Low back pain in adults with cerebral palsy: Toward comprehensive, lifelong, and equitable care

Low back pain (LBP) is the world's leading cause of disability.1 But the limited literature on the impact of LBP on individuals with another cause of disability raises an important issue of equity. The paper by Stutzbach et al.2 offers a very interesting exploration of this surprisingly under-researched area: specifically, the relationship between nonspecific LBP and cerebral palsy (CP). Various reasons may have contributed to the delay in exploring this field, including: (1) the frequent resilience of individuals with disabilities, who tend to accept pain as an inevitable effect of their health condition; (2) the possible resignation to (or even underestimation of) the clinical situation (LBP) by caregivers and health professionals, who consider it secondary to the primary neurological health condition (CP); and (3) the research need to focus on highly prevalent conditions, excluding by design all comorbidities: individuals with disabilities meet the exclusion criteria for most trials, while inclusion in research is a necessary first step toward appropriate health care for adults with CP.3 The current increased emphasis on equity in research, combined with the availability of large data sets and advanced informatics and statistical tools, enables us to study new highly relevant (albeit numerically less prevalent) subpopulations and generate meaningful insights. Such studies can initiate a virtuous cycle, leading to increased awareness among caregivers and health personnel, and subsequently, a more effective approach to the health concerns of individuals with disabilities. CP has recently been reframed as a lifelong physical disability.3 In many countries, there are already more adults than children with CP, and they need a continuous interdisciplinary follow-up by a multiprofessional rehabilitation team across the lifespan. Knowledge about possible causes of LBP in adults with CP can inform strategies for prevention and early intervention, and reduce the chance of chronicity. A key principle of habilitation in children is to prevent health issues in one anatomo-physiological system from interfering with another, thereby avoiding secondary health complications. The overall aim is to enable patients to reach adulthood in the best possible health, thereby facing the rest of their lives to their fullest potential. Learning more about adult issues, such as LBP, can lead to a deeper understanding of how to approach growth and transition into adulthood. The study by Stutzbach et al. has another significant impact. LBP has been recognized as a bio-psycho-social issue since the end of the 1980s.4 Treatments for chronic LBP mainly focus on the psychosocial aspect because it is difficult to target the biological issues precisely.5 However, there are areas, such as those involving physical disabilities, where a common biological background exists, and the contribution of the biological component in the bio-psycho-social model could be explored with more robust information. Many factors can potentially cause LBP in individuals with CP, such as spasticity, muscle weakness and imbalance, joint contractures, and scoliosis. Impaired and asymmetrical gait patterns can alter alignment and biomechanics, leading to overload and degenerative changes in the spine during adulthood. The lack of studies to confirm or refute these hypotheses is striking. Also, the effect of using assistive devices would be interesting to assess. Stutzbach et al.'s study paves the way in this direction, even if they limited the exploration of the biological aspect, also due to the constraints of the available survey-based data. We highly appreciate the focus on functioning (ambulant or not) rather than on the health condition or CP subtype, even though the latter would also be important. Moreover, various levels or types of gaits could be relevant. Similarly, the self-report of progressively reduced mobility can be both a physical sign and a perception that requires verification. Future studies, grounded in the present paper, should lead to an increased understanding. The work of both authors was supported and funded by the Italian Ministry of Health, "Ricerca Corrente". Not required.