Musculoskeletal disorders among children and young people: prevalence, risk factors, preventive measures
Kerstin Schmidt and Paul Schmidt, BioMath GmbH, Thomas Tischer, Universität Rostock
- 1 Introduction
- 2 Prevalence of MSDs among children and young people
- 3 Risk factors for MSDs in children and young people
- 4 Preventive measures
- 5 Conclusions
- 6 References
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. Suffering from musculoskeletal pain in childhood or adolescence increases the risk of having it as an adult, possibly through the development of maladaptive beliefs, behaviours, and attitudes related to the earlier pain events. If MSDs in children can be prevented, entry into a cycle of recurring episodes may be delayed and adult MSD prevalence decreased.
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”. 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.
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.
Prevalence of MSDs among children and young people
Eurostat Labour Force Survey 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 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).
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.
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 . 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.
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.
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. 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. Incorrect body postures are more frequently among children and adolescents with overweight and obesity.
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. There also were positive correlations between activity, bone health and self-esteem.
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.
Alcohol consumption: No association was found between alcohol consumption and back pain.
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.
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.
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.
Mental health/ psychosocial 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.
One study demonstrated that warm temperatures could increase the fracture risk in children.
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.
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.
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.
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.
Extreme environmental conditions (high temperatures) increase the risk of occupational injuries among young workers.
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. A concern regarding long-term consequences of youth sports injury is the risk of developing osteoarthritis at a young age.
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. Suffering from musculoskeletal pain in childhood or adolescence increases the risk of having it as an adult, possibly through the development of maladaptive beliefs, behaviours, and attitudes related to the earlier pain events. If MSDs in children can be prevented, entry into a cycle of recurring episodes may be delayed and adult MSD prevalence decreased. 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. 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.
Prevention or reduction of musculoskeletal pain
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.
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.
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.
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.
Prevention of childhood accidents
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. 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. 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.
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.
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.
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.
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.
- Rodríguez-Oviedo P, Santiago-Pérez MI, Pérez-Ríos M, Gómez-Fernández D, Fernández-Alonso A, Carreira-Núñez I, et al. Backpack weight and back pain reduction: Effect of an intervention in adolescents. [ct_00811]. Pediatr Res. 2018;84:N.PAG-N.PAG. doi:10.1038/s41390-018-0013-0.
- Kovacs F, Oliver-Frontera M, Plana MN, Royuela A, Muriel A, Gestoso M. Improving schoolchildren's knowledge of methods for the prevention and management of low back pain: A cluster randomized controlled trial. [ct_02946]. Spine (Phila Pa 1976). 2011;36:E505-12. doi:10.1097/BRS.0b013e3181dccebc.
- Michaleff ZA, Kamper SJ, Maher CG, Evans R, Broderick C, Henschke N. Low back pain in children and adolescents: a systematic review and meta-analysis evaluating the effectiveness of conservative interventions. [ct_03445]. European Spine Journal : Official Publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2014;23:2046–58. doi:10.1007/s00586-014-3461-1.
- Hill JJ, Keating JL. Daily exercises and education for preventing low back pain in children: Cluster randomized controlled trial. [ct_01531]. Phys Ther. 2015;95:507–16. doi:10.2522/ptj.20140273.
- Belin A, Graveling R, Bongers P, Hagen Mikkelsen S, Crawford JO, Davis A, et al. The ageing workforce: Implications for occupational safety and health : A research review. Luxembourg: Publications Office; 2016.
- Calvo-Muñoz I, Gómez-Conesa A, Sánchez-Meca J. Prevalence of low back pain in children and adolescents: A meta-analysis. [ct_04807]. BMC Pediatrics. 2013;13:14. doi:10.1186/1471-2431-13-14.
- Kamper SJ, Yamato TP, Williams CM. The prevalence, risk factors, prognosis and treatment for back pain in children and adolescents: An overview of systematic reviews. [ct_06266]. Best Practice & Research. Clinical Rheumatology. 2016;30:1021–36. doi:10.1016/j.berh.2017.04.003.
- EU-OSHA (2021), Musculoskeletal disorders among children and young people: prevalence, risk factors, preventive measures, available at https://osha.europa.eu/en/publications/musculoskeletal-disorders-among-children-and-young-people-prevalence-risk-factors-preventive-measures
- Beynon AM, Hebert JJ, Lebouef-Yde C, Walker BF. Potential risk factors and triggers for back pain in children and young adults. A scoping review, part I: incident and episodic back pain. [ct_04598]. Chiropr Man Therap. 2019;27:58. doi:10.1186/s12998-019-0280-9.
- Calvo-Muñoz I, Kovacs FM, Roqué M, Seco-Calvo J. The association between the weight of schoolbags and low back pain among schoolchildren: A systematic review, meta-analysis and individual patient data meta-analysis. [ct_05888]. Eur J Pain. 2020;24:91–109. doi:10.1002/ejp.1471.
- Blagojevic Z, Nikolic V, Kisic-Tepavcevic D, Terzic Supic Z, Kovacevic R, Zivkovic Z, Stevanovic D. Musculoskeletal pain and vitamin D deficiency in children: A pilot follow-up study of vitamin D therapy in musculoskeletal. [ct_03819]. Acta Chir Orthop Traumatol Cech. 2016;83:21–6.
- Moon RJ, Harvey NC, Davies JH, Cooper C. Vitamin D and skeletal health in infancy and childhood. [ct_06735]. Osteoporos Int. 2014;25:2673–84. doi:10.1007/s00198-014-2783-5.
- McVey MK, Geraghty AA, O'Brien EC, McKenna MJ, Kilbane MT, Crowley RK, et al. The impact of diet, body composition, and physical activity on child bone mineral density at five years of age-findings from the rolo kids study. [ct_06137]. Eur J Pediatr. 2020;179:121–31. doi:10.1007/s00431-019-03465-x.
- Contreras JJ, Hiestand B, O'Neill JC, Schwartz R, Nadkarni M. Vitamin D deficiency in children with fractures. [ct_06739]. Pediatr Emerg Care. 2014;30:777–81. doi:10.1097/PEC.0000000000000258
- Händel MN, Heitmann BL, Abrahamsen B. Nutrient and food intakes in early life and risk of childhood fractures: A systematic review and meta-analysis. [ct_03988]. The American Journal of Clinical Nutrition. 2015;102:1182–95. doi:10.3945/ajcn.115.108456.
- Ashley P, Gilbert SR. Obesity in pediatric trauma. [ct_04009]. Orthop Clin North Am. 2018;49:335–43. doi:10.1016/j.ocl.2018.02.007.
- Adams AL, Kessler JI, Deramerian K, Smith N, Black MH, Porter AH, et al. Associations between childhood obesity and upper and lower extremity injuries. [ct_00724]. Inj Prev. 2013;19:191–7. doi:10.1136/injuryprev-2012-040341.
- Jahre H, Grotle M, Smedbråten K, Dunn KM, Øiestad BE. Risk factors for non-specific neck pain in young adults. A systematic review. [ct_05289]. BMC Musculoskelet Disord. 2020;21:366. doi:10.1186/s12891-020-03379-y.
- Brzeziński M, Czubek Z, Niedzielska A, Jankowski M, Kobus T, Ossowski Z. Relationship between lower-extremity defects and body mass among Polish children: a cross-sectional study. [ct_05151]. BMC Musculoskelet Disord. 2019;20:84. doi:10.1186/s12891-019-2460-0.
- Maciałczyk-Paprocka K, Stawińska-Witoszyńska B, Kotwicki T, Sowińska A, Krzyżaniak A, Walkowiak J, Krzywińska-Wiewiorowska M. Prevalence of incorrect body posture in children and adolescents with overweight and obesity. [ct_04797]. Eur J Pediatr. 2017;176:563–72. doi:10.1007/s00431-017-2873-4.
- Guddal MH, Stensland SØ, Småstuen MC, Johnsen MB, Zwart J-A, Storheim K. Physical activity level and sport participation in relation to musculoskeletal pain in a population-based study of adolescents: The young-hunt study. [ct_04462]. Orthopaedic Journal of Sports Medicine. 2017;5:2325967116685543. doi:10.1177/2325967116685543.
- Smith AJ, O'Sullivan PB, Campbell A, Straker L. The relationship between back muscle endurance and physical, lifestyle, and psychological factors in adolescents. [ct_06275]. Journal of Orthopaedic & Sports Physical Therapy. 2010;40:517–23. doi:10.2519/jospt.2010.3369.
- Adelson SL, Chounthirath T, Hodges NL, Collins CL, Smith GA. Pediatric playground-related injuries treated in hospital emergency departments in the United States. [ct_04373]. Clin Pediatr (Phila). 2018;57:584–92. doi:10.1177/0009922817732144.
- Tuckel P, Milczarski W, Silverman DG. Injuries caused by falls from playground equipment in the United States. [ct_03065]. Clin Pediatr (Phila). 2018;57:563–73. doi:10.1177/0009922817732618.
- Shiri R, Karppinen J, Leino-Arjas P, Solovieva S, Viikari-Juntura E. The association between smoking and low back pain: A meta-analysis. [ct_05886]. Am J Med. 2010;123:87.e7-35. doi:10.1016/j.amjmed.2009.05.028.
- Calvo-Muñoz I, Kovacs FM, Roqué M, Fernández IG, Calvo JS. Risk factors for low back pain in childhood and adolescence: A systematic review. [ct_05280]. Clin J Pain. 2018;34:468–84. doi:10.1097/AJP.0000000000000558.
- Hulsegge G, van Oostrom SH, Picavet HSJ, Twisk JWR, Postma DS, Kerkhof M, et al. Musculoskeletal complaints among 11-year-old children and associated factors: The piama birth cohort study. [ct_03762]. Am J Epidemiol. 2011;174:877–84. doi:10.1093/aje/kwr205.
- Kedra A, Czaprowski D. Epidemiology of back pain in children and youth aged 10-19 from the area of the Southeast of Poland. [ct_02201]. Biomed Res Int. 2013;2013:506823. doi:10.1155/2013/506823.
- Stiglic N, Viner RM. Effects of screentime on the health and well-being of children and adolescents: A systematic review of reviews. [ct_02089]. BMJ Open. 2019;9:e023191. doi:10.1136/bmjopen-2018-023191.
- Rodríguez-Romero B, Pérez-Valiño C, Ageitos-Alonso B, Pértega-Díaz S. Prevalence and associated factors for musculoskeletal pain and disability among Spanish music conservatory students. [ct_04697]. Med Probl Perform Art. 2016;31:193–200. doi:10.21091/mppa.2016.4035.
- Ranelli S, Straker L, Smith A. Playing-related musculoskeletal problems in children learning instrumental music: The association between problem location and gender, age, and music exposure factors. [ct_04530]. Med Probl Perform Art. 2011;26:123–39. doi:10.21091/mppa.2011.3021.
- Gilkey DP, Keefe TJ, Peel JL, Kassab OM, Kennedy CA. Risk factors associated with back pain: a cross-sectional study of 963 college students. [ct_05256]. J Manipulative Physiol Ther. 2010;33:88–95. doi:10.1016/j.jmpt.2009.12.005.
- Huguet A, Tougas ME, Hayden J, McGrath PJ, Stinson JN, Chambers CT. Systematic review with meta-analysis of childhood and adolescent risk and prognostic factors for musculoskeletal pain. [ct_05821]. Pain. 2016;157:2640–56. doi:10.1097/j.pain.0000000000000685.
- Sinikumpu J-J, Pokka T, Hyvönen H, Ruuhela R, Serlo W. Supracondylar humerus fractures in children: The effect of weather conditions on their risk. [ct_05727]. European Journal of Orthopaedic Surgery & Traumatology. 2017;27:243–50. doi:10.1007/s00590-016-1890-8
- Henschke N, Kamper SJ, Maher CG. The epidemiology and economic consequences of pain. [ct_06085]. Mayo Clin Proc. 2015;90:139–47. doi:10.1016/j.mayocp.2014.09.010.
- Hanvold TN, Wærsted M, Mengshoel AM, Bjertness E, Twisk J, Veiersted KB. A longitudinal study on risk factors for neck and shoulder pain among young adults in the transition from technical school to working life. [ct_00075]. Scand J Work Environ Health. 2014;40:597–609. doi:10.5271/sjweh.3437.
- Wong AY, Chan LL, Lo CW, Chan WC, Lam KC, Bao JC, et al. Prevalence/incidence of low back pain and associated risk factors among nursing and medical students: A systematic review and meta-analysis. [ct_04756]. PM R 2021. doi:10.1002/pmrj.12560.
- Rotter G, Noeres K, Fernholz I, Willich SN, Schmidt A, Berghöfer A. Musculoskeletal disorders and complaints in professional musicians: A systematic review of prevalence, risk factors, and clinical treatment effects. [ct_03777]. Int Arch Occup Environ Health. 2020;93:149–87. doi:10.1007/s00420-019-01467-8.
- Yang H, Haldeman S, Lu M-L, Baker D. Low back pain prevalence and related workplace psychosocial risk factors: A study using data from the 2010 national health interview survey. [ct_03455]. J Manipulative Physiol Ther. 2016;39:459–72. doi:10.1016/j.jmpt.2016.07.004.
- van Nieuwenhuyse A, Burdorf A, Crombez G, Verbeke G, Masschelein R, Mairiaux P, Moens GF. Sick leave due to back pain in a cohort of young workers. [ct_05527]. Int Arch Occup Environ Health. 2013;86:887–99. doi:10.1007/s00420-012-0824-y.
- Kim S-S, Perry MJ, Okechukwu CA. Association between perceived union connection and upper body musculoskeletal pains among unionized construction apprentices. [ct_00678]. American Journal of Industrial Medicine. 2013;56:189–96. doi:10.1002/ajim.22053.
- Fatima SH, Rothmore P, Giles LC, Varghese BM, Bi P. Extreme heat and occupational injuries in different climate zones: A systematic review and meta-analysis of epidemiological evidence. [ct_02412]. Environment International. 2021;148:106384. doi:10.1016/j.envint.2021.106384.
- Jones S, Almousa S, Gibb A, Allamby N, Mullen R, Andersen TE, Williams M. Injury incidence, prevalence and severity in high-level male youth football: A systematic review. [ct_03083]. Sports Med. 2019;49:1879–99. doi:10.1007/s40279-019-01169-8.
- Koutures CG, Gregory AJM. Injuries in youth soccer: Clinical report. [ct_01240]. Pediatrics. 2010;125:410–4. doi:10.1542/peds.2009-3009.
- Bram JT, Magee LC, Mehta NN, Patel NM, Ganley TJ. Anterior cruciate ligament injury incidence in adolescent athletes: A systematic review and meta-analysis. [ct_00514]. Am J Sports Med. 2020:363546520959619. doi:10.1177/0363546520959619.
- Caine DJ, Golightly YM. Osteoarthritis as an outcome of paediatric sport: An epidemiological perspective. [ct_04134]. Br J Sports Med. 2011;45:298–303. doi:10.1136/bjsm.2010.081984.
- Orton E, Whitehead J, Mhizha‐Murira J, Clarkson M, Watson MC, Mulvaney CA, et al. School-based education programmes for the prevention of unintentional injuries in children and young people. [ct_05399]. Cochrane Database of Systematic Reviews. 2016;12:CD010246. doi:10.1002/14651858.CD010246.pub2.
- Slater H, Jordan JE, Chua J, Schütze R, Wark JD, Briggs AM. Young people's experiences of persistent musculoskeletal pain, needs, gaps and perceptions about the role of digital technologies to support their co-care: A qualitative study. [ct_06903]. BMJ Open. 2016;6:e014007. doi:10.1136/bmjopen-2016-014007.
- Enz A, Schöffl V, Simon M, Back DA, Tischer T, Lutter C. Generation „Social Media“ – Nutzung moderner Medien zum Informationsgewinn bezüglich Sportverletzungen. [Generation "Social Media": use of modern media to gain information regarding sports injuries]. Sportverletz Sportschaden. 2021;35:95–102. doi:10.1055/a-1386-6758.
- Vidal J, Borràs PA, Ponseti FJ, Cantallops J, Ortega FB, Palou P. Effects of a postural education program on school backpack habits related to low back pain in children. [ct_02001]. European Spine Journal : Official Publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2013;22:782–7. doi:10.1007/s00586-012-2558-7.
- Dolphens M, Cagnie B, Danneels L, Clercq D de, Bourdeaudhuij I de, Cardon G. Long-term effectiveness of a back education programme in elementary schoolchildren: An 8-year follow-up study. [ct_03387]. European Spine Journal : Official Publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2011;20:2134–42. doi:10.1007/s00586-011-1856-9.
- Molina-Garcia P, Mora-Gonzalez J, Migueles JH, Rodriguez-Ayllon M, Esteban-Cornejo I, Cadenas-Sanchez C, et al. Effects of Exercise on Body Posture, Functional Movement, and Physical Fitness in Children With Overweight/Obesity. [ct_02043]. J Strength Cond Res. 2020;34:2146–55. doi:10.1519/jsc.0000000000003655.
- Hill JJ, Keating JL. Encouraging healthy spine habits to prevent low back pain in children: An observational study of adherence to exercise. [ct_02168]. Physiotherapy. 2016;102:229–35. doi:10.1016/j.physio.2015.05.005.
- Dissing KB, Hartvigsen J, Wedderkopp N, Hestbæk L. Conservative care with or without manipulative therapy in the management of back and/or neck pain in Danish children aged 9-15: a randomised controlled trial nested in a school-based cohort. [ct_01416]. BMJ Open. 2018;8:e021358. doi:10.1136/bmjopen-2017-021358.
- Evans R, Haas M, Schulz C, Leininger B, Hanson L, Bronfort G. Spinal manipulation and exercise for low back pain in adolescents: A randomized trial. [ct_05621]. Pain. 2018;159:1297–307. doi:10.1097/j.pain.0000000000001211.
- Contardo Ayala AM, Salmon J, Timperio A, Sudholz B, Ridgers ND, Sethi P, Dunstan DW. Impact of an 8-month trial using height-adjustable desks on children's classroom sitting patterns and markers of cardio-metabolic and musculoskeletal health. [ct_02883]. Int J Environ Res Public Health 2016. doi:10.3390/ijerph13121227.
- Jacobs K, Kaldenberg J, Markowitz J, Wuest E, Hellman M, Umez-Eronini A, et al. An ergonomics training program for student notebook computer users: Preliminary outcomes of a six-year cohort study. [ct_00449]. Work. 2013;44:221–30. doi:10.3233/WOR-121584.
- Fritz J, Rosengren BE, Dencker M, Karlsson C, Karlsson MK. A seven-year physical activity intervention for children increased gains in bone mass and muscle strength. [ct_00182]. Acta Paediatrica (Oslo, Norway : 1992). 2016;105:1216–24. doi:10.1111/apa.13440.
- Koni A, Kufersin M, Ronchese F, Travan M, Cadenaro M, Larese Filon F. Approach to prevention of musculoskeletal symptoms in dental students: An interventional study. [ct_00560]. Med Lav. 2018;109:276–84. doi:10.23749/mdl.v109i4.6841.
- Rodríguez-Romero B, Bello O, Vivas Costa J, Carballo-Costa L. A therapeutic exercise program improves pain and physical dimension of health-related quality of life in young adults: A randomized controlled trial. [ct_00253]. Am J Phys Med Rehabil. 2019;98:392–8. doi:10.1097/PHM.0000000000001107.
- Davies J. Alexander Technique classes improve pain and performance factors in tertiary music students. [ct_00416]. J Bodyw Mov Ther. 2020;24:1–7. doi:10.1016/j.jbmt.2019.04.006.
- Parsons JL, MacDonald L, Cayer M, Hoeppner M, Titterton A, Willsie J, Webber SC. Functional fitness for dental hygiene students: Does it make them fit to sit? [ct_02581]. Canadian Journal of Dental Hygiene. 2019;53:149–56.
- Boini S, Colin R, Grzebyk M. Effect of occupational safety and health education received during schooling on the incidence of workplace injuries in the first 2 years of occupational life: A prospective study. [ct_01918]. BMJ Open. 2017;7:e015100. doi:10.1136/bmjopen-2016-015100.
- Gagnier JJ, Morgenstern H, Chess L. Interventions designed to prevent anterior cruciate ligament injuries in adolescents and adults: A systematic review and meta-analysis. [ct_03131]. Am J Sports Med. 2013;41:1952–62. doi:10.1177/0363546512458227.
- Hanlon C, Krzak JJ, Prodoehl J, Hall KD. Effect of injury prevention programs on lower extremity performance in youth athletes: A systematic review. [ct_01907]. Sports Health. 2020;12:12–22. doi:10.1177/1941738119861117.