Key messages
- We are uncertain whether physical activity reduces pain or improves disability compared with usual care. We did not find studies that compared physical activities with medical care intervention (e.g. education).
- We did not find studies that evaluated education about physical activity, with or without physical activity, in children and adolescents.
- Due to the small number of included studies, and the ways in which the studies were conducted, which could introduce errors into their results, we cannot conclude whether physical activity, education about physical activity, or both, are effective compared with active medical care or usual care.
What is chronic musculoskeletal pain in children and adolescents?
Chronic pain is pain that lasts longer than three months. Chronic musculoskeletal pain (e.g. pain in muscles and bones) is common in children and adolescents, and has a negative impact on their lives. The most common chronic musculoskeletal pain in children and adolescents is pain in their back, neck, and arms, and pain resulting from sports injuries.
What is the impact caused by musculoskeletal pain in children and adolescents?
Children and adolescents with chronic pain report disability and a low mood; they socialise less with their friends, and recognise pain as an obstacle to exercising and participating in physical activities. This can result in missed school, and overall poor health in adult life.
How is musculoskeletal pain treated in children and adolescents?
Chronic musculoskeletal pain is usually managed with physical activity, education about physical activity, or both. Most of the time, these approaches are delivered as part of a complex intervention, i.e. interventions with different components (e.g. psychology, medicines, physical activity).
What did we want to find out?
We wanted to find out if physical activity, education about physical activity, or both, was better than usual care or medical care treatment (also known as active medical care) for improving:
- Pain
- Disability
- Quality of life
We also wanted to find out if physical activity, education about physical activity, or both, led to any unwanted side effects.
What did we do?
We searched for studies that compared physical activity, or education about physical activity, or both, with usual care or active medical care, in school-aged children and adolescents (4 years to 18 years) with any chronic musculoskeletal pain.
We compared and summarised the results of the studies, and rated our confidence in the evidence, based on factors, such as study methods and size.
What did we find?
We found four studies with a total of 243 participants. The studies only included children and adolescents with juvenile idiopathic arthritis. The number of young people included in each study ranged from 32 to 93; the average age of the participants was 11 years. The treatments ranged from three to six months in length. Only one study assessed outcomes at long-term follow-up. We only found studies that compared physical activity with usual care.
We are uncertain if physical activity reduces pain or improves disability better than usual care. We are uncertain about the effects of physical activity on quality of life. None of the studies reported whether the participants experienced unwanted side effects.
What are the limitations of the evidence?
The studies only included a small number of children and adolescents, and may have been done in ways that could introduce errors in their results. Both reasons limit our confidence in the evidence.
Possible side effects of the physical activities and usual care were not adequately reported.
Our uncertainty in the results does not allow us to conclude whether physical activity for chronic musculoskeletal pain in children and adolescents improves their pain, disability, or quality of life.
In practice, healthcare providers should consider the availability and quality of research evidence about physical therapies, preferences of the young people in pain, and the professional's experience.
How up to date is this evidence?
The evidence is current to October 2022.
We are unable to confidently state whether interventions based on physical activity and education about physical activity are more effective than usual care for children and adolescents with chronic musculoskeletal pain.
We found very low-certainty evidence that physical activity may reduce pain intensity and improve disability postintervention compared with usual care, for children and adolescents with juvenile idiopathic arthritis.
We did not find any studies reporting educational interventions; it remains unknown how these interventions influence the outcomes in children and adolescents with chronic musculoskeletal pain.
Treatment decisions should consider the current best evidence, the professional's experience, and the young person's preferences.
Further randomised controlled trials in other common chronic musculoskeletal pain conditions, with high methodological quality, large sample size, and long-term follow-up are urgently needed.
Chronic pain is a major health and socioeconomic burden, which is prevalent in children and adolescents. Among the most widely used interventions in children and adolescents are physical activity (including exercises) and education about physical activity.
To evaluate the effectiveness of physical activity, education about physical activity, or both, compared with usual care (including waiting-list, and minimal interventions, such as advice, relaxation classes, or social group meetings) or active medical care in children and adolescents with chronic musculoskeletal pain.
We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PEDro, and LILACS from the date of their inception to October 2022. We also searched the reference lists of eligible papers, ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform.
We included randomised controlled trials (RCTs) that compared physical activity or education about physical activity, or both, with usual care (including waiting-list and minimal interventions) or active medical care, in children and adolescents with chronic musculoskeletal pain.
Two review authors independently determined the eligibility of the included studies. Our primary outcomes were pain intensity, disability, and adverse events. Our secondary outcomes were depression, anxiety, fear avoidance, quality of life, physical activity level, and caregiver distress. We extracted data at postintervention assessment, and long-term follow-up. Two review authors independently assessed risk of bias for each study, using the RoB 1. We assessed the overall certainty of the evidence using the GRADE approach. We reported continuous outcomes as mean differences, and determined clinically important differences from the literature, or 10% of the scale.
We included four studies (243 participants with juvenile idiopathic arthritis). We judged all included studies to be at unclear risk of selection bias, performance bias, and detection bias, and at high risk of attrition bias. We downgraded the certainty of the evidence for each outcome to very low due to serious or very serious study limitations, inconsistency, and imprecision.
Physical activity compared with usual care
Physical activity may slightly reduce pain intensity (0 to 100 scale; 0 = no pain) compared with usual care at postintervention (standardised mean difference (SMD) -0.45, 95% confidence interval (CI) -0.82 to -0.08; 2 studies, 118 participants; recalculated as a mean difference (MD) -12.19, 95% CI -21.99 to -2.38; I² = 0%; very low-certainty evidence). Physical activity may slightly improve disability (0 to 3 scale; 0 = no disability) compared with usual care at postintervention assessment (MD -0.37, 95% CI -0.56 to -0.19; I² = 0%; 3 studies, 170 participants; very low-certainty evidence). We found no clear evidence of a difference in quality of life (QoL; 0 to 100 scale; lower scores = better QoL) between physical activity and usual care at postintervention assessment (SMD -0.46, 95% CI -1.27 to 0.35; 4 studies, 201 participants; very low-certainty evidence; recalculated as MD -6.30, 95% CI -18.23 to 5.64; I² = 91%).
None of the included studies measured adverse events, depression, or anxiety for this comparison.
Physical activity compared with active medical care
We found no studies that could be analysed in this comparison.
Education about physical activity compared with usual care or active medical care
We found no studies that could be analysed in this comparison.
Physical activity and education about physical activity compared with usual care or active medical care
We found no studies that could be analysed in this comparison.