Eur Spine J DOI 10.1007/s00586-015-3953-7
ORIGINAL ARTICLE
Knowledge on health and back care education related to physical activity and exercise in adolescents V. Min˜ana-Signes1 • M. Monfort-Pan˜ego1
Received: 1 February 2015 / Revised: 9 April 2015 / Accepted: 10 April 2015 Ó Springer-Verlag Berlin Heidelberg 2015
Abstract Purpose The aim of this study was to analyze the relationship between the specific level of knowledge on health and back care-related physical activity practice and exercise with low back pain (LBP) in adolescents. Methods This is a cross-sectional study. The sample consisted of a total of 576 adolescents aged 13–18 years (mean age 15.5, SD 1.4). Self-reported questionnaires were used to record specific knowledge on health and back care and LBP in healthy adolescents. Results The prevalence of LBP was 46.3 % [95 % confidence interval (CI) 44.9–47.8]. Students with LBP scored slightly higher than non-sufferers, getting non-significant values. The level of specific knowledge increased with age (F = 7.308; p = 0.002). Stepwise logistic regression analysis showed that older girls group ([16 years old) was significantly associated with LBP odds ratio (OR) 2.9 (95 % CI 1.77–4.74; p = 0.000). Conclusions High school students have a low level of specific knowledge. Back care education in the school curriculum is recommended. Keywords Education Knowledge Physical activity Low back pain Adolescents
& V. Min˜ana-Signes [email protected] 1
Body Languages Didactics Department, Academic Unit of Physical Education, Teacher Training Faculty, University of Valencia, Av. dels Tarongers, 4, 46022 Valencia, Spain
Introduction It has been recognized that prevalence of low back problems in children and adolescents during the course of life is high. This problem increases steadily with age, appearing sooner and more frequently in girls than in boys [1, 2]. For these reasons, several authors advocate developing intervention programs and back health care in school [3–12]. Several authors argue that schools have a favorable context for intervention in the prevention and health promotion of the back [13, 14]. Therefore, the World Health Organization [15] has identified it as an effective environment for improving child health. Adolescents are subjected to a variety of risk factors, among them are inadequate physical activity, poor posture during physical exercise, sedentary lifestyle, high body mass index, reduced mobility and flexibility of muscles and joints, insufficient strength and stability in the muscles of the trunk, etc., [16–19]. The specific types of the physical exercise associated with back care education and assessment play a unifying role in the official curriculum [20]. Assessment instruments are needed to determine the level of specific knowledge about health and back care related to activity and exercise in students. On the other hand, it is also important to know if this level of knowledge could be considered as an indicator related to students with or without low back pain and if it could be interpreted as a preventing factor or risk indicator. Intervention studies that included assessment of general knowledge about back care agree that education and back care across the curriculum is an effective strategy to improve the cognitive aspect of back care in school [8, 21– 25]. Although knowledge of something, by itself, is not an indicator of behavioral change, it has been shown that a
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certain amount of information is needed to start the process that will lead to positive change [26, 27]. Despite this evidence related to back health at an early age, there are no studies that have been previously created that show evidence that students have knowledge of correct practice of physical exercise and the relationship that exists between them and the state of back health. That is why the aim of this cross-sectional study was to study the relationship between the level of knowledge about health and back care related to the practice of physical activity and exercise, and low back pain in adolescents in the Valencian Community. The hypothesis was that a low level of specific knowledge on physical activity for back care is associated with LBP in adolescents.
Materials and methods Subject population The study population consists of students in high school in the Valencian Community between the academic courses 2009–2010 and 2011–2012. The sample under study was selected through a convenience sample. The study included healthy adolescents aged 12–18 years, and students belonging to the four Secondary Schools selected from public and private schools. Students with disabilities: lesions of the spinal cord (i.e., spina bifida, quadriplegia, etc.), cerebral palsy, Down syndrome, autism, tumors, etc., and those who did not show up the day of the test were excluded. Data collection The questionnaires were filled out during physical education classes through the web platform Moodle in the computer rooms of the centers participating in the study. An experienced researcher presented the questionnaire to students, explained the procedure and rules for filling in the survey and personally attended to all doubts individuals had. The management of the centers, each group tutors and parents were informed of the study and expressed written consent.
that had experienced an episode at some point in their lifetime. Point prevalence was defined as the proportion of the population that had been cases within the previous week. This is a solid instrument with extended use and high reliability and reproducibility and it has been validated in several languages, among which is Spanish [29]. Measurement of the specific knowledge related to physical activity practice and exercise Individuals were required to complete a questionnaire to assess for knowledge of health and back care related to physical activity. The questionnaire was designed to identify knowledge about physical abilities such as strength, endurance, muscular flexibility, and proper exercises regarding posture and duration. Students were assessed using a 10-point scale. Students who achieved 5 points and higher passed the test. This questionnaire was validated in a previous study among 230 Spanish students aged 13–18 years, getting a good test–retest reliability, Cronbach’s a being 0.80 and intraclass correlation coefficient being 0.80 (p \ 0.01). Data analysis Descriptive statistics including means, standard deviations and 95 % confidence intervals (CIs) were performed to represent specific knowledge and low back pain data between gender and age groups. To asses the level of knowledge we used a 10-point scale and percentiles for ‘‘global score’’ because it was not normally distributed. Chi-square test, Student’s t test, analysis of variance (oneway ANOVA) were used at the significance level p \ 0.05. A stepwise binary logistic regression analysis was carried out to determine the risk factors associated with low back pain. Statistical analysis was conducted using SPPS v.18.
Results Descriptive analysis and univariate analysis Study group
Evaluation methods Prevalence of LBP Low back pain history was measured by Standardised Nordic questionnaire [28]. The questionnaire included a drawing of the low back, and defined LBP as aching, pain or discomfort in the low back during the preceding year that was not related to trauma or menstrual pain. Lifetime prevalence was defined as the proportion of the population
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A sample of 576 students was recruited. Individuals were aged between 13 and 18 years (mean age 15.47; SD 1.437). Boys were 51.9 % (n = 299; mean age 15.52; SD 0.084) and girls were 48.1 % (n = 277; mean age 15.42; SD 0.085). Lifetime prevalence of LBP Two hundred and sixty-three (127 boys and 136 girls) of 576 students reported having already experienced LBP at
Eur Spine J
least once in lifetime. The prevalence of LBP was 46.3 % (95 % CI 44.9–47.8), the 43.1 % (95 % CI 41.7–44.6) for boys and 49.8 % (95 % CI 48.4–51.4) for girls. The association of LBP between genders was independent of each other. The estimates for lifetime LBP gradually increased in girls from 35.7 % (95 % CI 34.3–37.3) in the 13-year-old to 64.7 % (95 % CI 63.3–66.3) in the 17-year-old, because 18-year-old group got 63.2 % (95 % CI 61.8–64.8). These differences were significant (v2 = 18.581, p = 0.002). The steepest increase was for the 15- and 16-year-old girls group ratting from 37.5 % (95 % CI 36.1–39) to 61.9 % (95 % CI 60.5–63.4), respectively. Boys reported an irregular and non-significant lifetime LBP between age groups starting at 13 years with 54.2 % (95 % CI 52.8–55.7) and finishing at 18 years with 66.7 % (95 % CI 65.3–68.2). The lifetime prevalence rates of LBP were at the maximum at age 17 years for girls and age 18 years for boys. Point prevalence of LBP Eighty-five (40 boys and 45 girls) of 300 adolescents registered 28.3 % (95 % CI 27.1–29.6) of LBP in point prevalence (7 days), the 27.6 % (95 % CI 26.4–29) for boys and 29.0 % (95 % CI 27.8–30.4) for girls. No significant associations were found. School absenteeism Forty-six students (23 boys and 23 girls) of 299 missed school because of LBP once in lifetime; a total of 15.4 % (95 % CI 14.3–16.6) with no differences between genders.
Table 1 Specific knowledge means and test passed per ages Specific knowledge n
Tests passed C5
X
SD
n
%
13 years
53
1.57
2.177
4
14 years
114
2.01
2.384
11
9.6
15 years
126
2.78
2.593
27
21.4
16 years
114
2.79
2.470
23
20.2
17 years
129
3.54
2.513
40
31.0
18 years
40
2.36
2.092
6
19.3
Total
576
7.5
111
p = 0.000). Tukey’s HSD post hoc test found significant differences among the age group of 13 years and 15 (p = 0.032), 16 (p = 0.033) and 17 (p = 0.000) years. Inside, we find statistical significant differences between the age group of 14 years and 17 (p \ 0.000) years. Dichotomizing the age variable, the mean knowledge of students until 15 years were 2.26 (95 % CI 1.98–2.55) and students up to age 15 years were 3.1 (95 % CI 2.78–3.36). The t test found statistically significant differences (p = 0.000). Students with LBP scored slightly higher than non-sufferers, 2.9 (95 % CI 2.55–3.2) and 2.5 (95 % CI 2.21–2.77), respectively, no significant differences were found. Those who sought for health care professional scored a mean of 3 (95 % CI 2.48–3.52) points and those who did not visit them got a mean of 2.9 (95 % CI 2.45–3.12) points. The t test did not find differences.
Seek health care professional Stepwise binary logistic regression Seventy-five teens (25.2 %, 95 % CI 24–26.5) visited the health professional (doctor, physiotherapist, chiropractor or other) in the past 12 months because of suffering from LBP. A total of 27.1 % (95 % CI 25.9–28.4) of girls sought health care professional while 23.1 % (95 % CI 21.9–24.4) was registered by boys. Chi-square test reported an independent relation.
A model for a stepwise binary logistic regression analysis for lifetime LBP was performed. This analysis showed that older girls group ([16 years old) was significantly associated with LBP (p = 0.000; OR 2.9, 95 % CI 1.77–4.74), but the significance disappeared after adjustments for specific knowledge. In boys, no significant associations were found.
Specific level of knowledge Four hundred and sixty-five students (80.7 %, 95 % CI 79.1–82.6) did not pass the questionnaire getting a score less than 5 points (Table 1). The mean of specific knowledge was 2.67 (95 % CI 2.38–2.95) for girls, and 2.66 (95 % CI 2.36–2.95) for boys, with no obvious difference between genders. One-way ANOVA showed that the age was significantly associated with higher specific knowledge (F = 7.308;
Discussion This investigation aimed to evaluate the level of specific knowledge on health and back care related to physical activity, and the prevalence of LBP in adolescents. A crosssectional study was carried out, therefore, it is only possible to show an association with several risk factors for LBP, but not to demonstrate causality.
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The results of the present study show a high level of lifetime prevalence of LBP in adolescents (46.3 %) similar to previous research carried out in Spain [30] and Europe [31]. These reports indicate that LBP is a serious health problem among secondary school students. Univariate and stepwise binary logistic regression analysis showed that increased age was significantly associated with LBP only in girls, according to the literature [1, 18]. Girls registered more than 30 % of lifetime LPB at 13 years and boys showed more than 50 % of LBP at the same age, reaching the maximum prevalence at 17 and 18 years, respectively. Preliminary studies have suggested that education about back health may be effective at reducing the incidence of low back pain in children [5, 22, 32–34]. Our results suggest that if we want to change these high rates, we should do some interventions in the previous educational stage (primary education) and continue keeping them in secondary education. This article is the first to develop a validated and reliable instrument to assess the specific knowledge related to the practice of physical activity and exercise for back care. We have shown that most students failed the test showing a low level of specific knowledge. Better level of knowledge was related with increasing age. However, in our study the specific knowledge is not associated with LBP. Despite our results, we think it is important to continue studying about improving knowledge and changing back health problems. Probably the improvement of knowledge has a positive effect on postural habits, about the absence and frequency of low back pain. Health education should be considered as a cognitive factor in determining behavioral change and the adoption of healthy lifestyles [26, 27]. For these reasons, several authors also take into account back care knowledge to prevent LBP [8, 35]. Furthermore, it could be suggested that older adolescents displayed higher knowledge because they have learned more from their experiences. It might seem logical that students with low back pain remedy it by seeking a doctor for their back problems and thereby increase their knowledge about back care [36]. Researchers consider that the hypothesis of the study has suffered a bias, because there is not a group of students who had an adequate and minimum specific knowledge. So they cannot compare properly the relationship between both groups, the students who have specific knowledge and students who do not have it. Implications for practice The fact that students have obtained very low results causes us to consider whether the content related to postural education is properly addressed in the annual programs of primary and secondary education classroom and whether
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teachers have adequate training. As recommended by Balague et al. and Cardon et al. [3, 21], it may be useful to incorporate back care education in the teacher trainer studies to inform future primary and secondary teachers. The insufficient measurement of specific knowledge in general might have impacted the results of the relationship between the variables. The lack of research on students in this age group may suggest that health and physical education professionals might have overlooked an important factor. Longitudinal studies are required to know how much specific knowledge is needed to prevent or to have students with healthier back. It is also unclear what effective and specific teaching contents could be used to increase student knowledge. Furthermore, the relationship between health physical activity knowledge and low back pain for students at different ages remains unclear.
Conclusion High school students have a low level of specific knowledge. However, as age increases the average level of knowledge improves. Adolescents should pay attention to back care. Back care education in the school curriculum is recommended. This present study failed to show the relationship between pain and specific knowledge. Acknowledgments The authors would like to thank the secondary schools and physical education teachers who accepted to participate in this study. Conflict of interest
None declared.
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Eur Spine J 8. Cardon G, De Bourdeaudhuij I, De Clercq D (2002) Knowledge and perceptions about back education among elementary school students, teachers, and parents in Belgium. J Sch Health 72(3):100–106 9. Sheldon MR (1994) Lifting instruction to children in an elementary school. J Orthop Sports Phys Ther 19(2):105–110 10. Spence SM, Jensen GM, Shepard KF (1984) Comparison of methods of teaching children proper lifting techniques. Phys Ther 64(7):1055–1061 11. Vicas-Kunse P (1992) Educating our children: the pilot school program. Occup Med 7(1):173–177 12. Viry P, Creveuil C, Marcelli C (1999) Nonspecific back pain in children. A search for associated factors in 14-year-old schoolchildren. Rev Rhum Engl Ed 66(7–9):381–388 13. Cardon G, De Bourdeaudhuij I, De Clercq D (2001) Generalization of back education principles by elementary school children: evaluation with a practical test and a candid camera observation. Acta Paediatr 90(2):143–150 14. Geldhof E, Cardon G, De Bourdeaudhuij I, De Clercq D (2007) Back posture education in elementary schoolchildren: a 2-year follow-up study. Eur Spine J 16(6):841–850 15. WHO (2012) The Ottawa Charter for Health Promotion. Available at: http://www.who.int/healthpromotion/conferences/ previous/ottawa/en/. Accessed 10 Aug, 2012 16. Balague F, Troussier B, Salminen JJ (1999) Non-specific low back pain in children and adolescents: risk factors. Eur Spine J 8(6):429–438 17. Trevelyan FC, Legg SJ (2006) Back pain in school children— Where to from here? Appl Ergon 37(1):45–54 18. Cardon G, Balague F (2004) Low back pain prevention’s effects in schoolchildren. What is the evidence? Eur Spine J 13(8): 663–679 19. Feldman DE, Shrier I, Rossignol M, Abenhaim L (2001) Risk factors for the development of low back pain in adolescence. Am J Epidemiol 154(1):30–36 20. Tinning R (2001) Physical education and back health: negotiating instrumental aims andholistic bodywork practices. Eur Phys Edu Rev 7(2):191–205 21. Cardon GM, de Clercq DL, Geldhof EJ, Verstraete S, de Bourdeaudhuij IM (2007) Back education in elementary schoolchildren: the effects of adding a physical activity promotion program to a back care program. Eur Spine J 16(1):125–133 22. Dolphens M, Cagnie B, Danneels L, De Clercq D, De Bourdeaudhuij I, Cardon G (2011) Long-term effectiveness of a back education programme in elementary schoolchildren: an 8-year follow-up study. Eur Spine J 20(12):2134–2142
23. Geldhof E, Cardon G, De Bourdeaudhuij I, De Clercq D (2006) Effects of a two-school-year multifactorial back education program in elementary schoolchildren. Spine (Phila Pa 1976) 31(17):1965–1973 24. Foltran FA, Moreira RF, Komatsu MO, Falconi MF, Sato TO (2012) Effects of an educational back care program on Brazilian schoolchildren’s knowledge regarding back pain prevention. Rev Bras Fisioter 16(2):128–133 25. Habybabady RH, Ansari-Moghaddam A, Mirzaei R, Mohammadi M, Rakhshani M, Khammar A (2012) Efficacy and impact of back care education on knowledge and behaviour of elementary schoolchildren. J Pak Med Assoc 62(6):580–584 26. Fineberg HV (1988) Education to prevent AIDS: prospects and obstacles. Science 239(4840):592–596 27. Stewart S, Mitchell M (2003) Instructional variables and student knowledge and conceptions of fitness. J Teach Phys Edu 22:533–551 28. Kuorinka I, Jonsson B, Kilbom A, Vinterberg H, Biering-Sørensen F, Andersson G et al (1987) Standardised Nordic questionnaires for the analysis of musculoskeletal symptoms. Appl Ergon 18(3):233–237 29. de Barros EN, Alexandre NM (2003) Cross-cultural adaptation of the Nordic musculoskeletal questionnaire. Int Nurs Rev 50(2):101–108 30. Pellise F, Balague F, Rajmil L, Cedraschi C, Aguirre M, Fontecha CG et al (2009) Prevalence of low back pain and its effect on health-related quality of life in adolescents. Arch Pediatr Adolesc Med 163(1):65–71 31. Jones MA, Stratton G, Reilly T, Unnithan VB (2004) A schoolbased survey of recurrent non-specific low-back pain prevalence and consequences in children. Health Educ Res 19(3):284–289 32. Mendez FJ, Gomez-Conesa A (2001) Postural hygiene program to prevent low back pain. Spine (Phila Pa 1976) 26(11):1280–1286 33. Steele EJ, Dawson AP, Hiller JE (2006) School-based interventions for spinal pain: a systematic review. Spine 31(2):226–233 34. Vidal J, Borras PA, Ponseti FJ, Cantallops J, Ortega FB, Palou P (2013) Effects of a postural education program on school backpack habits related to low back pain in children. Eur Spine J 22(4):782–787 35. Kovacs F, Oliver-Frontera M, Plana MN, Royuela A, Muriel A, Gestoso M et al (2011) Improving schoolchildren’s knowledge of methods for the prevention and management of low back pain: a cluster randomized controlled trial. Spine (Phila Pa 1976) 36(8):E505–E512 36. Balague F, Dudler J, Nordin M (2003) Low back pain in children. Lancet 361(26):1403–1404
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ORIGINAL ARTICLE
Knowledge on health and back care education related to physical activity and exercise in adolescents V. Min˜ana-Signes1 • M. Monfort-Pan˜ego1
Received: 1 February 2015 / Revised: 9 April 2015 / Accepted: 10 April 2015 Ó Springer-Verlag Berlin Heidelberg 2015
Abstract Purpose The aim of this study was to analyze the relationship between the specific level of knowledge on health and back care-related physical activity practice and exercise with low back pain (LBP) in adolescents. Methods This is a cross-sectional study. The sample consisted of a total of 576 adolescents aged 13–18 years (mean age 15.5, SD 1.4). Self-reported questionnaires were used to record specific knowledge on health and back care and LBP in healthy adolescents. Results The prevalence of LBP was 46.3 % [95 % confidence interval (CI) 44.9–47.8]. Students with LBP scored slightly higher than non-sufferers, getting non-significant values. The level of specific knowledge increased with age (F = 7.308; p = 0.002). Stepwise logistic regression analysis showed that older girls group ([16 years old) was significantly associated with LBP odds ratio (OR) 2.9 (95 % CI 1.77–4.74; p = 0.000). Conclusions High school students have a low level of specific knowledge. Back care education in the school curriculum is recommended. Keywords Education Knowledge Physical activity Low back pain Adolescents
& V. Min˜ana-Signes [email protected] 1
Body Languages Didactics Department, Academic Unit of Physical Education, Teacher Training Faculty, University of Valencia, Av. dels Tarongers, 4, 46022 Valencia, Spain
Introduction It has been recognized that prevalence of low back problems in children and adolescents during the course of life is high. This problem increases steadily with age, appearing sooner and more frequently in girls than in boys [1, 2]. For these reasons, several authors advocate developing intervention programs and back health care in school [3–12]. Several authors argue that schools have a favorable context for intervention in the prevention and health promotion of the back [13, 14]. Therefore, the World Health Organization [15] has identified it as an effective environment for improving child health. Adolescents are subjected to a variety of risk factors, among them are inadequate physical activity, poor posture during physical exercise, sedentary lifestyle, high body mass index, reduced mobility and flexibility of muscles and joints, insufficient strength and stability in the muscles of the trunk, etc., [16–19]. The specific types of the physical exercise associated with back care education and assessment play a unifying role in the official curriculum [20]. Assessment instruments are needed to determine the level of specific knowledge about health and back care related to activity and exercise in students. On the other hand, it is also important to know if this level of knowledge could be considered as an indicator related to students with or without low back pain and if it could be interpreted as a preventing factor or risk indicator. Intervention studies that included assessment of general knowledge about back care agree that education and back care across the curriculum is an effective strategy to improve the cognitive aspect of back care in school [8, 21– 25]. Although knowledge of something, by itself, is not an indicator of behavioral change, it has been shown that a
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certain amount of information is needed to start the process that will lead to positive change [26, 27]. Despite this evidence related to back health at an early age, there are no studies that have been previously created that show evidence that students have knowledge of correct practice of physical exercise and the relationship that exists between them and the state of back health. That is why the aim of this cross-sectional study was to study the relationship between the level of knowledge about health and back care related to the practice of physical activity and exercise, and low back pain in adolescents in the Valencian Community. The hypothesis was that a low level of specific knowledge on physical activity for back care is associated with LBP in adolescents.
Materials and methods Subject population The study population consists of students in high school in the Valencian Community between the academic courses 2009–2010 and 2011–2012. The sample under study was selected through a convenience sample. The study included healthy adolescents aged 12–18 years, and students belonging to the four Secondary Schools selected from public and private schools. Students with disabilities: lesions of the spinal cord (i.e., spina bifida, quadriplegia, etc.), cerebral palsy, Down syndrome, autism, tumors, etc., and those who did not show up the day of the test were excluded. Data collection The questionnaires were filled out during physical education classes through the web platform Moodle in the computer rooms of the centers participating in the study. An experienced researcher presented the questionnaire to students, explained the procedure and rules for filling in the survey and personally attended to all doubts individuals had. The management of the centers, each group tutors and parents were informed of the study and expressed written consent.
that had experienced an episode at some point in their lifetime. Point prevalence was defined as the proportion of the population that had been cases within the previous week. This is a solid instrument with extended use and high reliability and reproducibility and it has been validated in several languages, among which is Spanish [29]. Measurement of the specific knowledge related to physical activity practice and exercise Individuals were required to complete a questionnaire to assess for knowledge of health and back care related to physical activity. The questionnaire was designed to identify knowledge about physical abilities such as strength, endurance, muscular flexibility, and proper exercises regarding posture and duration. Students were assessed using a 10-point scale. Students who achieved 5 points and higher passed the test. This questionnaire was validated in a previous study among 230 Spanish students aged 13–18 years, getting a good test–retest reliability, Cronbach’s a being 0.80 and intraclass correlation coefficient being 0.80 (p \ 0.01). Data analysis Descriptive statistics including means, standard deviations and 95 % confidence intervals (CIs) were performed to represent specific knowledge and low back pain data between gender and age groups. To asses the level of knowledge we used a 10-point scale and percentiles for ‘‘global score’’ because it was not normally distributed. Chi-square test, Student’s t test, analysis of variance (oneway ANOVA) were used at the significance level p \ 0.05. A stepwise binary logistic regression analysis was carried out to determine the risk factors associated with low back pain. Statistical analysis was conducted using SPPS v.18.
Results Descriptive analysis and univariate analysis Study group
Evaluation methods Prevalence of LBP Low back pain history was measured by Standardised Nordic questionnaire [28]. The questionnaire included a drawing of the low back, and defined LBP as aching, pain or discomfort in the low back during the preceding year that was not related to trauma or menstrual pain. Lifetime prevalence was defined as the proportion of the population
123
A sample of 576 students was recruited. Individuals were aged between 13 and 18 years (mean age 15.47; SD 1.437). Boys were 51.9 % (n = 299; mean age 15.52; SD 0.084) and girls were 48.1 % (n = 277; mean age 15.42; SD 0.085). Lifetime prevalence of LBP Two hundred and sixty-three (127 boys and 136 girls) of 576 students reported having already experienced LBP at
Eur Spine J
least once in lifetime. The prevalence of LBP was 46.3 % (95 % CI 44.9–47.8), the 43.1 % (95 % CI 41.7–44.6) for boys and 49.8 % (95 % CI 48.4–51.4) for girls. The association of LBP between genders was independent of each other. The estimates for lifetime LBP gradually increased in girls from 35.7 % (95 % CI 34.3–37.3) in the 13-year-old to 64.7 % (95 % CI 63.3–66.3) in the 17-year-old, because 18-year-old group got 63.2 % (95 % CI 61.8–64.8). These differences were significant (v2 = 18.581, p = 0.002). The steepest increase was for the 15- and 16-year-old girls group ratting from 37.5 % (95 % CI 36.1–39) to 61.9 % (95 % CI 60.5–63.4), respectively. Boys reported an irregular and non-significant lifetime LBP between age groups starting at 13 years with 54.2 % (95 % CI 52.8–55.7) and finishing at 18 years with 66.7 % (95 % CI 65.3–68.2). The lifetime prevalence rates of LBP were at the maximum at age 17 years for girls and age 18 years for boys. Point prevalence of LBP Eighty-five (40 boys and 45 girls) of 300 adolescents registered 28.3 % (95 % CI 27.1–29.6) of LBP in point prevalence (7 days), the 27.6 % (95 % CI 26.4–29) for boys and 29.0 % (95 % CI 27.8–30.4) for girls. No significant associations were found. School absenteeism Forty-six students (23 boys and 23 girls) of 299 missed school because of LBP once in lifetime; a total of 15.4 % (95 % CI 14.3–16.6) with no differences between genders.
Table 1 Specific knowledge means and test passed per ages Specific knowledge n
Tests passed C5
X
SD
n
%
13 years
53
1.57
2.177
4
14 years
114
2.01
2.384
11
9.6
15 years
126
2.78
2.593
27
21.4
16 years
114
2.79
2.470
23
20.2
17 years
129
3.54
2.513
40
31.0
18 years
40
2.36
2.092
6
19.3
Total
576
7.5
111
p = 0.000). Tukey’s HSD post hoc test found significant differences among the age group of 13 years and 15 (p = 0.032), 16 (p = 0.033) and 17 (p = 0.000) years. Inside, we find statistical significant differences between the age group of 14 years and 17 (p \ 0.000) years. Dichotomizing the age variable, the mean knowledge of students until 15 years were 2.26 (95 % CI 1.98–2.55) and students up to age 15 years were 3.1 (95 % CI 2.78–3.36). The t test found statistically significant differences (p = 0.000). Students with LBP scored slightly higher than non-sufferers, 2.9 (95 % CI 2.55–3.2) and 2.5 (95 % CI 2.21–2.77), respectively, no significant differences were found. Those who sought for health care professional scored a mean of 3 (95 % CI 2.48–3.52) points and those who did not visit them got a mean of 2.9 (95 % CI 2.45–3.12) points. The t test did not find differences.
Seek health care professional Stepwise binary logistic regression Seventy-five teens (25.2 %, 95 % CI 24–26.5) visited the health professional (doctor, physiotherapist, chiropractor or other) in the past 12 months because of suffering from LBP. A total of 27.1 % (95 % CI 25.9–28.4) of girls sought health care professional while 23.1 % (95 % CI 21.9–24.4) was registered by boys. Chi-square test reported an independent relation.
A model for a stepwise binary logistic regression analysis for lifetime LBP was performed. This analysis showed that older girls group ([16 years old) was significantly associated with LBP (p = 0.000; OR 2.9, 95 % CI 1.77–4.74), but the significance disappeared after adjustments for specific knowledge. In boys, no significant associations were found.
Specific level of knowledge Four hundred and sixty-five students (80.7 %, 95 % CI 79.1–82.6) did not pass the questionnaire getting a score less than 5 points (Table 1). The mean of specific knowledge was 2.67 (95 % CI 2.38–2.95) for girls, and 2.66 (95 % CI 2.36–2.95) for boys, with no obvious difference between genders. One-way ANOVA showed that the age was significantly associated with higher specific knowledge (F = 7.308;
Discussion This investigation aimed to evaluate the level of specific knowledge on health and back care related to physical activity, and the prevalence of LBP in adolescents. A crosssectional study was carried out, therefore, it is only possible to show an association with several risk factors for LBP, but not to demonstrate causality.
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The results of the present study show a high level of lifetime prevalence of LBP in adolescents (46.3 %) similar to previous research carried out in Spain [30] and Europe [31]. These reports indicate that LBP is a serious health problem among secondary school students. Univariate and stepwise binary logistic regression analysis showed that increased age was significantly associated with LBP only in girls, according to the literature [1, 18]. Girls registered more than 30 % of lifetime LPB at 13 years and boys showed more than 50 % of LBP at the same age, reaching the maximum prevalence at 17 and 18 years, respectively. Preliminary studies have suggested that education about back health may be effective at reducing the incidence of low back pain in children [5, 22, 32–34]. Our results suggest that if we want to change these high rates, we should do some interventions in the previous educational stage (primary education) and continue keeping them in secondary education. This article is the first to develop a validated and reliable instrument to assess the specific knowledge related to the practice of physical activity and exercise for back care. We have shown that most students failed the test showing a low level of specific knowledge. Better level of knowledge was related with increasing age. However, in our study the specific knowledge is not associated with LBP. Despite our results, we think it is important to continue studying about improving knowledge and changing back health problems. Probably the improvement of knowledge has a positive effect on postural habits, about the absence and frequency of low back pain. Health education should be considered as a cognitive factor in determining behavioral change and the adoption of healthy lifestyles [26, 27]. For these reasons, several authors also take into account back care knowledge to prevent LBP [8, 35]. Furthermore, it could be suggested that older adolescents displayed higher knowledge because they have learned more from their experiences. It might seem logical that students with low back pain remedy it by seeking a doctor for their back problems and thereby increase their knowledge about back care [36]. Researchers consider that the hypothesis of the study has suffered a bias, because there is not a group of students who had an adequate and minimum specific knowledge. So they cannot compare properly the relationship between both groups, the students who have specific knowledge and students who do not have it. Implications for practice The fact that students have obtained very low results causes us to consider whether the content related to postural education is properly addressed in the annual programs of primary and secondary education classroom and whether
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teachers have adequate training. As recommended by Balague et al. and Cardon et al. [3, 21], it may be useful to incorporate back care education in the teacher trainer studies to inform future primary and secondary teachers. The insufficient measurement of specific knowledge in general might have impacted the results of the relationship between the variables. The lack of research on students in this age group may suggest that health and physical education professionals might have overlooked an important factor. Longitudinal studies are required to know how much specific knowledge is needed to prevent or to have students with healthier back. It is also unclear what effective and specific teaching contents could be used to increase student knowledge. Furthermore, the relationship between health physical activity knowledge and low back pain for students at different ages remains unclear.
Conclusion High school students have a low level of specific knowledge. However, as age increases the average level of knowledge improves. Adolescents should pay attention to back care. Back care education in the school curriculum is recommended. This present study failed to show the relationship between pain and specific knowledge. Acknowledgments The authors would like to thank the secondary schools and physical education teachers who accepted to participate in this study. Conflict of interest
None declared.
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