News Category: Child

Spiral fractures of the leg in children usually require surgery. A closed procedure may be possible if the break is short enough. Unstable, long fractures with multiple fragments will require an open operation.

Closed fracture repair can be done as a minimally invasive (MI) procedure. With MI surgery, only a small incision is required. The surgeon often relies on an imaging technique called fluoroscopy. This is a type of X-ray that allows the surgeon to see the bones while inserting and passing pins into the leg and through the bone.

In young children, there is some concern about the length of time they are exposed to radiation from this imaging tool. The surgeon and surgical staff are also exposed. Efforts are being made to reduce the total radiation dosage everyone is exposed to.

In this study, the length of time and dosage are measured for children with lower-extremity shaft fractures. The shaft refers to the main part of the long bone, rather than the top or bottom of the bone.

The average time children with femoral (thigh bone) shaft fractures were exposed to intensified radiation was about 70 seconds. This time was longer when the surgery was complex or when surgeons were being trained. Average radiation time was less for fractures of the lower leg.

The authors make several suggestions to help reduce radiation exposure in children with long fractures of the leg bones. First, pediatric trauma units should keep exposure to fluoroscopy to less than two minutes for lower leg bone fractures of the shaft.

A similar guideline should be applied to femoral shaft fractures but the time can be extended to three minutes. Routine use of the radiation imaging longer than this suggests a need to review the equipment. It’s possible the fluoroscopy device is outdated and should be replaced.

If the surgeon suspects radiation exposure will be longer, then an open incision should be considered instead of a closed reduction.

Fractures of the femur (thigh bone) in children may be difficult to repair surgically, depending on the fracture. One procedure, the locked plate fixation has been used with adults, but there is little in the literature indicating its use in children. The authors of this study studied the effectiveness of the procedure in 32 patients who had sustained femur fractures.

The patients, average age 11 years old, had broken their femur and had been treated with the locked plate fixation. The researchers examined their records, including the x-ray before surgery, to examine the fracture patterns and the bone growth after surgery. Records of the follow-up included the patients’ ability to bear weight, the union of the bone, and the presence of any complications.

The researchers found that all except one patient had optimal bone realignment. Seven patients had the implant from the surgery removed between eight and 13 months after surgery, due to surgeon preference, but no complications were noted. There were no complications among all patients during surgery, nor did any of the implants fail, requiring revision surgery.

In conclusion, the authors of the article point out that the surgery is not a first-choice treatment but may be used if there is no other viable option. It results in fracture stability, minimizes soft-tissue damage, and provides good clinical outcomes.

Young children with clubfoot are usually treated using the Ponsetti treatment. Researchers felt that ultrasound over the course of the treatment would allow for accurate assessment of treatment progress because of the good visualization with ultrasound of the young bones.

Researchers enrolled 26 patients, six of whom had bilateral clubfoot (both feet), for a total of 32 clubfeet. Patients were between 12 days and three months old; all patients had nonidiopathic clubfeet, not as the result of other disorders or deformity. The controls for the study were the non-affected feet in patients with only one clubfoot.

The clubfeet were scored by the researchers using the International Clubfoot Study Group (ICFSG) criteria. Before and after each manipulation, done weekly, clinical evaluation was performed using the Pirani scoring method. Ultrasound evaluations were done throughout treatment by a pediatric sonologist with experience taking these particular measurements. The manipulations were performed by a pediatric orthopedic surgeon.

The results of the study showed an average pre-treatment score of 14/20 using the ISCFSG scoring system. Using the Pirani scoring system, six feet had scores between three and four, and 26 feet had scores between four and six.

Surgery was required to release the Achilles tendon in 32 feet. At the end of the treatment, all patients had a score of zero according to the Pirani score.

The authors conclude that using ultrasound, which is relatively inexpensive and easy to access, to monitor the progress of clubfoot correction is effective and can help detect problems early on in treatment.

Children frequently have fingertip injuries and the most common one is called the mallet finger. Because the initial trauma may not be severe and the injury doesn’t appear to hinder movement or function, the injury frequently is not diagnosed in the early stages. By the time the injury is brought to a physician’s attention, a considerable period of time may have passed. As well, when the injury is treated early, the treatment is often too difficult for full compliance (full finger extension, full time), and the results may not be optimal.

Casting or full-time extension is the usual course of action when a patient presents with established mallet finger deformities, however, the authors of this study wanted to review the results of tenodermodesis, surgery to straighten the finger, to assess its effectiveness.

The records of 10 children, average age 7.4 years, who had undergone the procedure were reviewed and the patients were followed for an average of 6.5 years. The surgery had been performed because of functional and aesthetic reasons.

After an average of 6.5 years, all patients had some restored function to the finger; two patients obtained full extensor function, eight patients had a lag of 20 degrees or less, down from 40 degrees before the surgery. Two of the patients were left with mild nail plate deformities. Eight of the 10 patients found now significant limitation in function for their regular activities, although one patient did complain of mild pain and another temperature intolerance of the affected finger.

The authors conclude that, despite the small size of the study group, tenodermodesis is a viable option for treatment for chronic mallet fingers in children.

When a patient presents with patellofemoral (a joint in the knee) pain , there are many options for management. However, no option has ever been deemed more effective than another.

Although conservative treatment, physical therapy and quadriceps training, should be tried first, for patients who do not respond to conservative treatment, surgery may be necessary. The authors of this study sought to determine the failure rate of a procedure called lateral patellar retinacular release, outcomes, and if differences occurred depending on the patient’s demographics.

The researchers found the records of patients who had undergone this surgery, done by one particular surgeon. After attempting to contact the patients, the researchers had a group of 140 knees for evaluation. The study subjects completed a telephone interview, as well as a general satisfaction survey. The researchers evaluated knee function with the Cincinnati Knee Rating System and the Lysholm Knee Questionnaire. The researchers also looked for surgery failure, which was determined by the need for surgery for any of the original indications.

All patients underwent the same rehabilitation process: six weeks of physical therapy. The study findings showed that after 8.5 years on average, 25 knees out of 140 needed repeat surgery. The median score, using the Cincinnati Knee Rating System (for pain) of zero to 10, rose to eight for the 140 knees, and the mean Lysholm score, was 76 (out of 100). Both numbers indicate that patients were satisfied with the outcome. The researchers did not find any correlation with success and satisfaction among different age groups, sex, sports function, or Lysholm scores.

In conclusion, the authors report that the majority of patients who underwent the lateral patellar retinacular release were satisified with the outcome.

Children who have scoliosis (curvature of the spine) may also have neurological disorders such as syringomyelia(accumulation of fluid in the spinal cord) or Chiari I Malformation (a congenital malformation of the brain).

Surgeons may be concerned about not knowing about these issues in advance of performing spinal surgery and, therefore, order pre-operative magnetic resonance imaging (MRIs) to detect these abnormalities. The authors of this study wanted to determine if x-rays of the scoliosis curves and the findings regarding curve severity, could give them the information they require regarding the presence of the neurological abnormalities.

The records of 87 children were reviewed by researchers to collect data on the curves, the patterns (side to side, more than one, degree of curve, etc). The patients were then divided into three groups: group 1’s children had curves of 10 to 30 degrees, group 2’s children had curves of 30 to 60 degrees, and group 3’s children had curves of more than 60 degrees.

The researchers found both Chiari I malformation and syringomyelia in all patients, regardless of curve presentation. Also, the researchers noted if kyphosis, curving inward rather than from side to side, was present, this could be an indication of progressing scoliosis.

Ankle injuries are on the rise in young teens, most likely due to an increase in sports activity. The triplane ankle fracture is a complex pediatric injury in children ages 12 to 15. This article presents a review of this unique fracture.

The injury pattern includes fractures in three planes of the ankle. These include the sagittal, transverse, and frontal planes. Sagittal refers to a fracture that goes through the bone from front to back. Transverse fractures are from side to side. Frontal describes a fracture from top to bottom.

Trauma or a twisting injury is usually the cause of triplanar ankle fractures. Some growth areas close sooner than others. Theses unevenly closed growth patterns puts some children at risk for this injury.

Boys ages 13 to 15 are the most susceptible. Girls are more likely to have this type of fracture between the ages of 12 to 14 years old. Some of the growth plates close later in males. So they experience triplanar fractures later.

Because these fractures occur during this transitional period between growth and skeletal maturity, triplanar fractures are also called transition fractures. Triplanar fractures do not usually affect children of either sex under the age of 10 or older than 16.

X-rays are an important tool in making the diagnosis. But sometimes only one of the fractures present can be seen on X-rays. CT scans are needed to see the pattern and the full extent of the fracture.

Treatment can be conservative (without surgery) or surgical. Surgery is advised when there is concern about the joint matching on both sides. This is called articular incongruity. Uneven joint surfaces can lead to degenerative arthritis.

If there is no disruption of the joint surface, treatment consists of immobilization with a long leg cast. Most often, the typical triplane fracture requires open surgery to bring the pieces of bone back together. Metal plates, pins, and screws are used to hold everything together until it heals. This operation is called an open reduction and internal fixation (ORIF).

The authors carefully describe when and how to decide whether to use conservative or surgical care. Open versus closed procedures for surgical care is discussed in detail. The importance of accurate reduction of the fractures is stressed.

Although most back pain in children and adolescents is shortlived and nonspecific, some can be diagnosed as spondylolysis. This is a stress fracture of the pars interarticularis, a portion of the vertebra of the spine. The lumbar spine usually has five levels, numbered one through five. Spondylolysis most commonly occurs at the L4 or L5 level. It seems to occur more often amoung athletes participating in sports such as football, volleyball, gymnastics, wrestling, soccer, and tennis. It is the repetitive bending backward, called hyperextension that is thought to cause the stress fracture. The diagnosis is usually made by the history and radiographs such as plain xrays, bone scan, or computed tomography. Plain xrays were falsely negative in three fourths of the subjects. The spondylolysis in the remaining subjects was found with either a bone scan or CT scan.

The authors of the study reviewed the cases of 255 males and 181 juvenile and adolescents who were evaluated and diagnosed as having spondylolysis by a single physician. Back pain with extension, back spasms, and hamstring tightness were typical symptoms.

Initial treatment of the subjects in this study included stopping the activity that caused the symptoms, and wearing a custom fitted brace for three months. Treatment also included rehabilitation for strengthening of the abdominals and muscles along the spine. In the subjects who responded to conservative care, range of motion of the spine and hamstring length was restored without pain. Back spasm was eliminated. Most subjects returned to their preinjury activity level. Various studies have shown that conservative, nonoperative treatment is effective 78 to 95 percent of the time. Of the 436 subjects in this study, 95 percent of them had a favorable outcome.

Young children involved in certain sports can experience a fracture of the pars interarticularis. This condition is called spondylolysis.

The pars is a part of the posterior half of the vertebra. If the fracture displaces (separates), the body of the vertebra can slide forward. This more advanced condition is referred to as spondylolisthesis.

The cause and nonoperative treatment of spondylolysis are the focus of this article. Medical management is made up of three parts: reduction of activity, a back brace, and physical therapy.

Activities that must be avoided include hyperextension (backward bending motion) and twisting of the spine. Athletic training must be abandoned by football players, wrestlers, soccer players, gymnasts, or other sports participants. Any twisting or extension of the spine must be avoided.

If painful symptoms do not resolve, then an orthosis (back brace) may be prescribed. A custom made thoracolumbar orthosis (TLSO) must be worn everyday for at least three months. The child can be slowly weaned from the brace at the end of that time. A physical therapy program of range of motion, stretching, strengthening, and correct posture is then initiated.

In a study of 436 children who followed these three steps, results were excellent. Full cooperation and compliance with activity restrictions, brace wearing, and gradual return to sports was required to obtain such good outcomes. All of the patients were able to return to their sport full-time. No one needed further treatment or surgery.

When athletes return to their sport, they must learn how to avoid improper technique. They must to trained to avoid motions that stretch beyond their physical abilities and strength.

The use of all-terrain vehicles (ATVs) has increased dramatically since they were first sold in the 1970s. With faster models being used by younger and younger drivers, injuries have increased 4.7 times just in the last 10 years.

In this report, the records of ATV accidents in children were reviewed. Data was obtained from a pediatric trauma center in Kentucky. National records were also reported. The authors point out the increase in injuries and deaths have occurred since the 1988 Consent Decree was cancelled in 1998.

The Consent Decree was a safety agreement between the Consumer Product Safety Commission (CPSC) and manufacturers of ATVs. The goal was to decrease injury and death. This was accomplished by regulations that prevented the sale to or use of ATVs by anyone younger than 16.

Education, training, and safety warnings were required. Without this Decree in place, many more children are using (and being injured while using) ATVs.

Lack of protective gear and using an ATV that is too large for the child are two key factors. The authors point out that the speed of ATVs is another problem. Many models can now reach up to 75 mph.

Boys between the ages of 11 and 15 are the most likely to suffer injuries from ATV accidents. Face, skull, arms, and legs are affected most often. Brain injuries can be severe enough to result in permanent disability, paralysis, and even death.

It’s not clear yet what role helmets and other protective gear play in preventing or reducing injuries. Data does support the idea that injuries are less severe when protective equipment is used. Younger children are less likely to have the rational decision-making abilities of older children and adults.

The authors conclude the results of this study support the idea that restrictions should be placed on ATV drivers. They suggest no one under the age of 16 should be allowed to operate or ride on an ATV.

There should not be any passengers of any age. Helmets should be required by anyone driving or riding on an ATV. They suggest it’s time for stricter legislation on ATV use by children.

Ingrown toenails of the big toe are a rare problem in babies. In this report, four cases of congenital ingrown toenail are presented. Congenital means the problem was present at birth.

In all four babies, the ingrown toenail was bilateral. This means it was present on both sides. The toes were painful and in some cases, red and swollen.

There was no known family history of ingrown toenails. All the children were healthy otherwise. One child had another medical condition called Dandy-Walker syndrome. This did not appear to be linked with the ingrown toenails.

At first, treatment was conservative. Antibiotics were used for infection. Warm soaks and pushing the soft tissue away from the nail bed were tried. Only one case resolved with this treatment. The nonsurgical approach took months. In three of the four cases, symptoms persisted and surgery was finally needed.

The surgeon removed the extra soft tissue growing over the nailbed. This is called a wedge resection. The results were excellent. The problem went away in both feet. No one required any further treatment.

The authors conclude that although ingrown toenails are rare at birth, surgical treatment can be safe and effective. After a prolonged period of conservative care, if inflammation and infection don’t go away, then the extra flap of tissue can be removed. A good result can be expected.

Obesity measured by body mass index (BMI) has been linked with Blount disease. But how much obesity and why BMI is a risk factor remain unknown. Blount disease is a condition of extreme bowlegs. The bones of the lower leg start to form an angle and rotate inwardly.

In this study from Shriners Hospital in Texas, research shows that both the child’s BMI and the angle of the bones are important factors. Using the data, they were able to form a prediction rule for Blount disease.

A prediction rule is a way to look at risk factors and tell if a child will develop this condition. Such a rule would help orthopedic surgeons decide which children need nutritional counseling and early treatment. Some children will outgrow bowlegs. They don’t need medical treatment.

The prediction rule is: if the tibial metaphyseal-diaphyseal angle (TMDA) is 10 degrees or more and the BMI is 22 or more, then treatment is advised.

The metaphysis and diaphysis are the areas where growth occurs in the child’s bone. In the early stages of Blount’s disease, excess weight and load causes the medial side (inside edge) of the metaphysis to break down. Growth then stops. The lower leg starts to curve outwardly. The child does not outgrow the problem.

The authors report that this prediction rule is very sensistive and specific. That means when the test is positive, there’s no chance that the result is a mistake.

In a very small number of cases, a negative test may be in error. In other words, the test results suggest the child has bowlegs but not Blount disease when the child really does have the disease.

This is the first report published on the results of extensor tendon repair in children under the age of 15 years. Children included in the study ranged in age from 12 months to 15 years. Most of the cuts occurred from a sharp object such as glass, knife, or scissors.

Surgery to repair the damage was done within 24 hours in all cases. The authors carefully described the zones and locations of the tendon lacerations. The authors specifically looked at factors that might affect the outcomes.

Everyone was followed for at least one year after surgery. Some patients were followed for up to five years. Various types of repair procedures were used.

Results were measured by range of motion, function, and the presence of extensor tendon lag. Lag refers to an incomplete extension of the distal interphalangeal (DIP) joint. When the patient makes a fist and then extends the affected finger, the tip of the finger doesn’t straighten all the way.

Grip and pinch strength are often used as measures of results for hand injuries. They were not included in this study because of the young age of some patients.

Age, location of injury, and extent of injury were the most important factors influencing the results. Younger children (less than five years old) were more likely to have an extension lag. This may be because smaller fingers are harder to keep immobilized after surgery.

The authors report that children with complete lacerations had worse results than those with a partial tendon cuts. Extensor tendon lag was more likely when there was a complete tendon laceration.

Overall, the results were good to excellent. Extensor lag was the biggest mid- to long-term problem. Extensor tendon injuries don’t occur very often in children.

Studies comparing treatment are difficult because there are so many differences from patient to patient. Many times the injury involves skin loss or bone fractures. Isolated tendon lacerations occur much less often.

X-rays are usually the first imaging test done on children with hip pain of an unknown cause. There may be a fracture, tumor, or dislocation causing the painful symptoms. These kinds of problems show up readily on X-rays.

But when the X-ray appears normal, the physician must decide on the next step. This could be an ultrasound, CT scan, nuclear testing, or some other imaging test. In this report, each of these options is tested and reviewed for results.

Ultrasound is noninvasive and may be done after X-rays. The images produced by the sound waves help look for effusion (swelling) within the hip. Effusion suggests a hip infection.

At this point, the physician may aspirate the fluid. A long, thin needle is inserted into the pocket of fluid and a sample is withdrawn. Lab tests of the fluid can reveal the presence of infection.

In this study, 23 cases of suspected pelvic osteomyelitis were reviewed. Osteomyelitis is a bone infection caused by bacteria. Within the first four days of symptoms, X-rays were taken of everyone. Radiographic findings this early were negative. Lab tests were also done but blood cultures were only positive for three patients.

According to the results of this study, magnetic resonance imaging (MRI) may be the next best test to order to identify osteomyelitis. Early evidence of inflammation of the soft tissues and an abnormal bone marrow signal can lead to the diagnosis.

None of the MRIs in this group of patients were normal. There was always something to suggest soft tissue inflammation and bone marrow edema. MRIs enhanced by dye showed even greater soft tissue findings. Collections of fluid called phlegmons were often described.

MRIs of this patient group were also able to show distinct anatomical patterns within the pelvic area. Sometimes it was the sacroiliac joint that was involved.

In other cases, osteomyelitis was focused in the pubic symphysis. This is the area where the pelvic bones on both sides meet in the middle at the front of the pubic area. MRI also showed patterns affecting the growth plates of the pelvic bones.

The authors conclude by saying that MRIs speed up the diagnosis of pelvic osteomyelitis in children and teenagers. Any physician who suspects this problem may want to bypass the ultrasound, CT scan, and scintigraphy and go right to an MRI. This can save time and money in the long run.

In this study, researchers show the benefits of using 3-D models of complex pelvic and spinal deformities. The models were used when planning and performing surgery. In some cases, surgery was cancelled because of the information provided by the model.

CT scans were used to construct these rapid prototype (RP) models. A virtual model was created first using computer data. Once the surgeon approved the model, the 3-D version was made. Surgeons used the model to plan the placement of screws and other implants. Rehearsing the steps was possible. Accuracy was improved.

The models were useful when showing patients and family members what would be done during the operation. The surgeon kept the model close by during the procedure. This helped him or her visualize pathways for instruments. The time needed for the surgery was less with fewer errors when RP models were available.

After using the models to perform surgery, the surgeons filled out a survey and answered the researchers’ questions. From the information gathered, it was decided that opaque models showed the inner portion of the spine better. Semi-transparent models gave a clearer view of the surface anatomy.

All surgeons using the RP model reported it was useful in planning procedures involving the spine and/or pelvis. More than two-thirds said it was highly beneficial. Future use of RP models may improve the safety of surgery as well. These models are only available in an academic setting at this time. Studies such as this one to document the benefits may result in commercially available models for use by all surgeons.

Although osteoarticular tuberculosis (TB), or TB of the bones, is no longer common in Western countries, migrant populations and people who are immunocompromised have brought about a resurgence of the disease.

Osteoarticular TB can occur in the knee – one study found of 1074 cases, 8.3 percent – or 90 cases – affected the knee. However, among those affecting the knee, only 1 involved the patella, or kneecap. Therefore, it is a rare occurrence.

In this case, a 14-year-old boy presented to the doctor with a 2-month history of pain and swelling of his left knee. After testing for TB, the doctor found by x-ray a lesion of bone deterioration on the patella. Because of the TB test results, the doctor diagnosed osteoarticular TB. The lesion on the knee was biopsied (tested) and no cancer was found. The area was surgically cleaned and the patient was given a course of anti-TB medications.

The authors of this case note that early diagnosis of osteoarticular TB, although rare, is important in order to prevent the disease from spreading beyond the initial area. Although the knee is considered to be the third most common site for TB, the patella is not.

In conclusion, the authors suggest treatment should include biopsy to rule out cancer, cleaning and debriding of the lesion, and a prompt start to medication for treatment.

Infantile idiopathic scoliosis, unlike scoliosis (curvature of the spine) that occurs in older children, self-corrects in about 80 percent to 90 percent of children. Upon discovery of the spinal curve, for the diagnosis to be IIS, it must be found before the age of three years, however the majority are diagnosed between six and 12 months, with about five percent diagnosed in infants. The cause is unknown.

Also unlike scoliosis in older children, more boys are affected (three to two) than girls. Researchers have found that the thoracic curve is more often on the left side than the right, with a second curve below the thorax.

In order to diagnose IIS, physicians must rule out other factors that could contribute to the spinal deformation. These include neuromuscular (nerves and muscles) disorders, as well as those caused by a systemic or a genetic problem.

Children with IIS are often found to have other physical disorders as well. They include plagiocephaly (deformities of the skull), which is found in between 80 percent to 100 percent of cases. There are also many children with IIS who also have mental retardation and progressive curves. The incidence of hip problems is also increased five- to 10-fold. Another common finding in children with IIS is abnormalities in the neural axis. However, the children may show no signs of any neurological problems.

In an effort to determine the causes of IIS, some researchers have proposed that the deformity may have been caused while the fetus was in utero, while others felt it was caused by positioning on the back. However, the cause is not actually known.

The first step in management of IIS is to determine if it should be treated or if it will resolve on its own. Early research suggested that if a patient has a short curve length with a curve of more than 35 degrees, were younger on onset, and had other abnormalities, they were more likely to need treatment. The location of the curve and if there was a second curve below also played a role in if the condition would resolve itself.

Newer research proposed that x-rays showing where the head of the ribs were located could help determine if the curve would straighten on its own. A researcher studied 138 cases of IIS and found that all the patients who had two specific phases of curve patterns progressed rather than resolved.

No treatment is needed if the curves resolve, but if treatment is needed, the curves could reach an angle of 100 degrees or more. This, in turn, can cause cardiac and respiratory problems, resulting in death for some children. For this group, initial treatment should begin immediately, according to the author. This treatment involves bracing, under anesthetic. Future braces are fit as the child grows. Surgical techniques have had problems over the years. Initially, surgery was not recommended for children younger than 10 years, but with the improvements in surgery – including the Harrington rod – younger children were successfully undergoing surgical correction.

The newest approach is to use a vertical expandable prosthetic titanium rib that the author says, “appears to support more normal lung and spinal growth while adequately controlling spinal deformity in infants and young children.”

Adolescence is the period between ten and 19 years of age according to the World Health Organization. While adolescence is generally considered a healthy time period from a musculoskeletal perspective, spinal pain appears to a common experience for many young people. Figures range from 4.7 percent to 74.4 percent. The authors feel that the rate of occurrance of idiopathic adolescent spinal pain is difficult to conlude from the studies that were reviewed. There is a lack of standardized ways in which spinal pain is defined, collected, and described.

Despite the difficulties in determining the frequency of spinal pain in adolescents, the authors feel there is evidence that the rate increases with age. By age 18 years, the prevalence is similar to that in adults. Four out of five longitudinal studies reviewed found that spinal pain in adolescence was a significant risk factor for having spinal pain in adulthood.

Adolescence is a time when sleep patterns can be greatly affected due to the many physiological and social changes that take place during this period. However, adolescents who experience chronic pain have more problems with insomnia and poorer quality sleep than those without pain, say researchers of a recent study.

The authors of this study built on previous research and examined sleep issues among adolescents who have chronic pain. The authors hypothesized that this target group had reduced total sleep time, increased depressive symptoms, and higher levels of presleep arousal and worry.

Forty subjects, aged 12 to 17 years, participated in the study, 20 were controls who did not have any pain issues. The subjects’ parents completed demographic information forms and the researchers obtained through records, the patients’ histories regarding diagnosis, pain, and pain management. The subjects completed several questionnaires. Sleep quality was assessed by The Adolescent Sleep Wake Scale (ASWS) that scored sleep quality from 1 to 6, with “1” for always and “6” for never. This questionnaire assessed going to bed, falling asleep, staying asleep, going back to sleep, and waking. Sleep hygiene (routines before sleeping and the environment) was assessed by the Adolescent Sleep Hygiene Scale (ASHS). This questionnaire reviewed different sleeping habits, ranging from eating and drinking before bed or physical activities to the amount of light in the bedroom during the sleep period.

Using the Visual Analog Scale (VAS), the subjects rated their pain; “0” meant no pain and “10” was for the worst pain possible. Using the Likert scale, the subjects rated how often they experienced pain. Subjects also completed questionnaires before the study about the quality, location, frequency, and intensity of the pain. Worry and arousal at bedtime was assessed with the Pre-Sleep Arousal Scale (PAS), which uses a scale of 1 to 5, with “1” being for “not at all” and “5” being for “extremely.” Finally depressive symptoms were assessed with the major depressive disorder subscale of the Revised Child Anxiety and Depression Scale (RCADS). This scale rated from 1 to 4 the frequency of depressive symptoms.

Actual sleep and wakefulness were measured with a wrist-watch-like instrument called the Actiwatch-AW64 system (MiniMitter, Bend OR). This device is worn for 7 consecutive days to detect sleep patterns. A sleep log was also kept by the study subjects.

When analyzing the study findings, the researchers found that 70 percent of the subjects in the pain group reported daily pain in the moderate to severe range. To relieve the pain from chronic headache (40 percent), abdominal pain (10 percent), pain elsewhere in the body (40 percent), or complex regional pain syndrome (10 percent), the patients used either over-the-counter or prescription medications. There did not appear to be any significant differences in subjective sleep quality, sleep hygiene, sleep time, sleep efficiency, wake time, or wake bouts between subjects who took prescription medications and those who did not.

Subjects in the pain group had lower sleep efficacy than the control group. Both groups spent the same amount of time in bed, but those with pain woke up more frequently. Estimated sleep time and wake after sleep onset seemed to be the same between the two groups. When asked about sleep quality, those with chronic pain ranked their sleep quality significantly lower than their control peer. Bouts of insomnia were reported more often in the pain group. Sleep hygiene was found to be similar between the groups. The association between pain, depressive symptoms, presleep arousal and worry, and sleep variables showed a moderate association between more intense pain and more wake times. Those with pain had greater scores in presleep worry and depression.

The authors point out that their study has some limitations, including the small sample size and the fact that the adolescents were receiving treatment for their pain. Nonetheless, the authors say their findings that over half of adolescents who experience chronic pain also report insomnia, compared with only 10 percent of adolescents without chronic pain, indicates that there are clinical implications for the assessment and management of sleep issues among this patient group.

The question of school furniture has often come up when looking for ways to prevent or reduce low back pain (LBP) in school-aged children. Children between the ages of 14 and 17 years old come in a wide range of sizes and shapes. One size desk may not be best for everyone.

Is an adjustable desk needed? Would it be better to have a seat that is inclined forward more? Or perhaps a more slanting surface of the desk would be better? In this study, LBP in this age group was compared to the dimensions of school furniture. Weight and size of the children and weight of backpacks were also measured.

The results of this study showed no link between school furniture and LBP. Children with LBP were more likely to adjust their desks and chairs or ask for adjustable furniture. The use of adjustable school furniture was a result rather than a cause of LBP.

Height and/or weight was not linked with LBP. A more significant factor was the use of backpacks. The weight of the backpack was not an issue. The method of carrying heavy school bags was the real problem. Children were more likely to have LBP if they carried the backpack or school bag in one hand or over one shoulder.

The authors suggest more study is needed to understand the biomechanics of backpacks and LBP. Uneven loading on the spine from one-sided carrying of the packs may be the cause of LBP but his has not been proven.

It does not appear that furniture design is a major factor in LBP among this age group. Until further research can be completed, it is not advised to spend time and money developing school furniture that can prevent LBP in school-aged children.