Demographic and Pain Questionnaire
The questionnaire comprised questions related to participants’ educational level, their parents’ educational levels and occupations, physical activity levels in the last 7 days, brace use, and daily duration brace use for those who used it. We classified the respondents’ physical activity level as light (all or most leisure time spent in minimal physical activity), moderate (two to six times in the last week participating in physical activity/exercises during leisure time), and vigorous (seven or more times in the last week participating in physical activity/exercises during leisure time).
Additionally, the questionnaire also collected data regarding current pain in the thoracic and lumbar region; thoracic and lumbar pain at rest or during activity in the last 7 days, 30 days, 12 months, and lifetime as well as chronic thoracic and lumbar pain that lasted for at least 3 months during the last 12 months. If respondents reported back pain during any of those periods, they rated their pain using a 11-point numeric pain rating scale (NPRS), where 0 means no pain and 10 means the worst imaginable pain . The minimal clinical important difference for the NPRS is 2 [8, 10]. They also answered questions regarding the types of healthcare practitioners they visited for the current or previous spinal pain; the presence of radiating leg pain at rest or during activity in the last 7 days, 30 days, and 12 months; the number of recurrent back pain episodes in the last 12 months; and the impact of pain on one’s studying hours, working hours, and leisure activities. Participants also rated their degrees of satisfaction with their back pain treatments and their perceived acceptance of living with thoracic or lumbar pain for the rest of their life on an 11-point numeric rating scale (-5 means extremely unsatisfied and 5 means extremely satisfied).
A human body silhouette was used to help the respondent demarcate the location of their pain and the nature of the pain such as burning, pins and needles, dull ache, or sharp pain. A similar method has been used in prior research to document back pain in adolescents with AIS .
Depression, Anxiety, and Stress Scale-21 (DASS-21)
The DASS-21 is the shortened form of DASS for the assessment of the 1-week emotional states of depression, anxiety, and stress . It includes three seven-item subscales. Each subscale can be administered separately to evaluate respective emotional states. Each item is rated on a 4-point Likert-type scale; 0 means does not apply to the respondent, whereas 3 indicates applies to the respondent very much or most of the time. The sum of the item scores within each subscale equals the subscale scores (ranging from 0 to 21). From the subscale scores, the emotional condition is classified into normal (0-6), moderate to severe (7-13), and very severe (≥ 14). In the current study, only the depression and anxiety subscales were used to minimize the burden of respondents. The depression subscale assesses dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest/involvement, anhedonia, and inertia. The anxiety subscale evaluates autonomic arousal, skeletal muscle effects, situational anxiety, and subjective experience of anxious affect. The use of the DASS-21 has been validated for assessing depression and anxiety among adolescents in various countries with excellent psychometric properties (such as reliability) and good internal consistency [25, 43]. Because only 2.0% of participants reported very severe depression and 3.2% reported anxiety, participants were dichotomized into having no depression/anxiety and moderate-to-very severe depression/anxiety categories.
Insomnia Severity Index (ISI)
This seven-item scale evaluates the severity of insomnia, the satisfactory level with sleep, noticeability of insomnia, perceived stress associated with insomnia, and interference of insomnia on daily functioning. It is a clinically reliable instrument in detecting insomnia . Each item is rated on a 5-point Likert scale, where 0 indicates no problem and 4 indicates a very severe problem, yielding a high score of 28. The overall score is interpreted as follows: absence of clinically significant insomnia (0–7), subthreshold insomnia (8–14), moderate insomnia (15–21), and severe insomnia (22–28). The Chinese version of the ISI has demonstrated satisfactory test-retest reliability (r = 0.79) and high validity in detecting clinical insomnia among adolescents in Hong Kong . Because only 2.6% of participants reported having moderate insomnia and 0.1% reported having severe insomnia, participants were dichotomized into no insomnia and having subthreshold-to-severe insomnia categories.
Epworth Sleepiness Scale (ESS)
This eight-item self-reported questionnaire measures daytime sleep tendency . Respondents rated their tendency of dozing under eight daily living situations on a 3-point scale, where 0 indicates never dozing and whereas 3 indicates high propensity of dozing. From the overall scores of the ESS, participants were classified into normal daytime sleepiness (< 10), mild-to-moderate excessive daytime sleepiness (10-15), and severe excessive daytime sleepiness (16-24). Previous research has adopted the ESS in assessing daytime sleepiness of local adolescents with high test-retest reliability . Because only 1% of the participants reported having severe excessive daytime sleepiness, participants were dichotomized into normal daytime sleepiness and mild-to-severe daytime sleepiness categories.
Refined Scoliosis Research Society-22 (SRS-22r) Patient Questionnaire
This questionnaire is the most commonly used self-reported outcome measure for evaluating adolescents with AIS [1, 2]. The Chinese version of the SRS-22r has demonstrated high reliability and concurrent validity in the local population . The questionnaire consists of 22 questions encompassing five domains: function/activity (five items); pain (five items); self-perceived image (five items); mental health (five items); and satisfaction with scoliosis treatment (two items). Each item is rated at a 5-point scale ranging from 1 (worst) to 5 (best). The total scores in the first four domains range from 5 to 25, whereas that in the satisfaction domain ranges from 2 to 10. The highest total sum of all domains scores is 110. In the current study, the average score in each domain (total scores within the domain divided by the respective number of items) and average total score of the SRS-22r questionnaire were calculated to estimate differences between people with and without back pain.
Medical and Radiology Records
A blinded investigator (PWHC) retrieved the most recent medical information regarding comorbidities, age, sex, height, and weight from each participant’s electronic medical record, whereas an experienced orthopaedic specialist (JPYC), who was blinded to the questionnaire results, collected the radiographic information of each consented participant from the same system. Specifically, the standing coronal and sagittal radiographs were used to classify the spinal curve type of each participant using the Lenke classification . The coronal Cobb angles of all curves were measured and were classified as proximal thoracic, main thoracic, thoracolumbar/lumbar, and lumbar curves. Apical vertebral rotation (AVR) was measured at the apex of the spinal curve(s) using the Nash-Moe method . Thoracic kyphosis between T5 and T12 was classified into hypokyphosis (< 10°), normal kyphosis (10°-40°), and hyperkyphosis (> 40°) . Risser staging (0-5) was also documented on the same radiograph.
SPSS Version 24.0 software (IBM, Armonk, NY, USA) was used for statistical analyses. Descriptive data are expressed as means, SDs, or percentages. To identify the factors associated with back pain (thoracic, low back pain, or concurrent thoracic and low back pain) in adolescents with current back pain and back pain in the last 12 months, the demographic data (including age, sex, height, weight, body mass index, physical activity level, brace wearing status), radiologic data (Cobb angles at the proximal thoracic curve, main thoracic curve, thoracolumbar curve, lumbar curve, AVR at the four spinal regions, sagittal Cobb angles at the main thoracic region, single curve to double curve ratio, Lenke grades, Risser grades), depression, anxiety, and sleep-related factors between adolescents with and without back pain at present and in the last 12 months were first compared by independent t-tests, Mann-Whitney tests, or chi-square tests depending on the normality and types of data, either continuous or categorical. Potential parameters (that is, Cobb angles at the main thoracic and lumbar curves, AVR at the thoracolumbar region, Risser sign, anxiety, depression, dichotomized ISI variable, and dichotomized ESS variable) that showed considerable differences between groups (p < 0.20) were then entered into the respective stepwise logistic regression models. Specifically, we entered each dichotomized pain variable such as current back pain, back pain in the last 12 months, or chronic back pain in the last 12 months as a dependent variable while we entered the potential variables as independent variables. Age and sex were also entered into the models as independent variables because prior research reported that they might be factors associated with spinal pain in patients with AIS . On completion of the multivariate analyses, we found that Cobb angles at the main thoracic and the lumbar regions were related to back pain. To help clinicians apply these findings when identifying patients with AIS at risk for back pain, especially chronic back pain, we repeated separate multivariate analyses using dichotomized Cobb angles at the main thoracic and lumbar curves with cutoffs at 20°, 30°, and 40°. The significance level was set at < 0.05. Odds ratios (ORs) and 95% confidence intervals (CIs) were used to assess the strength of association and precision, respectively.
Point Prevalence, 7-day, 30-day, 12-month, and Lifetime Prevalence of Back Pain
Because approximately 2% to 8% of participants reported concurrent thoracic and low back pain at different time periods, these individuals were only counted once in the estimation of prevalence of back pain. There was no difference in all period prevalence rates of back pain (thoracic or lumbar pain) between male and female participants except that female participants (37%) had a higher lifetime prevalence than male participants (30%) (OR, 1.1; 95% CI, 1.02-1.2; p = 0.028) (Table 2). The point prevalence of thoracic pain was 9%, the 7-day prevalence was 11%, 30-day prevalence was 12%, 12-month was 13%, and lifetime prevalence of thoracic pain was 14%. For low back pain, the point prevalence was 13%, 7-day was 14%, 30-day was 20%, 12-month was 25%, and lifetime prevalence was 29%. Similarly, the point prevalence of back pain (thoracic pain, low back pain, or concurrent thoracic and low back pain) was 18%, 7-day was 21%, 30-day prevalence was 25%, 12-month was 30%, and lifetime prevalence was 36% (Table 2). The 12-month prevalence of chronic thoracic pain was 6%, for low back pain it was 6%, and for back pain it was 9%.
Factors Associated With Current Back Pain, Back Pain in the Last 12 Months, and Chronic Back Pain
After controlling for potential confounding variables (including Risser sign, Cobb angles of the lumbar curve), our analysis revealed that the presence of insomnia (OR, 2.48; 95% CI, 1.10-2.93), moderate/severe daytime sleepiness (OR, 1.75; 95% CI, 1.43-4.07), older age (OR, 1.18 per year; 95% CI, 1.02-1.36), and larger Cobb angles at the main thoracic curve (OR, 1.03 per degree; 95% CI, 1.01-1.04) were independent factors associated with the presence of current back pain (Table 3). Similarly, insomnia (OR, 2.40; 95% CI, 1.58-3.64), female sex (OR, 1.73; 95% CI, 1.08-2.77), older age (OR, 1.40 per year; 95% CI, 1.23-1.60), and larger Cobb angles at the lumbar curve (OR, 1.03 per degree; 95% CI, 1.01-1.05) were factors associated with back pain in the last 12 months. The factors associated with chronic back pain in patients with AIS included the presence of a single curve (OR, 3.85; 95% CI, 1.85-8.01), brace wearing (OR, 3.19; 95% CI, 1.56-6.52), moderate depression (OR, 2.49; 95% CI, 1.08-5.71), moderate/severe daytime sleepiness (OR, 2.17; 95% CI, 1.10-4.28), and older age (OR, 1.24 per year; 95% CI, 1.01-1.51) (Table 3).
After controlling for potential confounding variables such as height, weight, and body mass index, we found that a coronal Cobb angle > 40° at the main thoracic curve and older age were universal independent factors associated with back pain episodes and chronic back pain in patients with AIS (Table 4). The factors associated with current back pain included a main thoracic curve with coronal Cobb angles > 40° (OR, 2.93; 95% CI, 1.42-6.05), moderate/severe daytime sleepiness (OR, 2.41; 95% CI, 1.43-4.07), subthreshold or severe insomnia (OR, 1.76; 95% CI, 1.08-2.87), and older age (OR, 1.17 per year; 95% CI, 1.02-1.35). Likewise, a main thoracic curve with coronal Cobb angles > 40° (OR, 2.38; 95% CI, 1.18-4.80), subthreshold to severe insomnia (OR, 2.31; 95% CI, 1.53-3.51), older age (OR, 1.42 per year; 95% CI, 1.25-1.61), and females (OR, 1.71; 95% CI, 1.07-2.74) were factors associated with back pain within the last 12 months. Similarly, patients were likely to have chronic back pain if they had main thoracic Cobb angles > 40° (OR, 3.74; 95% CI, 1.45-9.66), presented with moderate depression (OR, 3.74; 95% CI, 1.45-9.66), daytime sleepiness (OR, 2.39; 95% CI, 1.23-4.68), wore a brace (OR, 3.00; 95% CI, 1.47-6.15), and were older (OR, 1.25 per year; 95% CI, 1.03-1.52) (Table 4). Although the dichotomized variable of Cobb angles > 30° was also related to current back pain (OR, 1.83; 95% CI, 1.06-3.15) and back pain in the last 12 months (OR, 1.74; 95% CI, 1.07-2.84) in two of the multivariate analyses, it was not associated with chronic back pain in the last 12 months (Appendix, Supplemental Digital Content 1, http://links.lww.com/CORR/A112).
Patients with AIS appear to have a higher prevalence of back pain, but it is unclear whether there is any important association between this symptom and spinal deformity. There is also limited understanding of the severity of this problem and factors associated with its occurrence, severity, or chronicity [7, 38, 41, 42]. Our results suggest that back pain is not uncommon (8.6%) among these patients. However, more importantly, patients with AIS and back pain not only experienced pain and physical dysfunction, but also demonstrated clinically significant anxiety, depression, insomnia, and daytime sleepiness. Factors including main thoracic Cobb angles > 30°, moderate-to-severe insomnia or daytime sleepiness, older age, and female sex were closely related to back pain at present or over a 12-month period. Other associated factors with chronic back pain include Cobb angles > 40°, brace wearing, depression, moderate-to-serve insomnia, and daytime sleepiness. These revelations suggest that clinicians should not only focus on the curve magnitude, but also investigate if there is any back pain and modifiable psychosocial factors such as sleep quality and depression.
Like with any study, limitations exist. Recall bias is an important and commonly encountered limitation with a cross-sectional study design because patients may have difficulty in recalling pain over longer periods and may overestimate/underestimate pain episodes based on current mood or current pain intensity [14, 18, 22]. Because the longer the recall period, the greater the risk of unreliable data [20, 29], we only asked patients to recall pain intensity within 7 days or chronic pain intensity within the last 12 months. This recall period aligns well with other similar epidemiologic studies . The current study was also limited by the adoption of some questionnaires (the DASS-21, ISI, and ESS) that have not been validated in Chinese teenagers with AIS. However, because they have been used in the pediatric population, our results should be relevant. Additionally, although the questionnaires used to collect data regarding the presence of back pain at different time periods or the perceived acceptance of living with back pain for the rest of their life have not validated, these questionnaires are simple and straightforward, and their findings should be easy to interpret. Even so, without validation, we urge some caution in their application.
Similar to prior research on the epidemiology of back pain in adolescents , our participants were asked to report back pain episodes over different time periods regardless of pain intensity or pain at rest or during activity. Although this might have overestimated some period prevalence rates of back pain in adolescents with AIS, this simple definition of pain could minimize the burden on adolescents in answering the questionnaire. Future studies should investigate the impacts of different definitions of back pain in affecting the reported prevalence of back pain in this population. In addition, the causal relationship between the identified factors and back pain cannot be established by our study. A prospective study design is warranted to address this relationship. Furthermore, because extra radiographic imaging was not taken at the time of this study, the spinal parameters were measured from the latest radiologic images in the electronic medical record. However, because patients usually undergo annual radiography, the changes in spinal structures should not be substantial. Limited analysis of sagittal spinopelvic parameters was conducted in the current study. Sagittal parameters like the sagittal vertical axis or pelvic incidence may play a role in back pain, although other factors (such as Lenke type) may also be associated with both sagittal parameters and back pain. A dedicated future study on sagittal alignment in the AIS population is warranted.
The current study has the advantage of representing a large homogenous sample of Chinese patients with AIS, whereby various confounding variables often found in mixed populations are diminished. Furthermore, the degree of relationship explored in our study suggests that the association of fundamental ethnic and cultural values may not be as strong. That said, evidence should be generated in future studies to address the generalizability of the findings to other populations. Importantly, given the very large sample size of the present study and the use of multiple radiographic parameters and psychosocial factors, robust multivariate analyses were performed to identify key determinants for back pain in adolescents with AIS. Our findings suggest that some modifiable and nonmodifiable factors are closely related to back pain in these adolescents. Clinicians should identify patients who experience back pain alongside insomnia and depression symptoms so that proper treatments can be given to minimize the risk of developing chronic back pain.
The reported prevalence rates of back pain in adolescents with AIS in prior studies range from 23% to 85% [13, 36, 37, 41, 45]. Sato et al.  conducted a cross-sectional population-based study to compare the prevalence of back pain in elementary schoolchildren with and without AIS. Their reported point and lifetime prevalence rates of children with AIS were 27.5% and 58.8%, which were much higher than the reported point (9%) and lifetime prevalence (23%) of patients with scoliosis found by Ramirez et al. . In the current study, our point (18.0%) and lifetime prevalences (35.4%) were between the ranges reported by these two studies. The discrepancy might be attributed to differences in data collection methods (population-based research versus consecutive sampling from scoliosis clinics) and sampling populations. Although Sato et al.  recruited approximately 44,000 participants, only 55 of them had AIS. Their results should be interpreted with caution. Although both Ramirez et al.  and the current study recruited patients from scoliosis clinics, Ramirez et al. included patients aged between 9 months and 22 years. As such, some of their findings were unrelated to adolescents with AIS. Given these results, our findings help clinicians better understand various period prevalence rates of back pain in patients with AIS. Future longitudinal studies should adopt a similar approach to determine trajectories of back pain in teenagers with AIS.
Compared with asymptomatic patients with AIS, those with back pain demonstrated poorer physical function and sleep problems. Although it is known that back pain can cause functional limitations in adolescents, the current study found that these young individuals with back pain were experiencing insomnia and daytime sleepiness, which may affect their learning, back pain perpetuation, and even scoliosis curve progression . Auvinen et al.  found that adolescents with insufficient sleep at 16 years old were more likely to experience neck, shoulder, and low back pain at age 18 years (OR range, 2.4–3.2) as compared with those without sleep problems. Given the findings from previous research [3, 35] and ours about the relationship between sleep and pain, it seems important that surgeons should consider referring young patients with AIS and back pain to sleep therapists for sleep hygiene training. Additionally, because the insomnia-related deprivation of melatonin may be related to the curve progression in patients with AIS , special attention should be given to the sleep quantity and quality of patients with AIS so that proper interventions can be implemented in these young and vulnerable individuals.
Prior research has reported that certain spinal deformities such as the location of the thoracic curve are related to the corresponding regional pain . Their findings were limited by the lack of adjustment for various physical and psychosocial factors. Because the causes of back pain are multifactorial , it is necessary to account for the effects of various potential confounders to clarify the relation between spinal deformity and back pain. For instance, depression, anxiety, or physical activity levels can influence the perception and perpetuation of pain. Thereby, the current study included multiple potential physical and psychosocial factors in the multivariate analyses so as to identify the modifiable and nonmodifiable factors associated with back pain in adolescents with AIS. Our results corroborate previous findings that the severity of the main thoracic curve and older age are related to the presence of back pain in these patients . Interestingly, although Theroux et al.  and Smorgick et al.  found that braced patients with AIS reported less pain than their nonbraced counterparts, we found that brace wearing is a factor associated with chronic back pain. The discrepancy may be attributed to the fact that patients with a larger spinal curve are prescribed brace treatment. Because larger Cobb angles are found to be a factor associated with pain in the current study, the revelation of brace wearing as a factor associated with chronic back pain further substantiates this notion.
In conclusion, our large-scale study found that the presence of back pain, regardless of whether it was acute or chronic, was associated with decreased sleep quantity and quality in young patients. Importantly, after adjusting for age, sex, and other psychosocial factors, we noted that a main thoracic Cobb angle > 40° was found to increase the odds of having back pain in adolescents with AIS, underscoring the critical implications of a curve magnitude threshold on pain generation. Because an early onset of back pain in adolescents can heighten the risk of recurrence in adulthood [5, 21, 23, 28, 32, 33], future studies should determine if some of the novel factors associated with pain identified in our study can successfully predict back pain and further flag such high-risk individuals. Our study further underscores the need to prospectively and longitudinally assess the implications of such parameters in the development of back pain and its natural history. Additional studies are needed to further replicate our findings in other ethnic populations and assess their implications on quality of life and healthcare-related costs.
We thank Mr. Matthew T. H. Chung for help with the literature search and with summarizing relevant information for the preparation of the manuscript.
1. Asher M, Min Lai S, Burton D, Manna B. Discrimination validity of the Scoliosis Research Society-22 Patient Questionnaire: relationship to idiopathic scoliosis curve pattern and curve size. Spine (Phila Pa 1976). 2003;28:74–78.
2. Asher M, Min Lai S, Burton D, Manna B. The reliability and concurrent validity of the Scoliosis Research Society-22 Patient Questionnaire for idiopathic scoliosis. Spine (Phila Pa 1976). 2003;28:63–69.
3. Auvinen JP, Tammelin TH, Taimela SP, Zitting PJ, Jarvelin MR, Taanila AM, Karppinen JI. Is insufficient quantity and quality of sleep a risk factor for neck, shoulder and low back pain? A longitudinal study among adolescents. Eur Spine J. 2010;19:641–649.
4. Balague F, Skovron ML, Nordin M, Dutoit G, Pol LR, Waldburger M. Low back pain in schoolchildren. A study of familial and psychological factors. Spine (Phila Pa 1976). 1995;20:1265–1270.
5. Brattberg G. Do pain problems in young school children persist into early adulthood? A 13-year follow-up. Eur J Pain. 2004;8:187–199.
6. Burton AK, Balague F, Cardon G, Eriksen HR, Henrotin Y, Lahad A, Leclerc A, Muller G, van der Beek AJ; COST B13 Working Group on European Guidelines for Prevention in Low Back Pain. How to prevent low back pain. Best Pract Res Clin Rheumatol. 2005;19:541–555.
7. Calvo-Munoz I, Gomez-Conesa A, Sanchez-Meca J. Prevalence of low back pain in children and adolescents: a meta-analysis. BMC Pediatr. 2013;13:14.
8. Cheung JPY, Cheung PWH, Law K, Borse V, Lau YM, Mak LF, Cheng A, Samartzis D, Cheung KMC. Postoperative rigid cervical collar leads to less axial neck pain in the early stage after open-door laminoplasty--a single-blinded randomized controlled trial. Neurosurgery. 2018 Aug 3. [Epub ahead of print]
9. Cheung KM, Senkoylu A, Alanay A, Genc Y, Lau S, Luk KD. Reliability and concurrent validity of the adapted Chinese version of Scoliosis Research Society-22 (SRS-22) questionnaire. Spine (Phila Pa 1976). 2007;32:1141–1145.
10. Childs JD, Piva SR, Fritz JM. Responsiveness of the numeric pain rating scale in patients with low back pain. Spine (Phila Pa 1976). 2005;30:1331–1334.
11. Chung KF, Kan KK, Yeung WF. Assessing insomnia in adolescents: comparison of Insomnia Severity Index, Athens Insomnia Scale and Sleep Quality Index. Sleep Med. 2011;12:463–470.
12. Clark EM, Tobias JH, Fairbank J. The impact of small spinal curves in adolescents who have not presented to secondary care: a population-based cohort study. Spine (Phila Pa 1976). 2016;41:E611–E617.
13. Dickson JH, Erwin WD, Rossi D. Harrington instrumentation and arthrodesis for idiopathic scoliosis. A twenty-one-year follow-up. J Bone Joint Surg Am. 1990;72:678–683.
14. Eich E, Reeves JL, Jaeger B, Graff-Radford SB. Memory for pain: relation between past and present pain intensity. Pain. 1985;23:375–380.
15. Eyvazov K, Samartzis D, Cheung JP. The association of lumbar curve magnitude and spinal range of motion in adolescent idiopathic scoliosis: a cross-sectional study. BMC Musculoskelet Disord. 2017;18:51.
16. Fong DY, Cheung KM, Wong YW, Wan YY, Lee CF, Lam TP, Cheng JC, Ng BK, Luk KD. A population-based cohort study of 394,401 children followed for 10 years exhibits sustained effectiveness of scoliosis screening. Spine J. 2015;15:825–833.
17. GBD 2015 DALYs and HALE Collaborators. Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1603–1658.
18. Gendreau M, Hufford MR, Stone AA. Measuring clinical pain in chronic widespread pain: selected methodological issues. Best Pract Res Clin Rheumatol. 2003;17:575–592.
19. Girardo M, Bettini N, Dema E, Cervellati S. The role of melatonin in the pathogenesis of adolescent idiopathic scoliosis (AIS). Eur Spine J. 2011;20(Suppl 1):S68–74.
20. Goodman JE, McGrath PJ. The epidemiology of pain in children and adolescents: a review. Pain. 1991;46:247–264.
21. Harreby M, Neergaard K, Hesselsoe G, Kjer J. Are radiologic changes in the thoracic and lumbar spine of adolescents risk factors for low back pain in adults? A 25-year prospective cohort study of 640 school children. Spine (Phila Pa 1976). 1995;20:2298–2302.
22. Jamison RN, Sbrocco T, Parris WC. The influence of physical and psychosocial factors on accuracy of memory for pain in chronic pain patients. Pain. 1989;37:289–294.
23. Jeffries LJ, Milanese SF, Grimmer-Somers KA. Epidemiology of adolescent spinal pain: a systematic overview of the research literature. Spine (Phila Pa 1976). 2007;32:2630–2637.
24. Joncas J, Labelle H, Poitras B, Duhaime M, Rivard CH, Le Blanc R. [Dorso-lumbal pain and idiopathic scoliosis in adolescence] [in French]. Ann Chir. 1996;50:637–640.
25. Le MTH, Tran TD, Holton S, Nguyen HT, Wolfe R, Fisher J. Reliability, convergent validity and factor structure of the DASS-21 in a sample of Vietnamese adolescents. PLoS One. 2017;12:e0180557.
26. Lenke LG, Betz RR, Harms J, Bridwell KH, Clements DH, Lowe TG, Blanke K. Adolescent idiopathic scoliosis: a new classification to determine extent of spinal arthrodesis. J Bone Joint Surg Am. 2001;83:1169–1181.
27. Makino T, Kaito T, Kashii M, Iwasaki M, Yoshikawa H. Low back pain and patient-reported QOL outcomes in patients with adolescent idiopathic scoliosis without corrective surgery. Springerplus. 2015;4:397.
28. Mikkelsson M, El-Metwally A, Kautiainen H, Auvinen A, Macfarlane GJ, Salminen JJ. Onset, prognosis and risk factors for widespread pain in schoolchildren: a prospective 4-year follow-up study. Pain. 2008;138:681–687.
29. Milanese S, Grimmer-Somers K. What is adolescent low back pain? Current definitions used to define the adolescent with low back pain. J Pain Res. 2010;3:57–66.
30. Nash CL Jr, Moe JH. A study of vertebral rotation. J Bone Joint Surg Am. 1969;51:223–229.
31. Negrini S, Hresko TM, O'Brien JP, Price N; SOSORT Boards; SRS Non-Operative Committee. Recommendations for research studies on treatment of idiopathic scoliosis: consensus 2014 between SOSORT and SRS non-operative management committee. Scoliosis. 2015;10:8.
32. O'Sullivan P, Beales D, Jensen L, Murray K, Myers T. Characteristics of chronic non-specific musculoskeletal pain in children and adolescents attending a rheumatology outpatients clinic: a cross-sectional study. Pediatr Rheumatol Online J. 2011;9:3.
33. O'Sullivan PB, Beales DJ, Smith AJ, Straker LM. Low back pain in 17 year olds has substantial impact and represents an important public health disorder: a cross-sectional study. BMC Public Health. 2012;12:100.
34. Osman A, Wong JL, Bagge CL, Freedenthal S, Gutierrez PM, Lozano G. The Depression Anxiety Stress Scales-21 (DASS-21): further examination of dimensions, scale reliability, and correlates. J Clin Psychol. 2012;68:1322–1338.
35. Pakpour AH, Yaghoubidoust M, Campbell P. Persistent and developing sleep problems: a prospective cohort study on the relationship to poor outcome in patients attending a pain clinic with chronic low back pain. Pain Pract. 2018;18:79–86.
36. Pratt RK, Burwell RG, Cole AA, Webb JK. Patient and parental perception of adolescent idiopathic scoliosis before and after surgery in comparison with surface and radiographic measurements. Spine (Phila Pa 1976). 2002;27:1543–1550; discussion 1551-1552.
37. Ramirez N, Johnston CE, Browne RH. The prevalence of back pain in children who have idiopathic scoliosis. J Bone Joint Surg Am. 1997;79:364–368.
38. Sato T, Hirano T, Ito T, Morita O, Kikuchi R, Endo N, Tanabe N. Back pain in adolescents with idiopathic scoliosis: epidemiological study for 43,630 pupils in Niigata City, Japan. Eur Spine J. 2011;20:274–279.
39. Smorgick Y, Mirovsky Y, Baker KC, Gelfer Y, Avisar E, Anekstein Y. Predictors of back pain in adolescent idiopathic scoliosis surgical candidates. J Pediatr Orthop. 2013;33:289–292.
40. Theroux J, Le May S, Fortin C, Labelle H. Prevalence and management of back pain in adolescent idiopathic scoliosis patients: a retrospective study. Pain Res Manag. 2015;20:153–157.
41. Theroux J, Le May S, Hebert JJ, Labelle H. Back pain prevalence is associated with curve-type and severity in adolescents with idiopathic scoliosis: a cross-sectional study. Spine (Phila Pa 1976). 2017;42:E914–E919.
42. Theroux J, Stomski N, Hodgetts CJ, Ballard A, Khadra C, Le May S, Labelle H. Prevalence of low back pain in adolescents with idiopathic scoliosis: a systematic review. Chiropr Man Therap. 2017;25:10.
43. Tully PJ, Zajac IT, Venning AJ. The structure of anxiety and depression in a normative sample of younger and older Australian adolescents. J Abnorm Child Psychol. 2009;37:717–726.
44. Weinstein SL, Dolan LA, Cheng JC, Danielsson A, Morcuende JA. Adolescent idiopathic scoliosis. Lancet. 2008;371:1527–1537.
45. Weinstein SL, Zavala DC, Ponseti IV. Idiopathic scoliosis: long-term follow-up and prognosis in untreated patients. J Bone Joint Surg Am. 1981;63:702–712.
46. Wong AY, Parent EC, Prasad N, Huang C, Chan KM, Kawchuk GN. Does experimental low back pain change posteroanterior lumbar spinal stiffness and trunk muscle activity? A randomized crossover study. Clin Biomech (Bristol, Avon). 2016;34:45–52.
47. Yu DS. Insomnia Severity Index: psychometric properties with Chinese community-dwelling older people. J Adv Nurs. 2010;66:2350–2359.
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