Adolescent Health Care: A Practical Guide
Back Pain in the Adolescent
Jordan D. Metzl
Lawrence S. Neinstein
Back pain (in particular, lower back pain) is one of the most common complaints among adult patients and the most common cause of disability in individuals younger than 45 years. Back pain is less common in prepubertal and young adolescent patients; middle, older adolescents and college students more frequently experience back pain. The etiology of adolescent back pain varies although muscular conditions, and bone-related and discogenic problems make up most causes.
The prevalence of back pain increases with age, with the lowest prevalence in children and adolescents. However, back pain, particularly lower back pain, can be relatively common in older adolescents. This has been well demonstrated in numerous studies:
- Balague et al. (1988): Back pain affected 27% of Swiss school students.
- Fairbanks et al. (1984): Back pain affected 26% of English school students.
- Burton et al. (1996): Followed up a class of English school children for 4 years. The annual incidence of low back pain rose from 11.8% at age 12 to 21.5% at 15. Lifetime prevalence was 11.6% at age 11, increasing to 50.4% at age 15. By age 15, 59% of the students described their pain as recurrent. Only 15.6% of patients who experienced back pain during the study sought treatment.
- Olsen et al. (1992): Back pain was experienced by 30.4% of 1,242 American adolescents aged 11 to 17. Of those with back pain, one third had a history of having to restrict their activity, and 7.3% sought medical attention for back pain.
- College students: In the 2006 National College Health Assessment, 47% listed back pain as a problem in the previous year (American College Health Association, 2006).
It must be noted, however, that back pain may be more common than estimated in these samples, particularly among pediatric and adolescent athletes. This especially includes young gymnasts, ballet dancers, and figure skaters.
The etiology of back pain varies with age. The younger the individual, the more likely that back pain is not related to simple musculoskeletal strain. Back pain can be divided into the following categories:
- Mechanical disorders
- Overuse syndromes (including muscle strain)
- Herniated nucleus pulposus
- Slipped vertebral apophysis
- Postural disorders
- Vertebral compression fractures
- Spondylolysis and spondylolisthesis (acquired)
- Developmental disorders
- Spondylolysis and spondylolisthesis (developmental)
- Scheuermann disease
- Inflammation and infections
- Discitis and vertebral osteomyelitis
- Disc calcification
- Rheumatological conditions including ankylosing spondylitis and reactive spondyloarthropathies such as Reiter syndrome
- Sickle cell disease and sickle cell pain crisis
- Epidural abscess
- Neoplastic processes
- Vertebral column or spinal canal
- Psychogenic causes
Alternatively, one can also divide back pain in adolescents into those that are muscular in etiology, bone-related, or discogenic.
In most individuals with acute back pain, the cause is never precisely known but the course is usually benign and self-limited. Nevertheless, a thorough history and physical examination are basic requisites and the history is a key part of the diagnosis. Table 17.1 differentiates muscular, bone-related, and discogenic causes using clues from the history, physical examination, and radiological tests.
- History: Key components of the history include the mechanism of injury (if any) and types of movement and activities associated with pain. In addition, ask about prior injuries or periods of back pain, the site of pain, and any pain radiation locations.
- General history
- History of trauma and mechanism of any injury.
- Characteristics of the pain, including location (lumbar, upper/lower thoracic, midline, paraspinal), severity, type, onset and duration, prior treatment and limitations, and exacerbating and alleviating maneuvers.
- Severe pain: Severe back pain in an adolescent is more likely associated with a pathological condition than a muscular strain and should be evaluated more carefully. Writhing pain suggests a possible intraabdominal condition. Unrelenting pain suggests tumor or an infectious process.
- Prior injuries or history of prior back pain.
- Exercise, athletic, and work history.
- History of being awoken at night due to the pain.
- Systemic symptoms: Bowel or bladder problems, abdominal pain, fever, weight loss, malaise, iritis, urethritis, arthritis.
- Symptoms unrelated to the back, which are suggestive of systemic infection, neoplasm, or a collagen vascular disease.
- Family history of rheumatological disease including back stiffness or spondylarthropathy.
- Neurological symptoms, including bladder or bowel changes.
- History for specific conditions
- Tumors: Back pain occurring at rest, especially at night, is a common feature of vertebral involvement with a neoplastic process. Constant back pain, associated neurological deficits, and rigidity of the spine on attempted movement may be associated with tumor or infection. Other suggestive historical information includes prior history of a malignant tumor and unexplained weight loss.
- Spondylolysis and spondylolisthesis: Back pain may radiate to buttocks or thighs. There may be a history of hyperextension activities of the spine, such as gymnastics or ballet. It is important to note that spondylolysis can be either developmental, or, can also be acquired, as is the case with spondylolysis acquired through repetitive and extension maneuvers.
- Infection: Discitis and osteomyelitis of a vertebra can lead to significant back pain. Malaise and severe stiffness are common complaints.
- Spondyloarthropathy: Back pain from spondyloarthropathies is associated with insidious onset, worsening of symptoms in the morning and with rest, decrease in symptoms with activity, onset before 30 years of age, and pain that persists longer than 3 months.
- Scoliosis: Back pain is not usually a feature of scoliosis and should suggest the possible presence of another disorder.
- Physical examination: This should include observation of gait and posture followed by testing of motion, strength, and neurosensory testing. The back should also be checked in the standing, sitting, and supine positions.
- Gait: Begin examination by asking the patient to walk across the room. See if gait is normal or if there is a tilt to one side.
- Standing position
- Asymmetry: Check for pelvic or leg length discrepancies. Assessment of scapular and hip height while standing is easily done when observing the patient from behind.
- Curvatures: Check for kyphosis or scoliosis and perform forward-bending examination.
- Inspect the spine from behind the patient and from the side.
- Percuss and palpate spine for local tenderness.
- Palpate the iliac crest, specifically cartilaginous apophysis or growth plates.
- Range of motion:
- Forward bending: Most adolescents should be able to bend forward to within 15 cm of their toes regardless of the problem. Individuals with paraspinal muscle spasm tend to arch their lumbar area while bending the spine at the hips.
- Backward bending: Also ask the patient to bend backward as pain on backward bending may suggest spondylolysis or a stress fracture.
- Twist back to left and right with hands on hips: Pain with twisting is consistent with muscle spasm or muscle pain.
- Midline defects: Midline defects including dimpling, hypertrichosis, hemangiomatosis, cutaneous nevi, and soft tissue masses may be related to an underlying spinal abnormality such as spina bifida, lipoma, or diastematomyelia.
- Sitting position
- Test knee and ankle reflexes and Babinski sign.
- Test muscle strength of lower extremities and reflexes. Specific signs include
- L5 disk herniation: weakness of hallucis longus muscle. Test by asking patient to extend the great tow upward against your resistance.
- L4 weakness: detected by inversion of the foot. Test by asking patient to evert the foot against resistance. L4 nerve root involvement can by assessed by dorsal and plantar flexion of the foot.
- Disk herniation between L3 and L4 would give diminished patellar refle Diminished Achilles reflex would indicate a possible disk herniation at L5 level.
- Perform distraction leg-raising test: Ask the patient to straighten his or her leg while seated. Patients with a disc problem arch backward in tripod position to take pressure off the sciatic nerve. Results of this test should correlate with results of straight leg raising in supine position.
- Supine position
- Measure leg length from anterosuperior iliac spine to medial malleolus. A difference in leg length of >2.5 cm should be evaluated.
- Check for muscle atrophy by measuring the girth of each leg at fixed measured distances above and below the patella.
- Perform a sensory examination. Remember to check for “saddle anesthesia,” which is indicative of a cauda equina syndrome.
- Straight leg-raising test: The patient should lie on his or her back. The tested leg is fully extended
while the opposite leg is flexed at the hip and knee with the sole of that foot resting on the table. Pain radiating down the back of the leg when the tested leg is lifted is a positive result. Pain occurring when the angle between the back of the thigh and the table is <60 degrees is an equivocal result. Pain when this angle is >60 degrees may also be caused by muscular irritability. To exclude this, the examiner can also lift the leg to the point of pain and then lower the leg 5 degrees and dorsiflex the foot. This stretches the sciatic nerve; pain indicates nerve impingement and is considered to be a positive result. If pain occurs in the opposite leg while lifting the tested leg, a positive crossed straight leg-raising sign is present. This has been highly correlated with a herniated disc.
- Femoral stretch test: With the teen facing prone and the knees straight, lift one leg backward, extending the hip but keeping the knee straight. This test stretches the femoral nerve, and pain radiating into the anterior thigh indicates L2, L3, and L4 nerve root irritation.
- In patients with chronic back pain, a rectal examination may be indicated to look for decreased sphincter tone, which suggests pressure on nerve roots from a tumor or herniated disc. In addition, the circumferences of the upper and lower legs should be measured to look for muscle atrophy.
- Other red flags on examination include fever, other systemic signs, major motor weakness in lower extremities, focal vertebral tenderness, very limited spinal range of motion, and neurological findings persisting beyond 1 month.
- Physical examination for specific conditions
- Tumors: Neurological deficits may be present, including weakness or bowel and bladder dysfunction.
- Spondylolysis and spondylolisthesis: The teen may have hyperlordosis. Stiffness and limited straight leg raising due to hamstring spasm or tautness may be present. Localized tenderness may occur at L5 to S1. Neurological deficits may be present if significant slippage has occurred.
- Infections: Tenderness may be well localized over affected vertebrae.
- Herniated disc: Pain commonly radiates down the leg. In more advanced cases, a herniated disc is associated with muscle weakness, atrophy, and decrease in sensation and reflexes.
- Functional pain: Tests for nonorganic causes are as follows:
- Press the patient's head with gentle downward pressure. If the patient collapses or complains of severe pain, the problem may be functional.
- Gently palpate the paraspinous muscles. Complaints of severe pain or falling to the floor may be indicative of a nonorganic problem.
- Hold the teen's wrists next to his or her hips, and turn the teen's body from side to side. Because this maneuver does not cause stress on the muscles or nerve roots, it should not cause any significant pain.
- Burns test: Have the teen kneel on a regular chair and touch the floor with his or her fingertips. If teen cannot reach within 15 cm of floor, the test result is considered positive and possibly indicative of a nonorganic cause.
- Imaging studies: A radiological examination should be performed for an adolescent with chronic back pain (>3 months). Other indications for radiological examination include a history of serious trauma; known history of neoplasia; pain at rest; unexplained weight loss; drug or alcohol abuse; point tenderness; treatment with corticosteroids; temperature >38°C; and clinical manifestations that are consistent with the diagnosis of scoliosis, kyphosis, spondylolisthesis, or ankylosing spondylitis or that demonstrate a neuromotor deficit. In the absence of history or physical findings suggestive of serious disease, spine films have a low diagnostic yield. Lumbar spine radiographs are estimated to be the largest source of gonadal irradiation in the United States. When obtaining radiographs of the lumbar spine, the correct views include anteroposterior (AP), lateral, and oblique views. Consider magnetic resonance imaging (MRI) if there is suspicion of a fracture, if spondylolysis is suspected but not clear on x-ray, or if there are clinical signs suggestive of significant discogenic disease.
Diagnosis and Management of Specific Conditions
Most back pain in adolescents and young adults falls into three general categories: muscular, bone-related, and discogenic (Table 17.1).
Muscular Back Pain
More than 30% of back pain in adolescents, and probably more in older adolescent and young adults, is muscular in origin. The physician must be especially careful to rule out other pathology in the child and young adolescent. In selected cases, the evaluation may require additional imaging studies and/or laboratory tests. Keys to the diagnosis include:
- History of overuse injury, such as heavy backpack
- Paraspinous, not midline pain
- More pain on spinal rotation than with bending forward or backward
- Radicular symptoms are absent
- Sports-related muscular injury: Muscular back pain is often the result of a sports-related injury. When assessing the adolescent patient with a presumed muscular injury, both the diagnosis and causative factors must be addressed. This means that history and physical examination are important both to help assess cause of pain, and once a diagnosis is established, to create a treatment plan which is specific to the adolescent athlete. This might include the use of a sports-minded physical therapist to address issues such as lack of strength and flexibility, which can predispose athletes to specific injury patterns. In addition, the specific maneuvers that an athlete is performing might also cause back pain. These might include improper form or excessive repetition of a particular movement such as a back bend in gymnastics or a porte-a-bras to the back in ballet.
- Backpacks: Another possible cause of muscular back pain is the use of backpacks. In a survey of more than 100 orthopedic surgeons conducted by the American
Academy of Orthopaedic Surgeons, 58% of the respondents reported seeing patients who complained of back and shoulder pain caused by heavy backpacks. Although serious problems due to backpacks are now recognized to be rare, these patients should be encouraged to balance the load over both shoulders, avoid excessive weight, or to use a rolling pack if the backpack continues to cause symptoms.
- Treatment: Most acute back pain, especially those associated with muscular strain, resolve in a relatively short period: 70% within 1 week, 80% by 2 weeks, and 90% by 2 months. For back pain secondary to muscular strain, the treatment includes back exercise, weight reduction, nonsteroidal anti-inflammatory medications, and sometimes a change in activities. Steroids and muscle relaxants are generally not indicated. For acute strain, cryotherapy using ice in a towel or a wet towel that has been kept in the freezer is helpful. It can be applied for 15 to 20 minutes, four times a day, for at least the first 3 days. After that time, cold can be replaced with heat (e.g., heating pad, moist hot towel). Further information can be found in the Tables 17.2 and 17.3 and at the Web sites listed at the end of this chapter. Some adolescents may benefit from referral to a physical therapist for cryotherapy, ultrasound, or electrical stimulation. Usually, the pain will resolve within 4 to 6 weeks.
Bone-Related Back Pain
Bone-related back pain may account for 25% to 50% of back pain in adolescents but is especially common in those who are involved in athletics. This is generally related to overuse syndromes in athletes who perform repetitive extension maneuvers, such as gymnasts, figure skaters, ballerinas, or volleyball players. The common presentation is lumbar pain with extension.
Keys to diagnosis of bone-related pain include:
- Pain on bending backward should be considered bone related until proved otherwise.
- Back pain that awakens the teen from sleep and worsens with sleep and not activity is suspicious for bone neoplasm, most commonly benign osteoid osteoma.
Spondylolysis and Spondylolisthesis
In overuse or repetitive stress injury, bone-related pain is related to edema in the bone and is a sign that could progress to an overt stress fracture—spondylolysis, a crack in the pars interarticularis. In one study of young athletes who presented to a sports medicine clinic with back pain, 50% had spondylolysis (Micheli and Wood, 1995). It should be noted that most individuals though are asymptomatic. In a study of 145 Indiana University football players screened for spondylolysis, 47% with spondylolysis were asymptomatic when they started college and 40% were still pain free at graduation (McCarroll et al., 1986).
- Etiology: Spondylolysis is a defect of the pars interarticularis, a posterior element of the spine. Spondylolysis can be either acquired or developmental. Spondylolisthesis is the forward slippage of one vertebra on another, almost always L5 on S1. These two conditions often occur together, and they represent the most common cause of chronic low-back pain in the adolescent. Adolescents who participate in athletic endeavors involving large extension forces across the low back are at high risk. These include gymnasts, ballet dancers, wrestlers, and down linemen.
- Clinical symptoms: Pain localizes in the low back, sometimes radiating into the buttocks. Pain is aggravated with sporting activities or heavy lifting. Hamstring tightness is a hallmark of both of these conditions. A noticeable lordosis may be seen with significant spondylolisthesis.
- Diagnosis: On physical examination, pain with extension is the hallmark feature of the examination (pain bending backwards). Pain may be present when bending backwards, or patients may have a positive “stork sign” (pain bending backwards while standing supported on one foot). Point tenderness is often present. The radiological diagnosis of spondylolisthesis is simple. Standing lateral films, especially the “spot lateral” film, centered on the L5-S1 junction, demonstrates the slip.
Diagnosis of spondylolysis is more difficult. Occasionally it can be seen on lateral films, but more commonly it is demonstrated on oblique films that bring out the profile of the pars interarticularis. A bone scan with single-photon emission computed tomography (SPECT) imaging is the most sensitive study for spondylolysis. It demonstrates the early stages of a stress fracture, before the pars interarticularis actually breaks. Increasingly, MRI is being used to evaluate for the presence of spondylolysis.
- Treatment: Treatment of spondylolysis in the adolescent is largely nonoperative. Modification of activities, especially avoiding hyperextension, along with nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, and possibly a lumbosacral orthosis have a high rate of success. Patients who fail nonoperative therapy can have an in situfusion or repair of the pars defect. A 2005 study clearly demonstrated the importance of activity limitation in determining good outcomes in spondylolysis. Patients should be warned that symptom resolution may take 2 to 3 months of activity limitation.
Treatment of spondylolisthesis depends on the percentage of the slip. Meyerding's 5-category classification system is often used to measure the degree of slippage. Meyerding's grade I is a 1% to 25% slip and grade II is a 26% to 50% slip. Slips of 50% or more are considered high grade and include grade III of 51% to 75% slip, grade IV of 76% to 100% slip, and grade V spondyloptosis is a slip >100% (Meyerding, 1947). Those patients with >50% slippage require fusion. If the slip percentage is >50%, treatment can be nonoperative with close monitoring to see whether the slip progresses. Seitsalo et al. (1991) demonstrated that 90% of slip progression had occurred in their patients by the time of the first radiographic study. If pain is refractory to nonoperative measures or progressive slippage is demonstrated, in situfusion has a high success rate.
Slipped Vertebral Apophysis (Apophyseal Ring Fracture)
This injury is unique to the pediatric population. It is a fracture through the junction of the bony vertebral body and its cartilaginous endplate (apophysis). The apophysis herniates into the canal along with fragments of disc. It is usually seen in adolescent boys who are involved in sports or heavy lifting. Symptoms are acute onset of back pain, often with sciatica. Plain films may show a bony fragment in the canal. In this case, a computed tomographic scan, rather than MRI, shows the pathology better, because it shows cortical bone more clearly. Treatment parallels that for a herniated disc. Nonoperative therapy may bring resolution of symptoms. Neurological compromise or failure of nonoperative therapy is an indication for operative decompression.
Bone tumors Thankfully, most spinal neoplasms in the adolescent are benign. Osteoid osteoma and osteoblastoma are the most common bone tumors in the pediatric population. Patients may present with back pain that is dramatically improved with NSAIDs. Pain may occur at the same time every day. The neurological examination finding is usually normal. During painful episodes the patient may demonstrate a stiff spine. Because of their small size, osteoid osteomas may be difficult to see on plain films. They show intense uptake on bone scans, and computed tomographic scanning helps delineate the exact location of the tumor. The patient may be treated with long-term NSAID use, because these tumors usually resolve spontaneously after skeletal maturity is reached. However, this may mean years of NSAID use, and the family may be unwilling to follow that course. The tumor can be successfully treated with surgical excision, but that may be difficult depending on its location.
Acute leukemia Back pain may be the presenting symptom of acute leukemia which sometimes may cause vertebral collapse. Approximately 90% of leukemic patients who present with vertebral collapse have an abnormal peripheral smear. Early leukemic infiltration of the vertebral body causes osteopenia before collapse.
Treatment of leukemia is with chemotherapy; a thoracolumbosacral orthosis (TLSO) helps prevent further deformity of the spine.
Spinal cord tumor Spinal cord tumors are most common in the first decade of life. Pain is usually severe and unrelenting. Constant back pain, pain that awakens the teen at night, painful scoliosis, and neurological findings are all warning signs for spinal cord tumors. As many as 90% of patients with spinal cord tumors demonstrate rigidity of the spine. MRI is the imaging modality of choice when a spinal cord tumor is suspected. Astrocytomas and ependymomas are the most common spinal cord tumors.
Discogenic (Nerve-Related) Back Pain
While discogenic back pain is fairly common in adults, it accounts for 10% or less of back pain in adolescents. This pain is related to herniation of an intervertebral disk and subsequent impingement on a central or peripheral nerve. Findings suggestive of discogenic pain include the following:
- Lumbar spine pain that worsens with bending forward
- May be accompanied by pain radiating into the hip or thigh
- Pain that tends to wax and wane
- Positive straight leg-raising test result
- Decrease in patellar or Achilles reflex
Herniated Nucleus Pulposus
Disc herniation in an adolescent is most likely to result from an acute event. Acute onset of back pain, especially with pain radiating into the legs, raises the possibility of a disc herniation. However, discogenic pain may be chronic and have a tendency to wax and wane. An AP and lateral view of the lumbar spine may be helpful in finding an underlying bone cause of discogenic pain; however, MRI is the study of choice for the diagnosis of a herniated disc. Nonoperative treatment is often successful and includes activity restriction (but bed rest is not recommended), NSAIDs, and physical therapy. Epidural steroid injections may also be of value. Disc excision is reserved for those patients with persistent neurological deficit or in whom nonoperative therapy to produce pain relief has failed.
Scheuermann kyphosis (see Chapter 15) is a rigid kyphosis of the thoracic spine. Patients often present with pain at the apex of their deformity. The cause remains undetermined. It is most often seen in adolescent males who are involved in heavy lifting. Physical examination reveals a sharp, rigid kyphosis that is best seen from the side when the patient is in the forward bend position. Diagnosis is made on standing lateral films of the entire spine. Radiographs reveal irregularities of the endplates, wedging of the vertebrae, and Schmorl nodes (invagination of disc material into the vertebral body).
Treatment depends on the degree of kyphosis, the amount of growth remaining, and the amount of pain. Physical therapy is often helpful in improving symptoms. Brace treatment can produce some correction of the kyphosis, but only in the skeletally immature patients. For severe kyphosis or intractable pain, spinal fusion with instrumentation may be required.
Atypical or lumbar Scheuermann disease is a painful condition of the lumbar spine. Unlike classic Scheuermann disease, there is no kyphosis, but radiographs show irregularities of the lumbar spine endplates. Treatment is almost always nonoperative. Physical therapy, NSAIDs, and occasional use of an orthosis usually give relief from symptoms.
Discitis and Vertebral Osteomyelitis
Once thought to be separate entities, these two conditions are probably part of the same disease spectrum. Patients present with back pain, malaise, and fever. The physical examination is remarkable for localized tenderness and spine rigidity.
Plain radiographs may reveal disc space narrowing and irregularities of the vertebral body. Laboratory work in a suspected infection should include a complete blood count (CBC)with differential (often normal), erythrocyte sedimentation rate (usually elevated), and blood culture (which reveals an organism in only 41% of cases). In the early stages of infection, plain films may be normal. Technetium bone scanning shows increased uptake in the endplates. However, MRI has the benefit of establishing not only the presence of infection but also the amount of vertebral involvement and the possible presence of an epidural abscess.
Treatment of these conditions is somewhat controversial. Because most of these infections are caused by Staphylococcus aureus, the need for vertebral or disc aspiration is unclear. Most patients respond to bed rest and intravenous antibiotics and are then switched to oral antibiotics and mobilization with a TLSO. There is a body of literature that has shown successful treatment of discitis with immobilization without antibiotics. The recurrence rate appears to be higher when antibiotics are not used. Decompression of these infections is usually not needed unless there is neurological compromise or a failure to respond to nonoperative management. The possibility of tuberculosis infection should not be overlooked.
Rheumatologic diseases should certainly be considered when the history is unclear, there is no trauma, and systemic symptoms such as fever or fatigue are present. If the history is consistent with a spondyloarthropathy or other arthritic conditions, CBC, sedimentation rate, and human leukocyte antigen (HLA)-B27 tests should be considered.
This is an important cause of back pain; however, its consideration should not preclude an appropriate investigation for other potential diagnoses. Further evaluation may be required in some teens, including plain films, bone scan, MRI, and laboratory evaluation. However, not all patients need all of these tests, particularly if the history and examination are consistent with psychogenic pain and the mental health history is consistent with the diagnosis. The possibility of back pain referred from other anatomical locations (e.g., pyelonephritis, endometritis) must not be overlooked. When symptoms exceed physical findings, clinical suspicion should be raised. These patients need help, and they will benefit from being referred to appropriate health care providers.
For Teenagers and Parents
http://www.ninds.nih.gov/health_and_medical/disorders/backpain_doc.htm. National Institutes of Health site on back pain.
http://familydoctor.org/flowcharts/531.html. Patient care flow chart on diagnosis from American Academy of Family Physicians.
http://www.physsportsmed.com/issues/1997/08aug/shiplepa.htm. Exercise photos from Physician and Sports medicine.
http://www.physsportsmed.com/issues/1997/01jan/back_pa.htm. Posture recommendations from Physician and Sports medicine.
http://orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=17&topcategory=Spine&searentry=minimize%20 problems. Exercises from American Academy of Orthopaedic Surgeons.
http://orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=105&topcategory=Spine. Information on backpacks and back pain in children from the American Academy of Orthopaedic Surgeons.
http://www.spine-health.com. Site for information on spine health.
References and Additional Readings
American College Health Association. it American College Health Association—National College Health Assessment (ACHA-NCHA) Web Summary. Accessed April 2007 at: http://www.acha-ncha.org/docs/acha-ncha_Reference_Group_Report_Spring2006.pdf.
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Editors: Neinstein, Lawrence S.