Musculoskeletal Disorders in Children and Young People
Lorna Taylor, Physiotherapist, Jolly Back
- 1 Introduction
- 2 Symptoms and Effects of MSDs in Children and young People
- 3 Life Course Approach to MSDs in Children and Young people
- 4 Risk Factors for MSDs in Children and Young People
- 5 Interventions to Promote Musculoskeletal Health in Children and Young People
- 6 Conclusion
- 7 Links for further reading
- 8 Resources
- 9 References
There is clear evidence that good musculoskeletal health underpins a person’s ability to live and work well . It is also fundamental to healthy ageing and independence beyond working years.
Yet, despite workplace legislation and initiatives aimed at preventing Musculoskeletal disorders (MSDs), they remain the most common work-related problem in the EU . Backache and muscular pains in the upper limbs are the most common reported problems, with around three in every five workers affected.
Direct and indirect costs of work-related MSDs to individuals, society and organisations are vast and workers in all sectors and occupations can be affected.
Consequences for children and young people are far reaching in terms of education and future health. School is the workplace of the child. Pre-existing MSDs are also be carried into future workplaces.
Encouragingly, MSDs are preventable. This article gives a holistic, life course approach to tacking MSDs from birth to employment. Interlinking musculoskeletal health development, risk factors and interventions for children and young people at home, in education and community requires an integrated, collaborative approach, focused on a culture of prevention.
Symptoms and Effects of MSDs in Children and young People
As with adults, musculoskeletal disorders affect the body’s bones, muscles, joints, ligaments, and nerves.
However, children and young people are different from adults as they are developing physically, socially, and psychologically. Due to physiology and biomechanics of growth, children and young people show a unique set of age-related problems, but physical symptoms of aches and pains, swelling, tingling, reluctance to move affected area and stiffness remain common complaints of MSDs.
MSDs in children include:
- Systemic conditions: affecting their entire body, for example Juvenile Idiopathic Arthritis and Hypermobility syndrome.
- Orthopaedic conditions: predominantly affecting specific areas, for example Scoliosis (affecting the back), Perthes Disease and Developmental Dysplasia of the Hip (affecting the hips) and non-specific spinal pain (affecting the neck, mid and lower back).
- Trauma: affecting single or multiple areas after accidents, for example upper and lower limb fractures and dislocations.
Non-specific spinal pain is an MSD affecting an increasing number of children and at an earlier age.
A comprehensive 2007 study reported incidence of neck and lower back pain in children aged 11-14 years was 27% and 22% respectively.
In 2014, 72% of primary school pupils sampled and 64% of secondary school-aged pupils reported back and/or neck pain in the past year. This study also stated the percentage of paediatric referrals to physiotherapy for back and neck pain treatment more than doubled in one year.
In 2019, a large 11000 cohort study reported 75% of 10-19-year olds had experienced back pain in the previous 12 months. Lumbar/lower spine pain was most frequently experienced (56%). As with most studies, girls reported a higher incidence of back pain than boys (83% vs 64%) and the incidence increased with age.
Severity of pain is often difficult to establish but a 2019 Danish National Birth Cohort study registered the prevalence of self-reported “severe spinal pain” in 11-14-year olds at 14% for girls and 10% for boys.
Concerningly, one longitudinal study indicates that lower back pain present at aged 14, continues through adolescence and into early adulthood. It is often comorbid with other musculoskeletal pain and reaches adult rates by 22 years old.
For some children and young people, back pain has little effect, for others its impact includes care seeking, taking medication, time off school and work, as well as modifying physical and functional life activity.
These levels of back pain have consequences for children’s future health and opportunities, in addition to impacting on future employment and employers.
MSDs via trauma also need consideration as young workers, aged 15-24 years, have an increased risk of accidents. Some evidence suggests workplace accidents are 50% higher. Potential reasons for this including lack of training, understanding and belief of safe practices, risk-seeking behaviour, and lack of exposure to graduated risk.
Life Course Approach to MSDs in Children and Young people
Early intervention is effective at tackling MSDs.
As children and young people develop physically, socially and psychologically from vulnerable infants into adults ready for the world of work, musculoskeletal health needs a continuous, cohesive approach taking into account emerging needs.
Childhood is an exceptional time for learning and the formation of healthy habits.
From birth, neuroplasticity ensures individual shaping and development of brains, bodies and behaviours from our experiences. Problem solving is a signature attribute of humans, it is important to encourage from a young age and is fundamental to giving graduated experience of risk.
Babies and developing infants benefit from being exposed to “risky play” or “safe danger”. These are not dangerous activities but a safe way to encourage problem solving, movement, sensory integration, self-awareness and sense of risk, dependant on developmental level.
Risky play can be unsettling for teachers and caregivers, as it occurs when children are not fully aware of the outcome and it involves a physical action e.g. reaching for a ball and rolling over, jumping off a self-built play structure, climbing a tree.
These experimental actions allow gradual learning of risk, postural control, succeeding and failing. In addition, they develop self-confidence, cognition, fine and gross motor skills, social skills and self-regulation. These factors assist risk assessment when older and strengthen core muscles required for optimal musculoskeletal health and dynamic postural control.
Throughout primary and secondary school, the benefits of problem solving, and physical activity continue to increase engagement, learning and musculoskeletal health.
The average 15-year-old will spend over 7500 hours inside schools and will be additionally exposed to increasing digital technology and sedentary postures at home as well as school. During these formative years, education can beneficially incorporate the safe use of mobile technology, healthy postures and introduce ergonomics.
From 16+, young people may be employed, continuing their studies or entering vocational careers, a life course approach to musculoskeletal health can continue by integrating recognised MSD prevention and occupational health and safety advice for young workers, specifically tailored to need identified.
If musculoskeletal health has been incorporated throughout education, this knowledge will be a natural extension with which young people are familiar and more accepting, advocating mainstreaming occupational safety and health into education.
Risk Factors for MSDs in Children and Young People
The main risk factors for MSDs in children and young people can be categorised as follows:
Too little or too much physical activity can impact MSDs.
Physical activity and movement are essential for good musculoskeletal health to build muscle strength, maintain flexibility, improve bone density, enable joint development and to allow movement between static postures.
From birth babies need to play in prone (on their stomach) when awake and supervised to develop motor behaviour, strength and perception. This stable posture helps develops shoulder and neck muscles required for crawling and the next stage of spinal development. Positional plagiocephaly can occur in babies, typically under 4 months with limited prone positioning. It is becoming more common with some reports estimating almost 50% of babies are affected under 1 year to varying degrees.
One side of the head becomes flatter from recurrent pressure on the side of the head. This altered shape can it more difficult to turn the head and neck muscles become tight, making it even more of a challenge. Sleeping and bottle feeding with the head turned to the same side are also associated with the development of positional plagiocephaly. Movement and regular changes of postures are important from birth.
Weight-bearing exercise also increases bone density with gains seen in the hips and spines of children who engaged in a 2-year school-based jumping program.
Physical activity throughout childhood and adolescence helps maintain a healthy weight (lessening undue stress on the musculoskeletal system), improves balance and coordination (which reduces sudden injuries), improves sleep (which aids recovery) and encourages bone development (necessary for a healthy skeletal long-term).
Movement breaks up prolonged sitting and improves circulation. Regular changes of position are important and enable joints and muscles to be nourished. In addition, movement in schools improves student achievement: a healthy, active body = a healthy, active mind.
Too much physical activity, causing overuse injuries is a risk factor for MSDs in children and young people. As is carrying out single sports, using inappropriate equipment and technique or regularly neglecting warming up or cooling down before and after physical activity.
Predictors of disabling lower back pain in adolescence are multi-dimensional and include negative back pain beliefs, poor mental health status, somatic complaints and altered stress responses .
Sleep is also an important consideration in children and young people, especially as modern technology can alter healthy sleep patterns. Chronic and recurrent pain present in adolescence can often co-occur with sleep problems.
A Finnish study showed frequent neck, shoulder and back pain, together with psychological problems, and daytime sleepiness are already common at the age of 10 and increase strongly between the ages of 12-15. Overall a greater number of girls suffered MSD symptoms and subjects with phycological problems suffered neck, shoulder and back pain more frequently. Daytime sleepiness in all ages was positively associated with the frequency of MSDs. Self-reported daytime sleepiness at 10 could predict neck and shoulder pain at 15 and back pain at age 10 indicated it would be present at age 15.
A 2020 meta-analysis identified several factors which were associated adolescent back pain risks and triggers, specifically headaches, abdominal pain, anxiety, somatisation and “feeling tense”.
MSD pain symptoms have a negative effect on school achievement, emotional wellbeing, sleep, and overall health. In addition, emotional stress, can exacerbate symptoms of MSD.
Physical and mental health are directly linked and particularly inter-related in children and young people as physical and emotional systems are developing.
Being overweight places additional stress on growing joints, can make physical activity more difficult and affect emotional wellbeing, all factors which impact MSDs.
Whilst children are growing, a healthy balanced diet is required for skeletal and muscular development and recovery from injury.
Obesity in adolescence is predictive of obesity during adulthood. An elevated Body Mass Index (BMI) in people aged 20 to 29 years increases the risk of Osteoarthritis (OA) by more than 3-fold.
The increased weight associated with obesity places cumulative stress on articular cartilage and often malalignment forces to the knee joints and may contribute to early degenerative joint disease.
Osteoporotic fractures in adulthood are both debilitating and costly MSDs. Certain childhood conditions elevate the risk of osteopathic fractures e.g. osteogenesis imperfecta.
Low calcium intake and inadequate physical activity in young people increase their risk of developing osteoporosis. Anderson and associates surveyed adolescents about their knowledge and beliefs about bone health and found that most teens do not know that weight-bearing exercise reduces the risk of osteoporosis. The adolescents also had difficulty in identifying foods that are high in calcium, and 58% of them had low calcium intake.
Adequate Calcium and vitamin D intake during childhood are also required to increase bone mass and for long term bone health.
Caffeine, phosphorus, and carbonation of soda are among the dietary factors related to bone health as they interfere with calcium absorption, leading to low bone mass
Hydration is also important for children and young people as spinal discs, which are shock-absorbers are approximately 80% water.
A Public Health commissioned review showed smoking plays a role in the progressive decline of the body’s major systems, including musculoskeletal. Smokers and ex-smokers experience 60% more pain in the back, neck and legs and 114% increase in disabling lower back pain
Smoking is associated with poorer development of the hip, spine and neck and lower bone density among men as young as 18 to 20. It is associated with more bone fractures and slower healing and up to a 40% increase risk of hip fractures among men.
In a meta-analysis examining the link between smoking and osteoporosis, cigarette smoking was reported as an independent risk factor for lower bone density and increased risk of fracture. The report highlighted 25% of the adolescents defined themselves as smokers and had risk factors for the development of osteoporosis.
Ergonomics for children and young people predominantly relates to school and home learning environments. It is the science behind enabling high productive learning and working while ensuring health and safety.
It can be considered as “physical” and “environmental” ergonomics.
Research and a growing anecdotal evidence from children and young people recognise MSD risks at school as carrying school bags, prolonged sitting position, uncomfortable seating and working at a computer. Additional risks are lifting heavy objects .
Frequently students declare they do not know ergonomic principles and wish to know more.
By age 14-15, children spend 30% of their waking hours in school, mostly in a seated position. Furniture has little adjustment, even though children can vary 50cm in height at aged 11-12. This makes healthy postures difficult to achieve. Classes are traditionally sedentary and little thought is given to ergonomic set up of computer-display screen workstations, despite the vast increase in digitalisation and technology use in schools and higher education.
Science and design laboratories are frequently filled with a mismatch of stool and bench heights which cause cumulative strain and MSDs from uncomfortable working postures and poor design.
Uncomfortable working postures are also found in classrooms where set seating plans can cause prolonged awkward sitting for students in fixed learning spaces.
The topmost uncomfortable homebased activities students reported were working at my desk, working at my computer and using my tablet device.
An important consideration relating to working posture is eyesight. Children and young people need to see books and screens clearly, without hunching over or eye strain.
As an increasing amount of education is online due to Covid19, the home learning environment and ergonomic considerations are becoming increasingly important, just as they are for flexible home working employees.
In addition to the physical design of the environment, the environment itself (temperature, lighting, noise and air quality) can impact MSDs and have a significant effect on the health and performance of children and young people.
A good amount of natural light, with no glare gives students better results than those receiving direct sun. Classroom noise also affects adolescents’ performance on reading and vocabulary-learning tasks in terms of number of questions attempted and the accuracy of answers.
Poor air quality and high temperatures cause lethargy, a tendency for slumped posture and reduced oxygenation to the brain and body’s systems.
Environmental risks are known to impact the performance of workplace employees and contribute to MSDs, evidence implies the same is also true for children and young people.
Knowledge and Training
Learning needs a context and a purpose. Understanding about the impact of MSDs, importance of MSK health and intervention strategies are often low in children and young people.
Children and young people have many influences on their learning. Particularly important to their knowledge and understanding are parents, carers and teachers.
MSD prevalence is high in the education workforce, especially within early years’ and primary teachers. If teachers themselves have limited knowledge and training about MSK health and risk factors of MSDs, it is difficult for them to promote good healthy principles to others.
MSK health and ergonomics are rarely taught on teacher training and school curriculums. In addition, if teachers do acquire MSK health and ergonomics knowledge through training, school leadership teams need to understand and embrace the concept of health promotion within their schools for maximum positive effect.
An integrated pedagogical approach is advocated for safety and health in education as learners have an opportunity to critically engage with health information rather than to simply be passive recipients of it. In addition, children and students should be actively involved in how schools can become more active for great engagement. “Healthy management” can benefit a whole school in terms of staff and student health, productivity and effective learning.
Parents of children from birth to teenagers also often have limited knowledge about the importance and impacts of musculoskeletal health for their children and importantly, how to improve it, this too is a risk factor for future MSDs.
Back and MSD pain are not routinely talked about in schools and homes. A total of 89% of pupils questioned had not reported their back/neck pain to anyone, but 78% wanted teaching on how to keep their backs healthy , highlighting there is interest in MSDs from children and young people.
Interventions to Promote Musculoskeletal Health in Children and Young People
Musculoskeletal health needs a coordinated, life course approach considering physical, social and emotional needs of children developing from birth until they enter employment. In addition to reducing MSDs, interventions can also improve learning and educational outcomes.
MSDs in children and young people cannot be seen in isolation as many interlinking factors are at play. A flexible, yet targeted multidimensional approach is required which includes: whole-community interventions promoting healthy child development, improved MSK health and ergonomics training of educators and school leaders, liaison with school designers and occupational health professionals to improve learning environments, MSD risk awareness and healthy lifestyle engagement for parents and children, together with pre-employment health and safety education, especially important for students entering workplaces at 16+ years.
Salutogenic interventions which promote “the origins of health” focus on wellness, rather than disease. The following integrated interventions, relating to each MSD risk factor are successful in enabling good musculoskeletal health from birth to adulthood.
Tummy Time: Encourage 3 x 10 minutes of tummy time positioning/play from birth. For babies in childcare, bottle feed from alternate sides.
Risky Play: Promote supervised risky play opportunities throughout home, childcare and school life, from birth. Encourage outdoor learning and sensory integration play activities.
Recommended Daily Exercise: Promote latest government guidance and interventions for exercise frequency, duration and type for different age groups. High impact exercises for bone health.
Movement in Schools: Thread activity wherever possible into the school day throughout lessons, active breaks and curriculum planning. Encourage 30:30 movement breaks in lessons (30 seconds moving for 30 minutes sitting). Do not ban active breaks and PE as a student punishment. Offer and promote after school and community activity clubs, aim to increase participation of girls in activity.
Active Travel: Encourage “walk, ride or scoot” to school. Promote safe active travel to families, community infrastructure is needed to support this.
Recreational community spaces: Well-maintained playgrounds and open spaces encourage active families, offer risky play to children and the formation of healthy exercise habits.
Injury Limitation: Ensure appropriate technique and equipment are used in sports. Regularly check safety of equipment. Recognise overuse injuries, ensure adequate warm up and cool down before and after exercise, encourage children to participate in a variety of sports rather than a single sport. Promote road safety schemes to reduce accidents.
Emotional wellbeing: Focus on transformative learning experiences instead of test scores in schools, promote recognised emotional wellbeing strategies for children and young people.
Mental Health Support: Provide in-school support for children and young people, reputable external support organisations shared with parents/carers and families.
Healthy Lifestyle Beliefs: Develop a pedagogical approach to positive healthy lifestyle and behaviour throughout education, including promoting benefits to learning and attainment.
Sleep: Share guidance on healthy sleep with children, young people and their families.
Healthy Body Mass Index: Promote initiatives which encourage healthy weight and BMI for children, young people and families (often linked with physical activity), ensure provision of healthy schools nutrition – including packed lunches, cooking lessons, growing vegetables to increase understanding of food and choices. Engage parents in family healthy eating and cooking workshops.
Bone Health: Ensure children and young people are aware of Calcium and Vit D requirements and can identify Calcium rich foods.
Hydration: Encourage and enable hydration through the school day via accessible water points, using refillable bottles.
Habit Prevention: Promote “no smoking” interventions in schools from an early age.
Support to Stop: Provide advice and support to quit – for students and families.
- School Bags: Aim for 10% of body weight carried, provide lockers or safe storage areas – if space is limited, offer to younger pupils who are lighter and therefore often carry more than their recommended percentage of body weight. Re-pack bags every night, so students only carried what they need each day. Limit punishment for younger students if books are accidently forgotten to deter over-carrying.
- A backpack worn on both shoulders if the preferred option, but a single strap bag worn across the body (swapping side carried) is a good alternative. Provide families with school bag advice before children transition to next classes to aid purchasing decisions.
- Seating and Furniture: School furniture should be considered an investment in children’s health and learning. A variety of seating should be provided to suit a range of student heights. Desks, tables, science benches and worktops should suit chair, stool and standing heights – and be age appropriate for students. British and European standard BSEN1729: Furniture: chairs and tables for educational institutions (Part 1) gives some guidance but is still not appropriate for all. A range of seating is beneficial within the same class for student choice, comfort and movement. Seating and furniture should be inspected at regularly intervals for damage. Limit time using science stools for non-science subjects through curriculum planning. Mobile furniture (with quality wheels) enables safer and easier moving when using, positioning and storing.
- Flexible Learning Spaces: Facilitate movement in schools wherever possible with a variety of dynamic learning, breakout and outdoor spaces which can be easily rearranged to create new spaces. Incorporate standing.
- Technology Use: Increase in digitalisation and EdTech in schools must be accompanied with healthy workstation set up and ergonomics advice. When using a screen, it should be raised so the top is at eye level. If using a laptop for >1hour a stand, separate mouse and keyboard are recommended. Limit time spent in poor postures at school. Communicate digital (including mobile device) and ergonomics advice home.
- Home Learning: Time spent learning and working at home needs consideration too in terms of ergonomic workstation set up, mobile device use and regular movement breaks. This is an emerging area of importance.
- Eyesight: Encourage regular eyesight checks from an early age.
- Temperature: Aim for classroom temperatures between 18-21°C.
- Light: Aim for classroom Lumen levels to be >450 lux, with a sensible target of 750+ lux.
- Noise: Aim to keep classroom noise below 70 decibels.
- Air Quality: Aim to keep classroom CO2 less than 1000ppm.
Knowledge and Training
Teacher Training: MSK Health on curriculums for early years educators and teachers covering educator/teacher MSK health for themselves and that of children and young people. This knowledge can be incorporated throughout each day. Regular updates provided as required.
School Leadership: Engage and support proactive, innovative school leadership teams who believe in the benefits of health education for students.
MSK Health Curriculum: Introduce age appropriate MSK health teaching, including manual handling principles, from an early age as part of school personal/health curriculums, thread topics throughout the life course of education from early years to adulthood. Involve and empower students with H&S tasks. Prepare young people for future workplaces in terms of OSH roles, responsibilities and legislation they will likely encounter. Local physiotherapists, occupational health and safety advisors and local/national future employers may provide voluntary advice sessions.
OSH Education Network: Form or join a network of “MSK health in education” advocates. This may include occupational health and safety advisors, ergonomists, child health experts, transformational school designers, innovative school leaders, policy writers, community activity leads, plus others who can support your work.
The incidence of MSDs is increasing in children and young people and shows little sign of slowing due to modern, often sedentary lifestyles, traditional educational environments, and digitalisation.
A life course approach to MSDs gives enormous opportunity to tackle and prevent MSDs in children and young people, our future workforce. Encouragingly many MSD risk factors already have accepted public health interventions in place, such as for increasing physical activity and reducing obesity.
A collaborative, integrated approach working with families, school leaders, educators, school designers, teacher training organisations, occupational health and safety advisors and community providers is needed to enable greater, combined impact.
Data collection will be required to understand local needs and measure impacts. However, there is a desire and genuine opportunity for children and young people to be successful, healthy achievers, prepared for current and future workplaces, without MSDs.
Links for further reading
Knowledge and Training
- Planning Learning Spaces book https://www.laurenceking.com/product/planning-learning-spaces/ p.122-125
- https://issuu.com/acpohe/docs/acpohe_ohp_18.3_november_2014 P14-19
- Safety and Health Competence- A Guide for Cultures of Prevention book Bollmann, U. and G. Boustras. 2020. Introduction. In U. Bollmann and G. Boustras (Eds.), Safety and health competence. A guide for cultures of prevention. Boca Raton: CRC Press, Taylor & Francis Group. https://www.taylorfrancis.com/books/e/9780429465253 p. 211