].

Work-related risk factors for MSDs in young workers

Work-related risk factors for young people comprise physical workload, long-term unnatural working positions, repetitive work, work under pressure, bullying, job insecurity, professional challenges, and extreme weather conditions. There is a lack of studies in professions with high exposure to noise, vibrations, heat or cold, and to physically demanding work factors such as working in awkward positions, handling heavy loads, and repetitive work. Studies that examined specific sectors (e.g., professional musicians and workers in the healthcare sector) found young workers to be at high risk to develop MSDs.

Physical factors

Physical workload: High physical demands, awkward trunk postures or extraordinarily long working hours are associated with musculoskeletal problems in young workers[10][37].

Occupation-/ industrial sector-related: There is a lack of studies in professions with high exposure to noise, vibrations, heat or cold, and to physically demanding work factors such as working in awkward positions, handling heavy loads, and repetitive work, but two small clusters of studies were however

identified that researched specific sectors, most notably professional musicians, and workers in the healthcare sector. In both sectors young workers are at high risk to develop MSDs, mainly due to long-term unnatural working positions[38][39].

Psychosocial factors

Psychosocial factors like job insecurity, work-family imbalance, or exposure to hostile work environment have an influence on MSD prevalence in young workers. Low back pain-related sick leaves turned out to be associated with a non-stimulating psychosocial work environment[40][41].

Socioeconomic factors

In one study, associations between perceived worker's connection to their trade union and neck or back pain were identified in young workers: the higher the perceived union connection of unionised apprentices the lower were the odds of reporting neck and back pain[42].

Environmental factors

Extreme environmental conditions (high temperatures) increase the risk of occupational injuries among young workers[43].

Individual factors

Gender: Relationships between gender and MSD risk in young workers corresponds to different exposures varying between sectors and tasks[37][40].

Sports as a risk factor for MSDs in children and young people

Further, sports were identified as a risk factor both for children and young amateur athletes as well as professionals athletes. In general, sport shows many positive effects on the health, but some positive effects are lost due to sport injuries. The reported injuries range from knee injuries (anterior cruciate ligament injury, meniscus) to fractures, concussions and muscle injuries as well as lower back pain and others[44][45][46]. A concern regarding long-term consequences of youth sports injury is the risk of developing osteoarthritis at a young age[47].

Preventive measures

Most MDSs caused by physical or psychosocial factors are preventable and manageable. The available studies show that health can effectively be improved by various types of interventions: education (e.g. school curricula, education sessions, presentations, materials or courses aimed at changing knowledge, attitudes or skills), exercises (e.g. movement or muscle strengthening programs, physical syllabi, mind-body techniques, gym lessons and exercise trainings), manipulative therapy (e.g. physiotherapy activities, soft-tissue treatment, chiropractic manipulation and correction of habitual position), ergonomic measures (specially designed seats, desks, computer accessories or lifting equipment, adjustment of worker’s environment), orthopaedic aids/ protective equipment and sports injuries prevention programs (warm-up, exercises, neuromuscular training).

Prevention of MSDs in children and adolescents

In many cases, MSD problems begin in childhood, when inappropriate postures are combined with little sports activity[1]. Suffering from musculoskeletal pain in childhood or adolescence increases the risk of having it as an adult[2], possibly through the development of maladaptive beliefs, behaviours, and attitudes related to the earlier pain events[3]. If MSDs in children can be prevented, entry into a cycle of recurring episodes may be delayed and adult MSD prevalence decreased[4]. Hence, prevention campaigns and interventions should include children. Moreover, campaigns already should address young children to prevent MSDs in adolescence, which currently is comparable to that of adults (see Error! Reference source not found.). The school setting offers the opportunity to deliver preventive interventions to a large number of children and has been used to address a range of public health problems[48]. Young people living with persistent musculoskeletal pain described the absence of age-appropriate pain services and clearly articulated their perceptions on the role of, and opportunities provided by, digital technologies to connect with and support improved pain healthcare. Innovative and digitally-enabled models of pain care are likely to be helpful for this group[49][50].

Prevention or reduction of musculoskeletal pain

Education

In general, education (e.g., school curricula, education sessions, presentations, materials or courses aimed at changing knowledge, attitudes or skills) is effective in increasing knowledge and carefulness about musculoskeletal discomfort and pain both in children and in young people. Nevertheless, increased knowledge not necessarily leads to improved behaviour, therefore the effectivity of school-based educational programs alone to prevent MSDs is poor[51][52].

Exercise

Exercises (e.g., movement or muscle strengthening programs, physical syllabi, mind-body techniques, gym lessons and exercise trainings) are promising interventions with rapid successes in the prevention or reduction of MSDs. For sustainable effects long-term adherence should be encouraged[53][54].

Manipulative therapy

When education or exercise interventions are applied, adding manipulative therapy (e.g., physiotherapy activities, soft-tissue treatment, chiropractic manipulation and correction of habitual position) does not have added values. Nevertheless, manipulative therapy may be effective in children with long-lasting or chronic pain[55][56].

Ergonomics

Ergonomic equipment (specially designed seats, desks, computer accessories or lifting equipment) plus training have a positive effect. The combination of these two measures is an example of good practice / intervention that can easily be transferred to other activities and occupational applications[57][58].

Prevention of childhood accidents

Accidents and injuries can effectively be reduced by injury prevention education programs and moderate physical activity[48][59].

Prevention of MSDs in young workers

Work-related musculoskeletal disorders due to abnormal positions maintained during work are very common, already among young workers. The problem of persistent musculoskeletal pain is big, and it imposes a substantial health and economic burden on young people and the broader community[49]. Disorders are usually caused by postural distortion, prolonged static postures, and repetitive movements while working. Early education for apprentices and students in ergonomic working posture is relevant to prevent unhealthy working postures in their prospective professional career and also to decrease the risk of MSDs in the future[60]. Exercise therapy also has been investigated extensively, and there is evidence that it is effective for the prevention and treatment of low back and cervical pain in young adults[61].

Prevention or reduction of musculoskeletal pain

Studies in professional musicians and health care professionals demonstrate that various training programs were useful to improve musculoskeletal symptoms and to learn basic ergonomic information. In both professions, musculoskeletal pain is highly prevalent, and educational, physical, and ergonomic interventions improved quality of work and life. It was proposed by many authors to promote MSD prevention programs early during education and training. Although there is a lack of comparative studies on young people in many sectors, conclusions from health care or professional music sectors could be mainstreamed or transferred to other sectors as examples of good practice[62][63].

Prevention of workplace injuries

The results of few identified studies suggest that there could be advantages of strengthening occupational safety and health as well as neuromuscular education. One approach could be widely taught occupational safety and health skills with a comprehensive approach in vocational diplomas[64][65].

Prevention of sports injuries

There is increasing evidence that many sport-related injuries are preventable. Since some risk factors (muscle performance, strength deficits, coordination, or endurance) are modifiable and, as such, could be targeted in injury prevention programs. The field of sports medicine, where a vast number of studies (some of highest quality) exist, shows that prevention of sports injuries is effective. Programs developed in this sector can be applied to other areas. Knowledge gained from sports injury prevention could be transferred e.g., to the prevention of work or leisure accidents[47][66].

Conclusions

Irrespective of scientifically evidence on the contribution of certain factors to the risk to develop MSDs, the prevalence among children, adolescents and workers is quite high. There is an urgent need for an early promotion of musculoskeletal health in children and young people. Maintaining long-term adherence to a combination of education, physical training and ergonomic measures promises the best results in sustainably preventing or reducing MSDs for (work) life.

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Contributors

Palmer