Factors Influencing Participation in Physical Activity, Sports, and Exercise in Children and Adolescents with Spinal Pain or Spinal Conditions: A Systematic Review and Meta-Ethnography
- To describe factors influencing participation in sports, exercise, and PA in children and adolescents aged 18 years or under with thoracic or lumbar spinal pain or diagnosed conditions;
- To identify any trends or differences in factors influencing participation between discrete sub-populations, such as age, gender, or spinal condition.
2. Materials and Methods
2.1. Patient and Public Involvement
2.2. Eligibility Criteria
2.3. Information Sources
2.4. Search Strategy
2.5. Data Management
2.6. Selection Process
2.7. Data-Collection Process
2.8. Data Items
2.9. Risk of Bias in Individual Studies
2.10. Outcomes and Prioritisation
2.11. Synthesis Methods
2.12. Reporting Bias and Trustworthiness Assessment
2.13. Certainty Assessment
3.1. Study Selection
3.2. Study Characteristics
(n = Children,
p = Parents,
c = Caregivers)
(F n = Female Children,
M n = Male Children,
F p = Female Parents,
M p = Male Parents,
F c = Female Caregivers,
M c = Male Caregivers)
|Bloemen, et al. (2015) ||4–7 years olds:|
n = 11
c = 33
p = 31
|4–7 years olds:|
F n = 4
M n = 7
8–18 years olds:
F n = 15
M n = 18
|n = 11 × 4 to 7|
n = 33 × 8 to 18
|Spina bifida||A rehabilitation centre, |
a paediatric physiotherapy
institution, or in the home
situation in The Netherlands.
|Gorzkowski, et al. (2011) ||c = 201||F n = 52%|
M n = 48%
|n mean age at|
interview = 12.60
n mean age at
injury = 7.19
|Spinal-cord injury||Three paediatric spinal-|
cord injury centres.
et al. (2019) 
|n = 10||F n = 4|
M n = 6
|n = 7 to 18||Spinal |
|Participants were recruited from three main rehabilitation centres from the north (n = 3), the middle (n = 3), and the south (n = 4) of the West Bank in Palestine.|
|Page and Coetzee (2021) ||n = 7||F n = 2|
M n = 5
F c = 2
M c = 5
|n = 13–16|
n mean age = 14.5
c = 39–75
c mean age = 49.5
|The Cape Flats,|
central Cape Town,
et al. (2021) .
|n = 32||F n = 20|
M n = 12
|n = 9 to 17|
n mean =13
n = 13 × 9 to 12
n = 9 × 12 to 15
n = 10 × 15 to 18
|Achondro-plasia||16 participants |
from the USA, and
et al. (2020) .
|n = 9||F n = 6|
M n = 3
|n = 1 × 14|
n = 2 × 15
n = 3 × 16
n = 3 × 17
n mean = 15.9
|Spina bifida outpatient |
clinic at a rehabilitation
centre located in a large
urban centre in Canada.
et al. (2021) .
|n = 8||F n = 4|
M n = 4
|n = 14 to 17 |
n mean = 15.4
|Returning to PA following spinal|
et al. (2015) .
|n = 11|
|F n = 7|
M n = 4
F p = 7
M p = 3
|n = 1 × 6|
n = 1 × 8
n = 1 × 9
n = 3 × 10
n = 1 × 14
n = 1 × 15
n = 1 × 16
n = 1 × 17
n = 1 × 18
|Spina bifida clinic at |
a large paediatric
rehabilitation hospital in Canada.
|Strömfors, et al. (2017) .||n = 8||F n = 4|
M n = 4
|n = 1 × 10|
n = 1 × 11
n = 1 × 12
n = 2 × 14
n = 1 × 15
n = 2 × 17
|Swedish children and adolescents. Recruitment took place at a bowel- and bladder-functions clinic for children and adolescents with SB.|
Two participants completed interviews at home.
Six participants completed
interviews at a local health-care facility that they
3.3. Study Trustworthiness
3.4. Results of Individual Studies
3.5. Results of Synthesis
3.5.1. Theme 1: Biological Factors
Subtheme 1: Challenges to PA, Sports, or Exercise Participation Resulting from Biological Aspects of Physical Condition
‘If he wants to go to a sledge hockey camp overnight and this kind of thing for a week, that’s the kind of thing you need to have more independence with’
‘… but still being aware if there is back pain… how much of it’.
- CERQual Summary:
Subtheme 2: Bladder and Bowel Care and Its Impact on Participation in PA, Sports, and Exercise
‘whenever I run [my bladder] just lets go’ (10 years, female)
‘The reason that I have not told my friends, is that I see how they are now. Young people, and now I mean people my age, they are kind of, what can I say, immature, or they say certain things. They think that if a person is different, then that person is a freak or something like that. That is why I have not dared [to tell them about having SB]’ (15 years, male).
‘Everything is difficult in my life. I feel tired of living with incontinence and diapers… I hate the catheterization… I wondered why children like me with spina bifida should stay alive’ (12 years, female)
- CERQual Summary:
3.5.2. Theme 2: Psychological Factors
Subtheme 3: Feelings of Struggle and Needing for Physical Assistance from Others; Desire for Independence When Participating in Sports, Exercise, and PA
‘I would like to join a public sports club. I love swimming and playing football with other children… I am very sad… It is difficult to reach these areas… I am not allowed to participate… I prefer to stay home’ (16 years, male)
- CERQual Summary:
Subtheme 4: Children and Adolescents Perceiving Themselves as Different from Their Peers; That They Do Not Fit in due to Physical Differences Limiting Activity Participation
‘The school took me out of my comfort zone… I became aware that I’m different from some children who stared at me and made fun of my shaky walk’ (12 years, female)
- CERQual Summary:
Subtheme 5: Emotions of Anger, Fear, or Sadness towards Limited Participation in School Activities and Social Events
‘I would like to join a public sports club. I love swimming and playing football with other children… I am very sad… It is difficult to reach these areas… I am not allowed to participate… I prefer to stay home’. (Boy, 16)
‘It sucked for a while; I was a pretty active person so the first 6–7 months kind of sucked’.
- CERQual Summary:
Subtheme 6: Need to Adjust and Accept Spinal Pain or Disability and Its Influence on Participation in Sports, Exercise, and PA
- CERQual Summary:
‘I went through very many emotional rollercoasters to finally realise that I was not like every-one else and I had to accept that’ (14 years, female)
- CERQual Summary:
3.5.3. Theme 3: Sociological Factors
Subtheme 7: Fear and Worry towards Participation in Sports, Exercise and PA; Fear towards Socialising in a Sports Group and Peer Rejection
‘Of those killing, killing kids, girls, taking girls and grabbing them and killing taking the body parts. I don’t go outside anymore. I never go outside’ (13 years, female).
- CERQual Summary:
Subtheme 8: Dependence of Child on Caregivers and Impact on Routine (Work, Family, and Time)
‘Managing university studies alongside a serious health condition and restrictions in mobility can be a daily struggle. I will not be able to study at university, or to work and get married. I’m afraid of what will happen to me if my mother is no longer able to care for me… who will help me in this miserable life?’ (14 years, male)
- CERQual Summary:
Subtheme 9: Negative Attitudes from Others and Lack of Social Acceptance; Experiencing Ridicule and Feeling Ashamed
‘The reason that I have not told my friends is that I see how they are now. Young people, and now I mean people my age, they are kind of, what can I say, immature, or they say certain things. They think that if a person is different, then that person is a freak, or something like that. That is why I have not dared (to tell them about having SB)’ (15 years, male).
- CERQual Summary:
Subtheme 10: Friends Providing Needed Emotional Support and Role Models
Three participants reported ‘many close friends’, ‘weekly sleepovers with friends’, and ‘a consistent group of close friends that she spent time with every weekend’
- CERQual Summary:
Subtheme 11: Youth Dependent on Parents for Physical and Emotional Advice or Support
‘I knew that I had to because my parents aren’t going to be there in Grade 1 and I just didn’t want everybody knowing and I didn’t want everybody to be involved in it. I’m just like okay, I’m gonna do it’ (9 years, female)
- CERQual Summary:
Subtheme 12: Lacking Information or Support from Sports Counsellors, Local Clubs or Organisations Regarding PA
‘A lot of things you have to find out yourself… I do miss that…I think, if you’re in a hospital, we visit the hospital regularly, that there should be…more information…and listening to what the child wants and I do miss that…they ask for example ‘how is it’, ‘yes everything goes well’ he (the child) says, well he always says everything goes well…but I think…you should ask ‘what else do you want, how is it going with playing sports, do you play sports’, it is always about what school do you go to and that’s that’ (Parent, child 8–18 years, unknown gender).
- CERQual Summary:
Subtheme 13: Desire to Be Active and Increase Environmental Access
‘Cause I don’t wanna be, like, in a wheelchair—it’s not fun to be in. Then I can do nothing, like, say (me) now I wanna go play soccer, then I can’t cause I’m in here. And then I can’t do what other children can do’ (13 years, male).
- CERQual Summary:
- Certainty of evidence
4.1. Strengths and Limitations
4.2. Clinical Implications
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
Appendix A. PRISMA Flow Diagram
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|Sample:||Studies were eligible if they included: (a) children or adolescents aged 18 years or under, |
(b) experiencing thoracic or (c) lumbar spinal pain, or with any diagnosed spinal condition.
Studies were excluded when there was a pure focus on the experience of neck pain.
|Studies had to report on the effect of thoracic or lumbar diagnosed spinal condition or spinal pain on physical function. Studies were required to include qualitative data from participants who were aiming to participate in, or who were participating in, any kind of physical functioning, PA, exercise, or sports. Studies examining participation in PA as part of physiotherapy and rehabilitation following medical interventions were included, provided factors influencing participation were examined.|
|Design:||Types of qualitative data were required for inclusion. |
The different types included (but not limited to): ethnography, descriptive approaches, types of
phenomenology, patient narratives, case studies, types of grounded theory, and action research. Studies were included where there was a clear identification, collection, and analysis of qualitative data.
|Evaluation:||Studies had to include qualitative factors influencing participation in exercise, sports, and PA. |
Qualitative interviews, field notes, open questions, or focus groups that identified data surrounding PA, exercise, or sports were also included. Studies that only contained quantitative data, or that
did not identify patient experiences, beliefs, or perceptions, were excluded.
|Qualitative studies and mixed-methods studies were included. |
Conference proceedings, abstracts only, editorials, and opinions were excluded.
|Other:||Studies where the language was not translatable into English were excluded.|
Studies requiring translation had to be translated by two authors independently.
Both authors had to agree that the clarity and language was clear and without substantial error.
Studies where the full text was unavailable from the inter-library loan system were excluded.
|1||‘adolescen *’ OR ‘child *’ OR ‘teen *’ OR ‘youth’ OR ‘young person’ OR ‘juvenile *’|
|2||‘back’ OR ‘spinal’ OR ‘thoracic’|
|3||‘barrier *’ OR ‘facilitator *’ OR ‘reason *’ OR ‘feeling *’ OR ‘belief *’ OR ‘obstacle *’ OR ‘challenge *’|
|4||‘exercise *’ OR ‘physical activit *’ OR ‘sport *’ OR ‘physical *’ OR ‘activ *’|
|5||‘questionnaire *’ OR ‘focus group *’ OR ‘interview *’|
|6||‘participation’ OR ‘quality of life’ OR ‘QOL’|
|7||‘qualitative’ OR ‘mixed method *’ OR ‘narrative’ OR ‘grounded theory’ OR ‘phenomenology’ OR ‘ethnography’ OR ‘action research’ OR ‘case studies’|
|8||1 AND 2 AND 3 AND 4 AND 5 AND 6 AND 7|
|Theme 1: Biological Factors||Theme 2: Psychological Factors||Theme 3: Sociological Factors|
|Challenges to PA, sports, or exercise participation resulting from|
biological aspects of physical
|Feelings of struggle and needing |
for physical assistance from others.
Desire for independence when
participating in sports, exercise,
|Fear and worry towards participation in sports, exercise, and PA. |
Fear towards socialising in a
sports group and peer rejection.
|Bladder and bowel care and its |
impact on participation in PA,
sports, and exercise.
|Children and adolescents perceiving themselves as different from their peers, and that they do not fit in.||Dependence of child on |
caregivers and impact on
routine (work, family, and time).
|Emotions of anger, fear or sadness|
towards limited participation in
school activities and social events.
|Negative attitudes from others |
and lack of social acceptance.
Experiencing ridicule and
|Need to adjust and accept spinal |
pain or disability and its influence
on participation in sports,
exercise, and PA.
|Friends providing needed |
and role models.
|Youth dependent on parents for|
physical and emotional advice
|Lacking information or support from sports counsellors, local clubs or|
organisations regarding PA.
|Desire to be active and increase|
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© 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Tucker, S.; Heneghan, N.R.; Gardner, A.; Rushton, A.; Alamrani, S.; Soundy, A. Factors Influencing Participation in Physical Activity, Sports, and Exercise in Children and Adolescents with Spinal Pain or Spinal Conditions: A Systematic Review and Meta-Ethnography. Behav. Sci. 2023, 13, 486. https://doi.org/10.3390/bs13060486
Tucker S, Heneghan NR, Gardner A, Rushton A, Alamrani S, Soundy A. Factors Influencing Participation in Physical Activity, Sports, and Exercise in Children and Adolescents with Spinal Pain or Spinal Conditions: A Systematic Review and Meta-Ethnography. Behavioral Sciences. 2023; 13(6):486. https://doi.org/10.3390/bs13060486Chicago/Turabian Style
Tucker, Susanna, Nicola R. Heneghan, Adrian Gardner, Alison Rushton, Samia Alamrani, and Andrew Soundy. 2023. "Factors Influencing Participation in Physical Activity, Sports, and Exercise in Children and Adolescents with Spinal Pain or Spinal Conditions: A Systematic Review and Meta-Ethnography" Behavioral Sciences 13, no. 6: 486. https://doi.org/10.3390/bs13060486