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Medicine & Science in Sports & Exercise:
doi: 10.1249/MSS.0b013e31818047a2
BASIC SCIENCES: Epidemiology

Musculoskeletal Pains in Relation to Different Sport and Exercise Activities in Youth

AUVINEN, JUHA P.1,2; TAMMELIN, TUIJA H.1; TAIMELA, SIMO P.3; ZITTING, PAAVO J.2,4; MUTANEN, PERTTI O. A.1; KARPPINEN, JARO I.1,2

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Author Information

1Finnish Institute of Occupational Health, Oulu and Helsinki, FINLAND; 2Institute of Clinical Medicine, University of Oulu, FINLAND; 3Department of Public Health, University of Helsinki, FINLAND; and 4Institute of Health Sciences, University of Oulu, FINLAND

Address for correspondence: Tuija H. Tammelin, Ph.D., Finnish Institute of Occupational Health, Aapistie 1, 90220 Oulu, Finland; E-mail: tuija.tammelin@ttl.fi.

Submitted for publication May 2007.

Accepted for publication May 2008.

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Abstract

Purpose: We examined the associations between participation in different sports and exercise activities and neck, shoulder, and low back pains in adolescents.

Methods: This population-based study included the members of the Northern Finland Birth Cohort 1986, who, at the age of 15 to 16 yr, completed a questionnaire including items about their musculoskeletal pains and participation in various sport and exercise activities (N = 6945). Logistic regression analysis was used to evaluate how musculoskeletal pains are associated a) with participation in a certain type of sport or exercise activity and b) with the clusters formed by latent class analysis (LCA) according to the adolescents' profiles of participation in different sport and exercise activities.

Results: Participation in certain sports showed some direct and inverse associations with musculoskeletal pains when adjusted for participation in other sports and for the amount of physical activity. However, after grouping the individuals into clusters by their participation in different sports, these associations vanished. Only the cluster characterized by boys' active participation in several sports (i.e., ice hockey, cycling, ice-skating, soccer, floorball, rinkball/bandy, swimming, roller-skating/skateboarding, Finnish baseball) had lower prevalence of neck pain compared with the physically inactive group.

Conclusions: Physically active adolescents usually engage in several different sport and exercise activities, which make associations between single sports and musculoskeletal pains inconsequential in the general population of adolescents. Participation in several sports seemed to protect from harmful effects of a single risk sport. However, this finding cannot be generalized to adolescent elite athletes who are often involved in intense training for a single sport.

Competitive sports training and high overall level of physical activity are considered as risk factors for neck, shoulder, and low back pains in adolescence (3,4,9,10,12,13,17,27,28). Some sports that cause a high level of loading for specific anatomic structures of neck, shoulder, and low back, such as gymnastics, javelin, and wrestling, may even cause structural spinal damage such as spondylolysis and spondylolisthesis (7,8,9,23). Sport and exercise activities that can potentially damage the growing musculoskeletal system due to excessive loading should be recognized to prevent musculoskeletal disorders among physically active adolescents. Furthermore, potentially beneficial forms of exercise that strengthen the musculoskeletal system without loading it excessively should also be identified.

Only a few population-based studies have assessed the association between participation in different sports and neck, shoulder, and back pains in adolescents (3,4,6,15,18,22,25,26). In most studies, the physical activity exposures have not been standardized, and the study populations have mostly been selected groups of athletes rather than representing the general population. Therefore, little is known about the relationships between participation in different sport and exercise activities and musculoskeletal pain. Furthermore, the patterns of involvement in different sport and exercise activities have changed among adolescents over past decades: recent Finnish surveys indicate that some new sports have gained popularity, and a trend toward participation in several sports instead of just one or two has been observed (11).

We conducted a cross-sectional study in a large general population of adolescents to evaluate the relationships between participation in different sport and exercise activities and neck, shoulder, and low back pains. The hypothesis was that some sport and exercise activities are associated with a high prevalence of musculoskeletal pains, potentially due to excessive loading (e.g., gymnastics and combat sports) to the musculoskeletal system, whereas some other sport and exercise activities may even prevent musculoskeletal symptoms, without loading the musculoskeletal system too much (endurance sports). We did not have a priori hypothesis concerning the clustering of different types of sport and exercise activities among adolescents and no expectations concerning the prevalence of musculoskeletal pains in the clusters.

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METHODS

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Study population.

This cross-sectional study was conducted in the Northern Finland Birth Cohort 1986 (NFBC 1986), which includes children born in the two northernmost provinces of Finland between July 1, 1985, and June 30, 1986 (N = 9479). In 2000-2001, at the age of 15 to 16 yr, a postal inquiry was sent to all living members of the cohort whose addresses were known (response rate 75%, N = 6945). The questionnaire included items about their health, including musculoskeletal pain; health habits such as physical activity, sedentary behavior, and smoking; weight, and height. The study followed the principles of the Declaration of Helsinki. The participants took part on a voluntary basis. They and their parents signed the informed consent. The data were handled on a group level only, withthe personal information being replaced by ID codes. The ethics committee of the University Hospital of Oulu approved the study plan.

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Musculoskeletal pains.

Pain in each anatomic location was asked about as follows: "Have you had any pain or aching in your a) neck/occipital, b) shoulder, or c) low back area within the past 6 months?" The anatomic locations were illustrated. The answer options were as follows: a) "No" ("No pain" group); b) "Yes, but I have not consulted a physician, physiotherapist, nurse, or health professional because of my pain" ("Reporting pain" group); and c) "Yes, and I have consulted a physician, physiotherapist, nurse or health professional because of my pain" ("Consultation for pain" group). In the analyses, the groups Reporting pain and Consultation for pain were combined.

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The level of physical activity.

The overall level of physical activity was described by the amount of moderate-to-vigorous physical activity after school hours. The test-retest reliability of this variable has been reported to be fairly good, intraclass correlation coefficient being 0.83 among Finnish adolescents aged 15 to 16 yr (24).

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Participation in different sport and exercise activities.

The subjects reported how often they had participated in different sport and exercise activities during the previous year in the season that was suited to those activities. The listed activities were walking, jogging, cycling, cross-country skiing, swimming, soccer, ice hockey, floorball, rinkball or bandy, Finnish baseball, basketball, volleyball, ice-skating, figure skating, track and field, horseback riding, aerobics, gymnastics, dancing, gym training (in Finland, gym training mainly includes weight training but may also include some endurance exercises), downhill skiing or snowboarding, roller-skating or skateboarding, badminton, tennis, orienteering running, judo or karate or wrestling, and golf. These activities were selected on the basis of the Finnish Physical Activity Survey, which reported these being the most common sport and exercise activities among young Finns in 1997-1998 (19). The frequency of participation in different activities was categorized as participation 1) once a month or less often, 2) two to four times a month, and 3) at least twice a week.

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Potential confounding factors.

Smoking, level of obesity, parents' socioeconomic status, and daily time spent sitting were regarded as potential confounding variables. Smoking status at 16 yr was inquired by the questions "Have you ever smoked in your life?" and "Do you smoke nowadays?"; the frequency of smoking was categorized as follows: no smoking at all, smoking 4 d·wk−1 or less, and smoking 5-7 d·wk−1. Body weight and height were bothusually measured during clinical examination at 16yr. Missing information for 798 individuals was replaced by self-reported values. Body mass index (BMI) was calculated as weight per squared height (kg·m−2). Overweight was defined as BMI between the 85th and the95th percentiles (24.10-27.88 kg·m−2 in boys and 23.95-27.30 kg·m−2 in girls), and obesity was defined as BMI above the 95th percentile (≥27.89 kg·m−2 in boys and ≥27.31 kg·m−2 in girls). Parents' socioeconomic status (father's status, but if not known then mother's status) were inquired and categorized into five groups: 1) superior clerical employees, 2) self-employed persons, 3) lower clerical employees, 4) employees, and 5) students, senior citizens, unemployed, and unknowns. Total sitting time was calculated by adding up self-reported daily time spent watching TV, using a computer, reading, and doing other sedentary activities. Daily time spent sitting was categorized as follows: ≤4 h, 4.1-7.9 h, and ≥8 h.

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Statistical analyses.

Because we have previously observed that higher levels of physical activity are associated with a higher prevalence of musculoskeletal pains in adolescence (1,2), this study focuses on active adolescents evaluating which of different sport and exercise activities are associated with musculoskeletal pains. Logistic regression was used to evaluate the association between participation in different sport and exercise activities and pains in the neck, shoulder, or low back area. The activities with too few participants (less than 3% of the population) were excluded in the logistic regression analysis. Subjects who did not participate in the evaluated activity were regarded as reference groups. The odds ratios(OR) and their 95% confidence intervals (CI) were calculated and adjusted for BMI, smoking, parents' socioeconomic status, daily sitting time, hours of total physical activity, and participation in all other sport and exercise activities.

Latent class analysis (LCA) was used to form natural clusters, that is, groups in which the individuals have similar profiles of participation in different sport and exercise activities (5,14). Individuals in the formed clusters are similar to each other (homogeneous, locally independent) with respect to their participation in 27 different sport and exercise activities, which were dichotomized as participation less than twice a week or at least twice a week. With the LCA method and the Bayes theorem, each individual's a posteriori probability in each class was calculated. Each individual was then assigned to the latent class cluster with the highest a posteriori probability. The number of clusters was determined with two statistical diagnostics: Akaike's Information Criterion (AIC) and the Vuong-Lo-Mendell-Rubin likelihood ratio test (16). The number of clusters was first determined on the basis of the likelihood ratio test (maximum clusters) and then checked if compatible with the AIC measure. Logistic regression was used to evaluate the relation between membership of a cluster and neck, shoulder, and low back pains. Cluster 4, characterized by participation in only a few sport and exercise activities (mostly cycling and walking), was regarded as the reference group. Adjustments were made for BMI, smoking, parents' socioeconomic status, hours of total physical activity, and daily sitting time. We used the statistical program SPSS for Windows (version 12.0) and M-Plus (version 3.13).

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RESULTS

The 6-month period prevalence of neck, shoulder, and low back pain were higher in girls than in boys at 16 yr (Table 1). Boys participated actively (at least twice a week) in a greater number of sport and exercise activities than girls (Table 1). In general, boys were physically more active than girls: 69% of boys and 59% of girls were classified as moderately active, that is, participating in moderate-to-vigorous physical activity at least 2 h·wk−1. An obvious gender difference was observed in the frequency of participation in different sport and exercise activities (Table 2). The most common ones (at least twice a week) for girls were cycling (67%), walking (38%), roller-skating or skateboarding (15%), swimming (14%), jogging (12%), and dancing (9%), whereas the most popular activities for boys were cycling (54%), ice hockey (23%), soccer (20%), ice-skating (19%), roller-skating or skateboarding (16%), and gym training (15%; Table 2).

Table 1
Table 1
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Table 2
Table 2
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The LCA resulted in the formation of four clusters in both boys and girls (Table 3). There were differences in the overall level of physical activity and number of sports with active participation between the clusters (Table 4). The overall level of physical activity was highest in cluster 1 in girls and lowest in cluster 4 in both boys and girls. The number of sports with active participation was highest in cluster 1 in both boys and girls (Table 4). In girls, cluster 1 (Generalist) participated most commonly in cycling, ice-skating, and roller-skating or skateboarding; cluster 2 (Endurance) in jogging, walking, and cycling; cluster 3 (Dance/Gymnastics) in cycling, dancing, and gymnastics; and cluster 4 (Active Transport) in cycling and walking (Table 5). In boys, cluster 1 (Generalist) participated most commonly in ice hockey, cycling, ice-skating, soccer, floorball, rinkball or bandy, swimming, roller-skating or skateboarding, and Finnish baseball; cluster 2 (Ice Sports) in ice hockey, ice-skating, and cycling; cluster 3 (Endurance) in jogging, cycling, and walking; and cluster 4 (Active Transport) in cycling (Table 5).

Table 3
Table 3
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Table 4
Table 4
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Table 5
Table 5
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Individual sports and neck pain.

In girls, frequent participation (at least twice a week) in downhill skiing or snowboarding was associated with a higher prevalence of neck pain (Fig. 1). In boys, frequent cycling or gymnastics was associated with a higher prevalence of neck pain, whereas cross-country skiing, Finnish baseball, or tennis associated with a lower prevalence of neck pain (Fig. 2).

FIGURE 1-Logistic re...
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FIGURE 2-Logistic re...
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Individual sports and shoulder pain.

In girls, frequent cross-country skiing, swimming, soccer, or Finnish baseball was associated with a lower prevalence of shoulder pain (Fig. 3). In boys, frequent participation in jogging, basketball, volleyball, ice-skating, gymnastics, or gym training was associated with a higher prevalence of shoulder pain, and participation in cross-country skiing, Finnish baseball, track and field, badminton, or tennis was associated with a lower prevalence of shoulder pain (Fig. 4).

FIGURE 3-Logistic re...
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Individual sports and low back pain.

In girls, frequent participation in gymnastics, dancing, or gym training was associated with a higher prevalence of low back pain, whereas cross-country skiing or aerobics was associated with a lower prevalence of low back pain (Fig. 5). In boys, frequent participation in volleyball, gymnastics, gym training, or downhill skiing or snowboarding was associated with a higher prevalence of low back pain, whereas participation in cross-country skiing was associated with a lower prevalence of low back pain (Fig. 6).

FIGURE 5-Logistic re...
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FIGURE 6-Logistic re...
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Physical activity clusters and musculoskeletal pains.

In boys, membership of cluster 1 (Generalist), characterized by frequent participation in many sport and exercise activities (ice hockey, cycling, ice-skating, soccer, floorball, rinkball or bandy, swimming, roller-skating or skateboarding, and Finnish baseball), was associated with a lower prevalence of neck pain compared with cluster 4 (Active Transport; Table 6). No other associations between membership of a cluster and prevalence of musculoskeletal pains were found.

Table 6
Table 6
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DISCUSSION

Frequent participation in some sport and exercise activities was associated with a high prevalence of musculoskeletal pains, whereas other activities were associated with a low prevalence of musculoskeletal pains. Most physically active adolescents, however, participated in many different sport and exercise activities, which make the associations between single sports and musculoskeletal pains inconsequential in the general population of adolescents. Participation in several sport and exercise activities seems to protect from harmful effects of a single risk sport. In boys, the cluster characterized by active participation in several sport and exercise activities had lower prevalence of neck pain compared with members of the cluster that participated in only a few activities (predominantly cycling and walking).

To the authors' knowledge, this is the first large-scale study in a general population of adolescents evaluating the association between different sport and exercise activities and various musculoskeletal pains. Our large general population made it possible to evaluate the associations between different sport and exercise activities and musculoskeletal pains in multivariate analysis with adjustments for participation in other activities and potential confounders.

As in any observational cross-sectional study, we cannot address causality. In our opinion, however, it is unlikely that adolescents begin to engage in some sport or exercise activity more frequently due to their neck, shoulder, or low back pains, although some adolescents may give up some specific sport and exercise activities due to the musculoskeletal pain it causes. Instead, the opportunities to perform different sport and exercise activities differ between individuals.

Reliance on self-reported measures of musculoskeletal pain symptoms and physical activity is a limitation in surveys of this kind. Self-reporting, however, is the only realistic way to conduct as large a population-based study as the present one, although self-reporting may contain some sources of bias. The 6-month period prevalence of musculoskeletal pains is a common outcome used in low back pain research and is suspected to be appropriate among adolescents. Self-administration of low back pain has been observed to be as good a method as face-to-face interview in adolescents (21). Furthermore, this outcome has been validated against lumbar degenerative magnetic resonance imaging (MRI) findings and recurrent low back pain symptoms among young adults (20).

The risk of injury may be higher in nonsupervised sportand exercise activities than in supervised ones, and some activities are almost always supervised. This should be taken into account when comparing the prevalence of musculoskeletal pains in different sport and exercise activities.

The earlier studies have mostly been case-control investigations involving athletes or elite athletes from various sports. They showed that the risk of neck, shoulder, and low back pain depends on the type of sport, the level of competition, and the intensity of physical training. The present study evaluated a general population of adolescents and the level of participation in sport and exercise activities that are common among people of this age. In reality, most adolescents do not practice just a single sport but are rather engaged in many sport and exercise activities. This fact made it important to evaluate both the theoretical effect of involvement in single sports and the effect of natural participation in several different sport and exercise activities on musculoskeletal pains. We also made the analyses comparing the "No pain" group to the "Reporting pain" group (without "Consultation for pain" group). The results, however, remained similar to those shown above.

Only a few studies have reported the relationships between different sport and exercise activities and neck and shoulder pains. Physical exercises that involve movements of the upper limbs have been suggested to decrease the prevalence of neck and shoulder pains (18,22). Our results partly accord with these findings. In boys, active participation in cross-country skiing, Finnish baseball, or tennis was associated with a lower prevalence of neck pain, whereas active participation in cross-country skiing, Finnish baseball, track and field, badminton, or tennis was associated with a lower prevalence of shoulder pain. In addition, active involvement by boys in a variety of different sport and exercise activities (ice hockey, cycling, ice-skating, soccer, floorball, rinkball or bandy, swimming, roller-skating or skateboarding, and Finnish baseball) was associated with a lower prevalence of neck pain. It seems that participating in many different sport and exercise activities may decrease the risk of musculoskeletal disorders in boys. Among girls, active participation in cross-country skiing, swimming, soccer, or Finnish baseball was associated with a lower prevalence of shoulder pain.

Adolescents who participated actively in physical exercises involving high risk of trauma or heavy forces had more neck pain. In girls, active participation in downhill skiing or snowboarding was associated with neck pain. In boys, active participation in gymnastics associated with neck pain, and participation in basketball, volleyball, gymnastics, or gym training was associated with a higher prevalence of shoulder pain. Interestingly, in boys, cycling was also associated with neck pain, and jogging or ice-skating was associated with shoulder pain.

Our study supports previous findings that gym training associates with an increased prevalence of low back pain in schoolchildren (3,25). Gym training is relatively common among boys of this age. In Finland, gym training mainly includes weight training but may also include some endurance exercises. According to the authors' own experience, boys do more weight training, and girls do more aerobic gym training. We have also observed that adolescents often perform gym weight training in an inappropriate way: without warming-up, without proper supervision to ensure correct performance of exercises, with too heavy loads, and without stretching afterward. All this may partly explain the increased risk of low back pain. Gymnastics has been suggested to increase the risk of low back pain and spine abnormalities seen in MRI (7,9,23). Also in the present study, active participation in gymnastics was associated with low back pain. Frequent participation in dancing was associated with low back pain in girls, but unfortunately, we do not have information about the kinds of dancing our subjects were engaged in. In both boys and girls, participation in cross-country skiing was associated with a lower prevalence of low back pain, and in girls, participation in aerobics was associated with a lower prevalence of low back pain.

Despite the complexity related to the analyses, participation in some sport and exercise activities was found to be related to higher or lower prevalence of neck, shoulder, and low back pains. Some sports and exercise activities, such as those in gymnastics, involve repetitive motion and maximalextensions to the back, which may increase the risk of back injuries and pain. However, our study included a general population of adolescents instead of athletes, and participation in gymnastics was only slightly associated with low back pain in girls. Some sport and exercise activities may improve the endurance and strength of trunk muscles, which might have a protective effect against neck, shoulder, and low back pains. Participation in cross-country skiing was associated with a lower prevalence of neck, shoulder, and low back pains. We hypothesize that the beneficial effect of skiing is due to its versatility; it loads the extremities, both the upper and lower backs. The style of skiing was not inquired, but the classic style may be better due to easier technique, whereas the skating style could load the musculoskeletal structures more-especially if the technique is not proper. The results of the present study and our previous findings suggest (1,2) that pursuing physical activity at a moderate level is not harmful but that active participation in sports such as gym training, downhill skiing or snowboarding, and gymnastics may be associated with a higher prevalence of neck, shoulder, and low back pains. However, participation in several sport and exercise activities seemed to protect from harmful effects of single risk sport. More attention should be paid to the quality and quantity of training in the risk sports. Adolescents participating in aerobic exercise seem to have less neck, shoulder, and low back pains than those involved in activities known to include high risk of trauma or heavy forces. Although physical activity is well known to have positive effects in the prevention of many diseases, some sport and exercise activities might be harmful for the growing musculoskeletal system.

This study was partly funded by the Ministry of Education, Academy of Finland (grant 200868), the Research Foundation of the Institute of Sports, Finland (Urheiluopistosäätiö), the Juho Vainio Foundation, and the Research Foundation of Orion Corporation. The authors acknowledge Professor Simo Näyhä from the University of Oulu and the Finnish Institute of Occupational Health for his valuable comments on the manuscript.

Conflict of interest: None declared.

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Keywords:

PHYSICAL ACTIVITY; ADOLESCENCE; LOW BACK; NECK; SHOULDER

©2008The American College of Sports Medicine

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