Musculoskeletal Pain In Children Research Articles

P051 Trends in consultations for musculoskeletal pain in children and young people presenting to United Kingdom primary care: an electronic health record study

Abstract Background/Aims Musculoskeletal pain in childhood increases the risk of such pain in adulthood but there is an absence of management guidance for this group, not helped by a lack of evidence on the extent and nature of pain in children. The aim was to determine the extent and patterns of consultations for musculoskeletal pain in children and young people (CYP) presenting to UK primary care. Methods Data were obtained from an anonymised nationally representative UK primary care electronic health record database (Clinical Practice Research Datalink, CPRD). The study population was patients aged 8-18 years between 2005-2021 with consultations for musculoskeletal pain. Consultation prevalence was calculated per 10,000 registered population for each calendar year, and by age (8-11, 12-15 and 16-18 years), gender and body site (prevalence presented for 2019 prior to COVID-19 pandemic). Results 1.12 million children and young people (48% female; median age 14 years) were recorded with musculoskeletal pain, with an annual consultation prevalence of over 9% (932/10,000, 95% CI 928-937). Consultation prevalence increased until 2015, stabilised until 2019, and was lower during 2020 due to the COVID-19 pandemic, but climbed slightly in 2021. Consultation prevalence in 2019 was highest for those aged 12-15 years (1105/10,000 vs 8-11 years 736/10,000 and 16-18 years 984/10,000) and for females. Age and gender differences were observed by body site with foot/ankle the most common site of pain in younger children (ages 8-11: females 277/10,000, males 229/10,000,), back the most common site in older females (ages 16- 18: 247/10,000) and knee the most common site in older males (ages 16-18: 178/10,000). Conclusion Musculoskeletal pain in CYP is common with almost one in ten consulting primary care annually, but pain sites vary by age and gender. Understanding the extent and nature of musculoskeletal pain in CYP presenting to primary care can help inform targeted and effective care, and underpin much needed intervention studies, potentially reducing risk of continued pain into adulthood. Disclosure K.J. Mason: None. K.P. Jordan: None. J. Bailey: None. A. Jöud: None. S. Jowett: None. J. Protheroe: None. F. Mughal: None. K.I.E. Snell: None. M. Thomas: None. K.M. Dunn: None.

Developing and assessing the measurement properties of an instrument to assess the impact of musculoskeletal pain in children aged 9 to 12—the pediatric musculoskeletal pain impact summary score

BackgroundDespite the high prevalence of musculoskeletal (MSK) pain in children, there is a lack of instruments to measure the impact of MSK pain on children's activity and participation. ObjectiveTo assess the reliability and construct validity of the Pediatric MSK Pain Impact summary score in school children (aged 9 to 12) with MSK pain. MethodsWe used a pragmatic approach in a reflective framework to assess internal consistency, structural validity, convergent validity, and discriminative validity in a sample of 615 children with MSK pain. ResultsThe confirmatory factor analysis results indicate that the summary score has limited internal consistency and construct validity. The estimated Cronbach's alpha was 0.63, and most goodness of fit indices met the recommended thresholds (SRMR = 0.030; GFI = 0.993, CFI = 0.955, RMSEA 0.073), although they were close to the lower bounds of the thresholds. The convergent validity showed appropriate correlation of the summary score with quality of life (r = -0.33), care-seeking (r = 0.45), and medication intake (r = 0.37). Discriminative validity showed that the instrument can discriminate between the impact of pain on children with frequent and infrequent (2.93; 95% CI: 2.36 - 3.50) MSK pain. ConclusionThe Pediatric MSK Pain Impact summary showed limited internal consistency and construct validity; however, it can discriminate between children with frequent and infrequent pain. The results are promising for clinical and research practices as it is a short and convenient tool to be used in school-aged children.

Musculoskeletal pain in 13-year-old children: the generation R study.

Musculoskeletal (MSK) pain is a common reason for consultation in general practice and frequently reported in children and adolescents. This study examined the prevalence of MSK pain in 13-year-old children and assessed associations with physical and psychosocial factors. Data from the Generation R Study, a population-based birth cohort, was used. Prevalence and characteristics of MSK pain were assessed, using a pain mannequin, at 13 years of age (N = 3062). Demographics and data on physical activity, sedentary behaviors, previous reported MSK pain, and behavioral problems were extracted from questionnaires. The body mass index (BMI) SD-score was calculated from objectively measured weight and height. A prevalence of 23.3% was found for MSK pain in children of which 87.2% persisted for more than 3 months (ie, chronic), 45.5% experienced pain daily. More physically active children and children with a higher BMI reported MSK pain more frequently compared with non-MSK pain and no pain. The knee was the most often reported location. Children with MSK pain were more likely to have reported MSK pain at 6 years. Multivariable analyses showed significant associations for male sex (OR 0.74, 95% CI 0.56-0.98), high maternal educational (OR 0.69, 95% CI 0.49-0.96), higher BMI (OR 1.19, 95% CI 1.05-1.35), being physically active (OR 1.41, 95% CI 1.03-1.91), and behavioral problems (OR 1.85, 95% CI 1.33-2.59) with the presence of MSK pain. The chronic nature of MSK pain in combination with the relatively high prevalence of MSK pain in this study shows that MSK pain is already an important problem at a young age.

Cochrane Corner

This edition of the Cochrane Corner looks at the three reviews that were published in the second half of 2023: surgical versus non-surgical interventions for displaced intra-articular calcaneal fractures; cryotherapy following total knee arthroplasty; and physical activity and education about physical activity for chronic musculoskeletal pain in children and adolescents.

Prevalence of disabling musculoskeletal pain in children and adolescents in Brazil: A cross-sectional study

BackgroundEstimates of prevalence of musculoskeletal pain in children and adolescents vary considerably and the impact of pain on children's life is often not considered. ObjectiveTo determine the one-month prevalence of disabling musculoskeletal pain in children and adolescents. The secondary aims are to: 1) determine the body region with the highest prevalence; 2) understand the characteristics of the children with disabling musculoskeletal pain; and 3) describe the parents' perception of the prevalence. MethodsThis cross-sectional study was conducted in public and private schools in the states of São Paulo and Ceará, Brazil. Children self-reported presence and impact of pain, pain intensity, psychosomatic symptoms, and quality of life. Parents completed parent-proxy versions and perception of the child's sleep quality. Descriptive statistics were used to summarise the data. ResultsA total of 2,688 children and adolescents were included in this study. The prevalence of disabling musculoskeletal pain in the previous month was 27.1%. The back was the region most often affected (51.8%). Children with disabling musculoskeletal pain were older, heavier, had worse relationships with their family, perceived their backpacks as heavy, carried their backpacks more with one shoulder, had more negative psychosomatic symptoms, had poorer quality of life, and had higher pain intensity. Parents tended to underestimate the presence of pain in their children. ConclusionThe one-month prevalence of activity limiting musculoskeletal pain in children and adolescents was 27.1% with the back being the most often affected body region. Parents tended to underestimate the presence of pain in their children.

Approach to Musculoskeletal Pain in Children.

Musculoskeletal (MSK) pain is a common pediatric problem and can occur due to many etiologies. A pediatrician should be clinically equipped to identify the cause of musculoskeletal pain by a meticulous history, a detailed physical examination and judicious use of appropriate investigations. In this review, the authors attempt to delineate the approach and discuss a few common causes of musculoskeletal pain.

Overview of the economic burden of musculoskeletal pain in children and adolescents: a systematic review with meta-analysis.

Studies suggest a high economic burden among children and adolescents with musculoskeletal pain. There is no summary in the literature on the overall economic burden of musculoskeletal pain in children and adolescents. The aim of this systematic review of cost-of-illness studies was to synthesize the economic burden of musculoskeletal pain in children and adolescents. We conducted electronic searches on MEDLINE, EMBASE, CINAHL, EconLit, NHSEED, and HTA databases. We included cost-of-illness studies that estimated healthcare, patient/family, lost productivity, and/or societal costs in children and adolescents with musculoskeletal pain. The risk of bias was assessed with the Consolidated Health Economic Evaluation Reporting Standards checklist. All values were adjusted to the same reference year (2021) and converted to American Dollar. We included 45 cost-of-illness studies (n = 665,623). Twenty-two studies estimated the annual healthcare costs that ranged from $143 to $41,379 per patient. Nine studies estimated the annual patient/family costs that ranged from $287 to $27,972 per patient. Seven studies estimated the annual lost productivity costs that ranged from $124 to $4671 per patient. Nine studies estimated the annual societal costs that ranged from $1095 to $69,351 per patient. Children and adolescents with juvenile idiopathic arthritis and musculoskeletal pain had higher annual incremental healthcare costs than those without these conditions (mean difference: $3800 higher, 95% confidence interval [CI]: 50-7550; mean difference: $740 higher, 95% CI: 470-1,010, respectively). In conclusion, the estimated annual economic burden of children and adolescents with musculoskeletal pain ranged from $124 to $69,351.

The Text Neck Epidemic: Unveiling the Hidden Burden of Neck Pain among Medical Students

Objective: Text neck syndrome, caused by prolonged mobile device use, is increasingly common, especially among teenagers. Neck pain is a significant public health issue, affecting 40% of the population. Little research has focused on musculoskeletal pain in children and adolescents, including medical students. A cross-sectional study is needed to investigate text neck syndrome among medical students and provide effective prevention and treatment strategies. Materials & Methods: This cross-sectional study (n=508) utilized an online self-designed questionnaire incorporating the Neck Disability Index and the Nordic Musculoskeletal questionnaire. Descriptive and inferential statistics, including chi-square tests and p-value calculations using SPSS version 25, were employed. The study aimed to examine neck pain prevalence and consequences to inform interventions for improved health outcomes. Results: Among the 508 participants, 69.4% reported past neck pain. Females, those with higher stress levels, individuals using laptops/tablets for four or more hours, and medical students studying for 4 to 6 hours daily had higher neck pain prevalence (52.0%, 88.2%, 61.9%, and 57.5% respectively). Prevalence remained consistent between pre-clinical and clinical-year medical students. Multivariate analysis revealed a significant association between neck pain and longer mobile phone use, extended study hours, and lack of exercise. Only 16% sought treatment from a chiropractor/physiotherapist for their neck pain.Conclusion: The study emphasizes the importance of better education on neck pain prevention and seeking professional help. Adding exercise to daily routines can also be extremely helpful in preventing neck pain. To fully understand the effect on medical students and develop effective interventions

Scurvy mimic acute Leukemia in a female child and review of literature

Scurvy is a nondiscriminatory disease process resulting from a nutritional deficiency of ascorbic acid (vitamin C). Identifying scurvy can be demanding due to the perceived rarity of the condition, and it can become a tricky diagnostic question given to the variety of nonspecific symptoms, including skeletal and other systems affected. Diffuse musculoskeletal pain in children with no specific cause is usually fugue. Differential diagnoses include growing pain, joint hypermobility, psychogenic disorders, somatoform disorders, inflammatory diseases, and malignancies. Children with leukemia can be referred to the orthopedic when the diagnosis is still unknown; in fact, musculoskeletal pain or radiographic abnormalities can be very frequent at presentation and it could be the primary manifestation of leukemia and scurvy. We report one of rarest cases of patient present with feature of scurvy in developed area mimic Leukemia.

Association of anxiety and depression to headache, abdominal- and musculoskeletal pain in children.

The comorbidity between recurrent pain, anxiety, and depression among children is frequent and well documented. However, only a few studies of the predictive effect of anxiety and depression on pain have adjusted for symptoms of the other disorder when examining the respective relations to different pain locations, rendering the unique contribution from anxiety and depression undetermined. In the current investigation we explore the strength of associations between pain at different locations with symptoms of anxiety and depression in a community sample of 10-year-old children (n = 703). The children were interviewed about the frequency of pain during the last 3 months. Parents and children were interviewed separately about symptoms of anxiety and depression using a semi-structured diagnostic interview. Results of three multivariate regression models for each of headache, abdominal and musculoskeletal pain revealed that depression was associated with musculoskeletal pain and headache, whereas anxiety was not. The associations for depression were not significantly stronger compared to anxiety. Gender-specific models found that depression was related to headache only among girls, but the association was not statistically different compared to boys. These results may, in turn, influence our interpretation of different forms of pain in children, with less weight given to abdominal symptoms viewed as a strong correlate with psychological problems, compared to for instance headache. The results provided no clear support for neither a differential relationship between anxiety and pain and depression and pain nor gender differences.

Pilot study of a ‘Dance Fitness Group’ for children referred to physiotherapy

Keywords: Dance; Compliance; Group Purpose: Deconditioned, hypermobile, and symptomatic musculoskeletal pain in children can cause a reduced level of physical activity leading to weakened muscles and poor tolerance to exercise. Dance and music have been shown to positively affect mood and mental health in individuals, helping to increase compliance of physical activity. Group settings provide evidence for increasing compliance through improving patient's sense of belonging, self-confidence and social engagement. This pilot looks at combining the enjoyment of dance to music in a group setting with physiotherapy strengthening and core exercises to increase engagement, We aim to evaluate the outcome measures to direct the formation of a larger scale study. Methods: The pilot study included children aged 8–16 years old referred by Southampton Paediatric Physiotherapy team with a diagnosis of hypermobility, poor postural fitness and deconditioning with an interest in dance. Children were excluded if they were 7 years old or younger and if they would be unable to follow a group session. The group comprised of a four week (once weekly) group for 45 min consisting of group exercise with warm up, 15 min dance cardio fitness including balance, strengthening, core stability, and cool down sections. A questionnaire assessing patients perceived fitness, pain and overall enjoyment was the outcome measure completed at the beginning and end of the group. Results: Two patients attended the group between November 2020 and December 2020. The post group questionnaire showed both patients found the group very useful or extremely useful. The questionnaire also showed an improvement in sporting activity post group. Both patients also stated an interest in repeating the group and found that it was a positive experience for young people of their age to do fitness in a safe environment. The Coronavirus Pandemic impacted on the sample size of this pilot. Conclusion(s): The results of this small sample pilot have shown very positive outcomes. The pilot highlights the success of using dance as a positive motivator to increase physical activity in those deconditioned and hypermobile patients. The use of music and dance movements helped to engage patients to strengthen weakened muscles and improve compliance to exercise. Future Dance fitness groups could include patients with back pain with the outcome measure Rowland Morris to be used. Limitations of COVID-19 restrictions meant a small sample, however future groups should be repeated on a large scale with up to 6 children in a group. Impact: This was a small scale pilot study which has shown positive evaluation to transform the way we run our groups. With future larger scale quantitative and qualitative results we will further evaluate the impact on our physiotherapy practice. We aim to reduce 1:1 out-patient appointments due to positive outcomes of group treatment using a holistic and innovative approach to improve engagement and compliance to physical activity. Funding acknowledgements: This pilot study was not funded.

Pain medication use for musculoskeletal pain among children and adolescents: a systematic review.

Musculoskeletal pain is common among children and adolescents. Despite the lack of evidence regarding harms and benefits, musculoskeletal pain is often managed with pain medication. The aim of this systematic review is to assess the prevalence of pain medication use for musculoskeletal pain among children and adolescents and the factors and side effects associated with use. Three databases (EMBASE, CINAHL and PsychINFO) were systematically searched to identify studies designed to examine the prevalence, frequency or factors associated with the use of pain medication for musculoskeletal pain in children and adolescents (aged 6-19 years). The included studies were assessed for study quality and data were extracted. The search initially provided 20,135 studies. After screening titles, abstracts and full-texts, 20 studies were included. In school settings, 8-42% of children used pain medication for musculoskeletal pain, and 67-75% of children in sports clubs and from pain clinics used pain medication. The most consistent factors associated with the use of pain medications were pain characteristics and psychological factors (e.g. being bullied, low-self-esteem), while mixed evidence was found for increasing age and female gender. Only two studies reported on the duration of use and only one study on adverse effects related to the use of pain medication. We found that 8-42% of adolescents from school-based samples use pain medication for MSK pain, while the prevalence among adolescents from sports clubs and pain clinics is higher (67-75%). Pain characteristics (pain duration, severity, intensity, disability levels and the presence of≥2 pain conditions or multisite pain) and psychological factors were associated with a higher use of pain medication, while for higher age and female gender the evidence of association was mixed. Future studies should systematically collect information on the type, duration of use of pain medication and side effects to confirm the findings of this review.

A rare cause of chronic musculoskeletal pain in children: complex regional pain syndrome

The Journal of the Postgraduate Institute of Medicine (JPGIM) is an open access, peer-reviewed, biannual journal published by the Postgraduate Institute of Medicine (PGIM) of the University of Colombo (UOC), Sri Lanka. The JPGIM aims to publish articles relevant to clinicians, policymakers, and researchers on topics relating to the practice of medicine, medical education, professionalism, integrity, and ethics of the research enterprise. The JPGIM has been in publication since 2014 and publishes accepted manuscripts online immediately after copy-editing, enabling rapid dissemination of scientific knowledge. The published articles are compiled into two issues in June and December.The Journal practices a double-blind peer review policy. The JPIGM does not charge any article processing or publication fee.We recommend that you review the About the Journal page for the journal's section policies, as well as the Submission Guidelines. Authors need to register with the journal prior to submitting or, if already registered, can simply log in and begin the five-step process.

Efficacy of ibuprofen in musculoskeletal post-traumatic pain in children: A systematic review.

Musculoskeletal (MSK) injuries are one of the most frequent reason for pain-related evaluation in the emergency department (ED) in children. There is still no consensus as to what constitutes the best analgesic for MSK pain in children. However, ibuprofen is reported to be the most commonly prescribed analgesic and is considered the standard first-line treatment for MSK injury pain in children, even if it is argued that it provides inadequate relief for many patients. The purpose of this study was to review the most recent literature to assess the efficacy of ibuprofen for pain relief in MSK injuries in children evaluated in the ED. We performed a systematic review of randomized controlled trials on pharmacological interventions in children and adolescents under 19 years of age with MSK injuries according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The primary outcome was the risk ratio for successful reduction in pain scores. Six studies met the inclusion criteria and provided data on 1028 children. A meta-analysis was not performed since studies were not comparable due to the different analgesic treatment used. No significant difference in term of main pain score reduction between all the analgesics used in the included studies was noted. Patients who received oral opioids had side effects more frequently when compared to children who received ibuprofen. The combination of effect on pain relief and tolerability would suggest ibuprofen as the initial drug of choice in providing relief from mild-to-moderate MSK pain in children in the ED. The results obtained in this review and current research suggest that there’s no straightforward statistically significant evidence of the optimal analgesic agent to be used. However, ibuprofen may be preferable as the initial drug of choice in providing relief from MSK pain due to the favorable combination of effectiveness and safety profile. In fact, despite the non-significant pain reduction as compared to children who received opioids, there are less side effect associated to ibuprofen within studies. The wide range of primary outcomes measured in respect of pain scores and timing of recorded measures warrants a future standardization of study designs.

Comparison of Vitamin D Levels in Children with Musculoskeletal Pain with and without Hypermobility of Joints

Background Vitamin D supplementation has been suggested as a part of an interdisciplinary approach for the management of chronic musculoskeletal pain in children and adolescents. This study aimed to compare vitamin D serum levels in Iranian children with chronic musculoskeletal pain with and without hypermobility. Materials and Methods: This cross-sectional study was performed on otherwise healthy children aged 16 years or younger with chronic musculoskeletal pain, who were admitted to the rheumatology clinic of Bahrami Children Hospital, Tehran, Iran, from January 2018 to January 2019. Chronic musculoskeletal pain was defined as recurrent episodes of musculoskeletal pain within the past month to the past week. The subjects were categorized into two groups, with or without hypermobility. Hypermobility was diagnosed using Modified Criteria of Carter and Wilkinson. Serum 25-hydroxy vitamin D (25-(OH)D) level and baseline characteristics were compared, and 25-(OH)D Results: A total of 72 children (41 girls and 31 boys, with the mean age of 7.36 ± 2.42 years) were included. Most participants (73.6%) were 3 to 7 years old. Sixty-four patients (88.8%) were diagnosed with vitamin D deficiency (25(OH)D Conclusion Our study results suggested a high prevalence of vitamin D deficiency among children and adolescents with chronic musculoskeletal pain, but the difference in vitamin D deficiency between children with and without hypermobility was not statistically significant.

The relationship between the use of personal electronic devices and musculoskeletal pain in children: a systematic review

Purpose: Musculoskeletal disorders (MSDs) in the adult population have increased over the past decade. Evidence suggest that this is due to the rapid development and usage of computer technology and personal electronic devices (PEDs). Research has identified risk factors associated with musculoskeletal (MSK) pain as: duration of use, type of device used, and positions people are using them in. Similarly, children's usage of PEDs has rapidly increased. With this growth comes a need to understand the potential link between PED use and MSK pain in children. There is a dearth of evidence related to risk factors linked to children's use of PEDs and any relationship between this usage and MSK pain. It is important to explore and identify these risk factors.

Relationship between School Backpacks and Musculoskeletal Pain in Children 8 to 10 Years of Age: An Observational, Cross-Sectional and Analytical Study.

Back pain in children is a reality and various factors are involved in its etiology. The study’s aim was to analyze the relationship between the use and type of backpack and pain in children. An analytical observational cross-sectional study was conducted among 123 schoolchildren between 8–10 years. Data on the participants’ weight and height and their backpacks were collected, as well as the way of travel to school and their physical activity during the week. The results indicated that all backpacks were large because the backpack’s height is longer than torso length. Participants who studied in a traditional educational system (62.60%) carried backpacks that exceeded 10% of their body weight. Additionally, 31.7% of the students presented pain. There is no significant correlation between the weight or type of backpack and the pressure pain threshold collected from shoulders muscles. Participants who carried backpacks heavier than 10% of their body weight did not have more musculoskeletal pain or a lower pressure pain threshold than the others, although they did report greater fatigue. All these topics should be debated considering the student’s social environment and the backpack’s discomfort to the children, even though no relationship was found between musculoskeletal pain and backpack weight.

Physical activity and education about physical activity for chronic musculoskeletal pain in children and adolescents

Physical activity and education about physical activity for chronic musculoskeletal pain in children and adolescents

Musculoskeletal pain in 6-year-old children: the Generation R Study.

Musculoskeletal (MSK) pain is frequently reported among adolescents and children and is a common reason for consultation in primary care. Our aim is to examine its prevalence in 6-year-old children in a general population and to assess associations with physical and psychosocial factors. Data from the Generation R Study, a population-based cohort, was used. Prevalence and characteristics of MSK pain were assessed with parent-reported questionnaires at 6 years of age (N = 6200). Demographics and data on physical activity, sedentary behaviors, previous reported MSK pain, and behavioral problems were extracted from questionnaires. The body mass index SD score was calculated from objectively measured weight and height. A 3-month prevalence of 10.0% was found for MSK pain in children, of which one-third was chronic, and 44.6% experienced together with pain at other sites. Univariate analyses showed that boys and children with lower socioeconomic status reported MSK pain more frequently compared to other pain and no pain. Although no associations were found between MSK pain and children's body mass index and physical activity level, children with MSK pain were more likely to watch television ≥2 hours/day. Multivariable analysis showed significant associations for MSK pain at 3 years of age (odds ratio 5.10, 95% confidence interval 3.25-7.98) and behavioral problems (odds ratio 2.10, 95% confidence interval 1.19-3.72) with the presence of MSK pain. So, MSK pain is already common in young children and is often chronic or recurrent. Previous reported MSK pain and behavioral problems are independently associated with MSK pain in the studied population.

Sleep problems and psychological symptoms as predictors of musculoskeletal conditions in children and adolescents.

Population-based studies show that sleep problems and psychological symptoms may increase the risk of musculoskeletal pain onset in children/adolescents. However, there is no evidence of these associations within primary care settings, where interventions can take place. This study investigated whether children/adolescents who consulted their general practitioner for sleep problems or psychological symptoms are at higher risk of subsequent consultations for musculoskeletal conditions. This prospective matched-cohort study used electronic medical records of children/ adolescents (aged 6-19years) from a UK primary care database. Associations between a consultation for sleep problems or psychological symptoms at baseline and a subsequent consultation for musculoskeletal conditions within the 2-year follow-up were investigated using survival analysis, producing hazard ratio (HR) and 95% confidence interval (CI) with adjustment for confounders. Children/adolescents who consulted for sleep problems had a significant increased risk of consultation for musculoskeletal conditions (HR=1.72; 95% CI 1.14, 2.60), which became nonsignificant after adjustment for confounders (HR=1.49; 95% CI 0.98, 2.27). Children/adolescents who consulted for psychological symptoms had a significant increased risk of consultation for musculoskeletal conditions (HR=1.59; 95% CI 1.31, 1.93), which was attenuated after adjustment (HR=1.39; 95% CI 1.14, 1.70). Children and adolescents who visit primary care for sleep problems or psychological symptoms have increased risk of future musculoskeletal consultations. Further work is needed to understand the causal mechanisms that explain these associations, before designing interventions strategies within primary care settings. Population-based studies showed that sleep problems and psychological symptoms may be important precursors of musculoskeletal pain in children and adolescents. By investigating these associations in primary care settings, this study showed that children and adolescents with consultations for sleep problems or psychological symptoms were at increased risk of subsequent consultations for musculoskeletal conditions. These findings support results from population-based studies, and identify potential areas for further research and potential intervention within primary care.