Are ulterior motives at the heart of a recent study in the journal Pediatrics?1 The study showed that acute backpack-related injuries are usually not related to the back, but to tripping over packs and swinging them as weapons.
Prompted by the growing concern that backpacks worn by children may be damaging their backs and causing chronic low back pain, the study identified the primary mechanisms and areas of injury related to book backpacks in schoolchildren - based on visits to the emergency room. Wiersema, et al. analyzed 247 children ages 6-18 with backpack injuries in 100 ERs in the U.S. that participate in the National Electronic Injury Surveillance System (NEISS) of the Consumer Product Safety Commission.
The study found that 89% of the backpack injuries in the ER setting did not involve the back. The head/face was the most likely site for injury (22%); in fact, injuries to the hand (14%), elbow/wrist (13%), shoulder (12%) and foot/ankle (12%) were all more likely than backpack-related injuries to the back (11%). Also, tripping over a backpack was the most likely mechanism of injury (28% of injuries), followed by injury while wearing or getting hit with a backpack being used as a weapon.
The authors recommend, "Backpack injury prevention strategies should include the important mechanisms of being hit by a backpack and tripping over a backpack." They also suggest that children "... put their backpacks in a safe place so they do not trip over them, and not to use them as a weapon to hit another person...."
Do we need a study to reach this conclusion? Kids can be rough; sometimes they trip and fall over their backpacks, and sometimes they even use them as weapons to duel with their classmates. But should that be the focus of preventing childhood injuries from backpacks?
And what about back pain that's not reported to ERs? A study that appeared in Spine in January 2002 evaluated whether children's perceptions of backpack weight or actual backpack weights were related to back pain. The study, involving 11-year-old schoolchildren in Milan, Italy, showed that backpack-related activities led to low back pain in almost half of the students; four out of five felt their backpacks were heavy; and two-thirds responded that they felt fatigue when carrying their backpacks.2
Another study of Danish children and adolescents (Spine, 2001) put the one-month occurrence of back pain at 39%. Among back pain sufferers in that study, 38% reported consequences, such as visiting a physician, refraining from physical activities, or staying home from school.3 A more recent study in the British Medical Journal showed that chronic back and neck pain may be increasing in adolescents. Based on this Finnish study, between 1985 and 1997, back and neck pain doubled in girls and increased one-and-a-half times in boys, ages 14-18.4 Isn't this the type of pediatric pain that should be researched?
According to the authors of the Pediatrics study, the Web site for the American Academy of Orthopaedic Surgeons provides a fact sheet with tips for parents to help their kids avoid back problems from backpacks, such as "use hip straps for heavier weights and use both of the backpack straps." Yet the authors state, "Following these recommendations would only eliminate 11% of backpack injuries requiring emergency department visits." This is probably true for ER visits. But how many chronic-LBP cases might these tips prevent?
Yes, 11% of children reporting to emergency rooms due to back pain from backpacks is a fairly significant number - but it is just the tip of the iceberg. Imagine all the kids who may have back pain from packs, but whose parents don't deem it severe enough to go to an emergency room.
Consider these results from a different angle: Some people probably report to the ER due to events such as "acute computer injury," i.e., from being struck by a keyboard wielded by an angry colleague or after tripping over the power cord. But of most concern are the chronic, long-term problems due to computer use, including poor posture and carpal tunnel syndrome. For this reason, studies focus on these disorders - and not on acute injuries that simply happen to involve computers.
The authors of the Pediatrics study claim their results suggest "... the actual use of a backpack is not exceptionally dangerous, and efforts should be directed toward educating children on proper backpack safety habits rather than restricting loads and redesigning backpacks." This statement hints at a fundamental difference in perspective between a doctor of chiropractic and a doctor of medicine. The MD is worried most about severe injuries that put children into the emergency room; the chiropractor is focused on the health of the child outside the emergency room.
At best, this study explains the gap between the low number of backpack injuries reported in pediatric orthopedic offices and the higher number reported by chiropractors. At worst, it is an attempt to divert attention away from back pain that is experienced by most children, and suggests that emergency room visits should be the measure of our children's spinal health. Needless to say, this would eliminate the need for chiropractic to address the millions of cases of back pain experienced by our children each month.
Even the authors of the study admit in their conclusion, "This study would miss... most chronic injuries that would be diagnosed and treated elsewhere...."
References
Ryan Lockwood, associate editor
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