Abstract

Background

Chronic pain is a major health and socioeconomic burden, which is prevalent in children and adolescents. Among the most widely used interventions in children and adolescents are physical activity (including exercises) and education about physical activity.

Objectives

To evaluate the effectiveness of physical activity, education about physical activity, or both, compared with usual care (including waiting‐list, and minimal interventions, such as advice, relaxation classes, or social group meetings) or active medical care in children and adolescents with chronic musculoskeletal pain.

Search methods

We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PEDro, and LILACS from the date of their inception to October 2022. We also searched the reference lists of eligible papers, ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform.

Selection criteria

We included randomised controlled trials (RCTs) that compared physical activity or education about physical activity, or both, with usual care (including waiting‐list and minimal interventions) or active medical care, in children and adolescents with chronic musculoskeletal pain.

Data collection and analysis

Two review authors independently determined the eligibility of the included studies. Our primary outcomes were pain intensity, disability, and adverse events. Our secondary outcomes were depression, anxiety, fear avoidance, quality of life, physical activity level, and caregiver distress. We extracted data at postintervention assessment, and long‐term follow‐up. Two review authors independently assessed risk of bias for each study, using the RoB 1. We assessed the overall certainty of the evidence using the GRADE approach. We reported continuous outcomes as mean differences, and determined clinically important differences from the literature, or 10% of the scale.

Main results

We included four studies (243 participants with juvenile idiopathic arthritis). We judged all included studies to be at unclear risk of selection bias, performance bias, and detection bias, and at high risk of attrition bias. We downgraded the certainty of the evidence for each outcome to very low due to serious or very serious study limitations, inconsistency, and imprecision.

Physical activity compared with usual care

Physical activity may slightly reduce pain intensity (0 to 100 scale; 0 = no pain) compared with usual care at postintervention (standardised mean difference (SMD) ‐0.45, 95% confidence interval (CI) ‐0.82 to ‐0.08; 2 studies, 118 participants; recalculated as a mean difference (MD) ‐12.19, 95% CI ‐21.99 to ‐2.38; I² = 0%; very low‐certainty evidence). Physical activity may slightly improve disability (0 to 3 scale; 0 = no disability) compared with usual care at postintervention assessment (MD ‐0.37, 95% CI ‐0.56 to ‐0.19; I² = 0%; 3 studies, 170 participants; very low‐certainty evidence). We found no clear evidence of a difference in quality of life (QoL; 0 to 100 scale; lower scores = better QoL) between physical activity and usual care at postintervention assessment (SMD ‐0.46, 95% CI ‐1.27 to 0.35; 4 studies, 201 participants; very low‐certainty evidence; recalculated as MD ‐6.30, 95% CI ‐18.23 to 5.64; I² = 91%).

None of the included studies measured adverse events, depression, or anxiety for this comparison.

Physical activity compared with active medical care

We found no studies that could be analysed in this comparison.

Education about physical activity compared with usual care or active medical care

We found no studies that could be analysed in this comparison.

Physical activity and education about physical activity compared with usual care or active medical care

We found no studies that could be analysed in this comparison.

Authors' conclusions

We are unable to confidently state whether interventions based on physical activity and education about physical activity are more effective than usual care for children and adolescents with chronic musculoskeletal pain.

We found very low‐certainty evidence that physical activity may reduce pain intensity and improve disability postintervention compared with usual care, for children and adolescents with juvenile idiopathic arthritis.

We did not find any studies reporting educational interventions; it remains unknown how these interventions influence the outcomes in children and adolescents with chronic musculoskeletal pain.

Treatment decisions should consider the current best evidence, the professional's experience, and the young person's preferences.

Further randomised controlled trials in other common chronic musculoskeletal pain conditions, with high methodological quality, large sample size, and long‐term follow‐up are urgently needed.

Author(s)

Mariana Nascimento Leite, Steven J Kamper, Neil E O'Connell, Zoe A Michaleff, Emma Fisher, Priscilla Viana Silva, Christopher M Williams, Tiê P Yamato

Abstract

Plain language summary

How effective are physical activity and education for chronic musculoskeletal pain in children and adolescents?

Key messages

‐ We are uncertain whether physical activity reduces pain or improves disability compared with usual care. We did not find studies that compared physical activities with medical care intervention (e.g. education).

‐ We did not find studies that evaluated education about physical activity, with or without physical activity, in children and adolescents.

‐ Due to the small number of included studies, and the ways in which the studies were conducted, which could introduce errors into their results, we cannot conclude whether physical activity, education about physical activity, or both, are effective compared with active medical care or usual care.

What is chronic musculoskeletal pain in children and adolescents?

Chronic pain is pain that lasts longer than three months. Chronic musculoskeletal pain (e.g. pain in muscles and bones) is common in children and adolescents, and has a negative impact on their lives. The most common chronic musculoskeletal pain in children and adolescents is pain in their back, neck, and arms, and pain resulting from sports injuries.

What is the impact caused by musculoskeletal pain in children and adolescents?

Children and adolescents with chronic pain report disability and a low mood; they socialise less with their friends, and recognise pain as an obstacle to exercising and participating in physical activities. This can result in missed school, and overall poor health in adult life.

How is musculoskeletal pain treated in children and adolescents?

Chronic musculoskeletal pain is usually managed with physical activity, education about physical activity, or both. Most of the time, these approaches are delivered as part of a complex intervention, i.e. interventions with different components (e.g. psychology, medicines, physical activity).

What did we want to find out?

We wanted to find out if physical activity, education about physical activity, or both, was better than usual care or medical care treatment (also known as active medical care) for improving:

‐ Pain

‐ Disability

‐ Quality of life

We also wanted to find out if physical activity, education about physical activity, or both, led to any unwanted side effects.

What did we do?

We searched for studies that compared physical activity, or education about physical activity, or both, with usual care or active medical care, in school‐aged children and adolescents (4 years to 18 years) with any chronic musculoskeletal pain.

We compared and summarised the results of the studies, and rated our confidence in the evidence, based on factors, such as study methods and size.

What did we find?

We found four studies with a total of 243 participants. The studies only included children and adolescents with juvenile idiopathic arthritis. The number of young people included in each study ranged from 32 to 93; the average age of the participants was 11 years. The treatments ranged from three to six months in length. Only one study assessed outcomes at long‐term follow‐up. We only found studies that compared physical activity with usual care.

We are uncertain if physical activity reduces pain or improves disability better than usual care. We are uncertain about the effects of physical activity on quality of life. None of the studies reported whether the participants experienced unwanted side effects.

What are the limitations of the evidence?

The studies only included a small number of children and adolescents, and may have been done in ways that could introduce errors in their results. Both reasons limit our confidence in the evidence.

Possible side effects of the physical activities and usual care were not adequately reported.

Our uncertainty in the results does not allow us to conclude whether physical activity for chronic musculoskeletal pain in children and adolescents improves their pain, disability, or quality of life.

In practice, healthcare providers should consider the availability and quality of research evidence about physical therapies, preferences of the young people in pain, and the professional's experience.

How up to date is this evidence?

The evidence is current to October 2022.

Author(s)

Mariana Nascimento Leite, Steven J Kamper, Neil E O'Connell, Zoe A Michaleff, Emma Fisher, Priscilla Viana Silva, Christopher M Williams, Tiê P Yamato

Reviewer's Conclusions

Authors' conclusions 

Implications for practice 

For children and adolescents with musculoskeletal pain

We found very low‐certainty evidence that interventions based on physical activity may improve pain intensity, disability, and quality of life when compared with usual care, for children and adolescents with juvenile idiopathic arthritis.

We did not identify any evidence for physical activity compared with active medical care, education about physical activity, or physical activity plus education. Therefore, the use of these interventions in clinical practice for children and adolescents with chronic musculoskeletal pain needs to be evaluated.

For clinicians

We found very low‐certainty evidence that physical activity interventions may be effective in reducing pain intensity and improving disability and quality of life in children and adolescents with juvenile idiopathic arthritis.

We did not find any studies evaluating educational interventions, and therefore, we do not know whether these interventions can have positive outcomes in this population. Therefore, treatment decisions should consider the best current evidence, the professional's experience, and the child's or adolescent's preferences. There are other potential benefits to physical activity and exercise, not captured in this review, which should be considered when guiding clinical decisions for this group.

For policy makers

The very low certainty evidence for physical activity interventions for chronic musculoskeletal pain in children and adolescents prevents strong conclusions.

Currently, there is no evidence for interventions involving an educational component. The scarcity of evidence for chronic pain in children and adolescents is alarming, and funding for high‐quality research in this area is needed.

For funders of the intervention

It is necessary to prioritise research calls, research grants, and universities' funders for the research of musculoskeletal pain in children and adolescents. Only then will it be possible to conduct large and high‐quality clinical trials that provide better certainty of the evidence for the treatment of this condition.

Implications for research 

General implications

We found very low‐certainty evidence on whether physical activity potentially reduces pain intensity and improves disability and quality of life at postintervention assessment, compared with usual care. Due to the uncertainty of the evidence, further studies are likely to influence the estimates of effects. Further randomised controlled trials, with high‐quality methodology and large sample size are urgently needed. Future studies should be sufficiently powered to detect between‐group differences.

Design

All the included studies evaluated children and adolescents with juvenile idiopathic arthritis, with unclear generalisability to other painful chronic musculoskeletal conditions. We need randomised controlled trials that evaluate promising treatments in children with common chronic musculoskeletal pain conditions (e.g. back pain, neck pain, upper and lower limb pain). Future studies need sample sizes large enough to precisely estimate the effectiveness of interventions.

Future studies also need to be high‐quality, aiming to reduce selection bias (i.e. allocation concealment), treatment expectations, detection bias, and to conduct intention‐to‐treat analysis. Future studies must be transparent, which can be achieved through prospective registration of trial protocols, and by reporting findings in accordance with reporting guidelines (e.g. CONSORT statement). For future interventions to result in high‐certainty evidence, they must be developed with key stakeholders, be designed to provide real‐world solutions, have biological or theoretical plausibility in terms of how the intervention may work, and be described accurately and in sufficient detail to enable treatments to be replicated in clinical practice (e.g. in accordance with the TIDieR checklist). To improve the quality of details about the intervention, trialists can use the Consensus on Exercise Reporting Template (CERT (Slade 2016)) and the Consensus on Therapeutic Exercise Training (CONTENT (Hoogeboom 2012)) as extensions of the TIDieR checklist. Thus, some core elements should be considered when designing interventions (Skivington 2021):

• Evaluate the context, as it can directly influence the effects of the intervention;
• Base the intervention on a theory that can explain the main mechanisms and components of the intervention, and that can guide future studies and implementation strategies;
• Include the participation of stakeholders in the development of the intervention, with the aim to achieve positive health impacts on public policies;
• Identify the main uncertainties of the intervention to guide the clinical implications, clinical decisions, and limitations regarding the intervention;
• If necessary, make adjustments and refinements to the intervention, guided by the initial theory, and according to how it was standardised in the protocol;
• Evaluate the costs of the intervention at all stages, in order to answer the most important questions for decision makers.

These are key elements in the design of the intervention, and should be evaluated at all stages, i.e. in the development of the intervention, during the assessment of feasibility and acceptability, and during the evaluation and implementation of the intervention (Skivington 2021). These studies should also provide long‐term follow‐up data (up to 12 months) to determine the maintenance of the effects of interventions, and should assess outcomes recommended by the Paediatric Pain Assessment in Clinical Trials in children and adolescents (PedIMMPACT) consensus (McGrath 2008; Palermo 2021). Finally, researchers need to answer questions that are helpful in real‐life situations to children, adolescents, and their families, practitioners, and decision‐makers, rather than questions that can be answered with higher levels of certainty (Skivington 2021). Therefore, children, adolescents, practitioners, and policymakers should be involved from the early stages of the interventions. Future studies must also investigate how to translate the intervention into practice, whether it will be acceptable, implementable, cost‐effective, scalable, and transferable between contexts. Only by taking these actions can the certainty of evidence be increased.

Measurement (end points)

Few studies have adopted the PedIMMPACT criterion. This would have improved the comparability across studies. It is important to better understand pain‐related psychological outcomes, by using appropriate measurements (e.g. anxiety and depression). Physical activity levels were not measured in any of the included studies. This is an important outcome when evaluating physical activity interventions, because it is an indicator of sedentary behaviour, which is a health risk factor. It is also essential to understand whether physical activity interventions can improve physical activity levels in children and adolescents with chronic musculoskeletal pain, as the pain experience is often accompanied by fear of movement and activity avoidance.

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