Back Pain Among Long-term Survivors of Childhood

Leukemia
Daniel C. Bowers, MD,*wz Terri Grith, MD,* Lynn Gargan, PhD,z Cindy J. Cochran, RN,
CPNP,w Beverly Kleiber, PhD,w Aleksandra Foxwell, MS,y8 Alan Farrow-Gillespie, MD,z
Angela Orlino, MD,# and Julie N. Germann, PhDy8
Background: The objectives of this study are to determine the
prevalence and relative risk (RR) of back pain and identify possible
mechanisms of back pain among childhood acute lymphoblastic
leukemia (ALL) survivors.
Methods: Surveys were mailed to 5 +-year survivors of childhood
ALL aged 13 to 25 years. Survivors siblings were also invited to
participate in the study. Prevalence of back pain and hip pain
among ALL survivors was determined and compared with siblings.
Sex, treatment with radiation therapy, obesity, and physical
activity were examined for an association with back pain and hip
pain.
Results: Forty-four of 99 (44.4%) ALL survivors reported back
pain compared with 11 of 52 (21.2%) their siblings (P=0.007; RR:
2.01; 95% condence interval =1.15-3.56). In contrast, 10 of 99
(10.1%) ALL survivors reported experiencing hip pain compared
with 1 of 52 (2.0%) siblings experiencing hip pain [P=0.07; RR:
4.95 (0.65 to 37.57)]. Twenty-six of 43 female survivors reported
back pain compared with 18 of 56 male survivors who reported
back pain (P=0.005). Obesity, physical activity, and treatment
with radiation therapy were not associated with back pain or hip
pain.
Conclusions: This is the rst study demonstrating an increased
frequency of back pain among survivors of childhood ALL. Future
studies are needed to better dene the causes of back pain among
childhood ALL survivors.
Key Words: back pain, leukemia, lumbar puncture, late eects,
spine
(J Pediatr Hematol Oncol 2012;34:624629)
A
cute lymphoblastic leukemia (ALL) is diagnosed in an
estimated 2519 children and adolescents per year in the
United States and accounts for 19.1% of all malignancies
among children younger than 19 years of age.
1
Because of
current 5-year survival rates of >80% for children with
ALL, a large majority of children with ALL will become
long-term survivors.
2,3
Coinciding with increasing survival
is an increased recognition that survivors of childhood ALL
have an increased risk of chronic medical conditions.
4
A report by Mody et al
4
from the Childhood Cancer Sur-
vivor Study (CCSS) identied 50% of ALL survivors
reported 1 or more chronic medical conditions. In their
study, survivors were found to be 3.7 times more likely than
their siblings to report a severe or life-threatening chronic
medical condition and 2.8 times more likely to report more
than 1 chronic medical condition. The most frequently
reported chronic medical conditions include musculoskel-
etal, cardiac, and neurological conditions.
4
Because of anecdotal reports at our institution of a
high rate of back pain in the ALL survivor population, we
hypothesized that long-term survivors of childhood ALL
are at an increased risk of back pain. We believe that back
pain is an underappreciated and poorly understood late
eect of childhood ALL survivors. A study by Goldsby
et al,
5
also from the CCSS, compared late occurring neu-
rological decits among childhood ALL survivors and their
siblings. Relative to siblings, ALL survivors were at an
elevated risk for late pain sensation. However, this study
did not provide detailed information about the location of
or potential causes of the pain. There are several possible
contributing factors to the development of back pain
among ALL survivors, including obesity, physical inactiv-
ity, repetitive lumbar puncture, and treatment with radia-
tion therapy; but these have not been demonstrated to have
a causal relationship with back pain. The objectives of this
study are to calculate the prevalence of back pain among
long-term survivors of childhood ALL and determine
whether ALL survivors are at increased risk of back pain.
Furthermore, for patients reporting back pain, this study
attempts to identify risk factors for back pain in this
population.
MATERIALS AND METHODS
The study was reviewed and approved according to the
expedited review process for patient protection and con-
dentiality by the Institutional Review Board of UT
Southwestern Medical Center at Dallas. Eligible patients
were identied from the Clinical and Research Database of
the long-term follow-up program (the After the Cancer
Experience Program) for survivors of childhood cancer of
UT Southwestern Medical Center/Childrens Medical
CenterDallas. Eligibility for the study included being at
least a 5-year survivor of ALL diagnosed before the age of
18 years; currently being between the ages of 13 and 25
years; being in rst complete remission and not having
undergone stem cell transplant. Finally, participants must
have had no known orthopedic abnormalities of the spine
(eg, severe scoliosis, spina bida, osteoarthritis, ankylosing
spondylitis, degenerative disk disease, etc.) and no prior
history of surgical procedures on the spine.
Received for publication March 8, 2012; accepted August 22, 2012.
From the Departments of *Pediatrics; yPsychiatry; #Internal Medicine,
UT Southwestern Medical Center at Dallas; wAfter the Cancer
Experience (ACE) Program; Departments of zAnesthesia; zNeuro-
Oncology; and 8Psychiatry, Childrens Medical Center, Dallas, TX.
The authors declare no conict of interest.
Reprints: Daniel C. Bowers, MD, Division of Pediatric Hematology/
Oncology, UT Southwestern Medical School at Dallas, 5323 Harry
Hines Blvd., Dallas, TX 75390-9063 (e-mail: daniel.bowers@
utsouthwestern.edu).
Copyright
r
2012 by Lippincott Williams & Wilkins
ORIGINAL ARTICLE
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Volume 34, Number 8, November 2012
Pain Assessment Survey
Eligible ALL survivors were mailed a letter inviting
them to participate in the study. The mailing included a
survey asking participants to provide demographic infor-
mation; whether they had back and hip pain (questions
regarding the presence of hip pain were included primarily
to serve as an internal control within patients for the
presence of pain); the location, duration, and severity of the
pain; whether the participant had received radiation ther-
apy as part of their leukemia therapy; and whether they
smoked cigarettes. Survivors were asked to complete the
survey and invite up to 2 siblings within the same age range
to also participate in the survey to serve as a comparison
group. Participants, both survivors and their siblings, were
asked to provide a possible cause for their back pain. The
survey also included the Behavioral Risk Factor Surveil-
lance System Survey Questionnaire,
6
which assesses levels
of physical activity. Variables examined for an association
with back pain among leukemia survivors included sex,
coexisting obesity, physical activity, and treatment with
radiation therapy.
The survey was rst mailed to ALL survivors in
January 2010. Two subsequent mailings followed at 3-week
intervals. After the mailings, telephone calls were made to
the last known telephone numbers of survivors who were
persistent nonresponders.
Assessment of Body Mass Index (BMI) and
Physical Activity
Self-reported height and weight were obtained to cal-
culate participants BMI. The categories used for BMI were
underweight: <18.5 kg/m
2
; normal weight: 18.5 to 24.9 kg/
m
2
; overweight: 25 to 29.9 kg/m
2
; and obese: >30 kg/m
2
.
To dene physical activity, questions regarding phys-
ical activity from the 2005 Behavioral Risk Factor Sur-
veillance System survey, were used with permission from
the Centers for Disease Control and Prevention (CDC).
6
Participants were asked to quantify time spent performing
moderate activities by indicating amount of days per week
and total time per day spent doing certain activities. Par-
ticipants were also asked to quantify the amount of time
performing vigorous activities by assessing days per week
and time per day spent doing certain activities. Participants
were identied as either meeting the CDC recom-
mendations of moderate-intensity physical activity (>30-
min activity on >5 d/wk) or vigorous-intensity physical
activity (>20-min activity on >3 d/wk) or not. All
responses were self-reported. Survey responses completed
with do not know/not sure or refused were coded as
incomplete/missing data.
Sample Size Determination and Statistical
Analysis
The null hypothesis was that there was no dierence
between the frequency of back pain in survivors of child-
hood ALL compared with a sibling comparison group. The
alternative hypothesis was that there was an increased
frequency of back pain among childhood ALL survivors.
On the basis of prior reports of back pain among a young
adult population, the prevalence of lower back pain among
our comparison group was estimated to be 18%.
7
For this
study, the predicted prevalence of back pain among ALL
survivors was 40%. It was also estimated that there would
be 0.67 participating siblings for every participating ALL
survivor. Assuming a 5% type I error and 80% power to
detect a dierence in lower back pain between the ALL
survivors and the sibling comparison group, the study was
estimated to require accruement of 83 ALL survivors and
55 siblings.
The clinical data were expressed as means SD where
appropriate. Clinical parameters were compared using w
2
test. The statistical package SPSS version 15.0 and
Advanced Statistics version 7.5 for Windows (SPSS Inc.,
Chicago, IL) were used to conduct statistical analysis. A P
value <0.05 was considered statistically signicant, and all
tests were 2-tailed. Relative risks (RRs) [including 95%
condence intervals (CIs)] were calculated for self-reported
back pain among leukemia survivors compared with the
sibling cohort. Descriptive statistics were used to identify
demographic features, height, weight, BMI, physical
activity, and treatment with cranial radiation therapy for a
possible association with the subsequent development of
back pain.
RESULTS
One hundred sixty-six survivors of childhood ALL
from the After the Cancer Experience long-term follow-up
program met inclusion criteria and were invited to partic-
ipate in the study. There were 3 active refusals and 58
passive refusals (eg, did not respond to letters or telephone
calls); these nonparticipating survivors will be referred to as
nonresponders. Six additional survivors (several of whom
also had Down syndrome) were excluded because of
parents reporting survivors having poor cognitive func-
tioning and not being able to complete the survey. Surveys
were returned by 99 ALL survivors and 53 siblings. The
numbers of siblings participants per ALL survivors are as
follows: no siblings per participating survivor: 49; 1 sibling
per survivor: 37; 2 siblings per survivor: 6. Overall response
rate of surveys returned by ALL survivors was 60%. Par-
ticipating ALL survivors and nonresponders were not dif-
ferent in sex ratio (P=0.69) and age at diagnosis
(P=0.81). However, nonparticipating ALL survivors were
slightly older at time of study than those who participated
in the study (mean =19.8 vs. 18.6 y; P=0.045).
The ALL survivors included 43 females (43.4%); mean
age =18.1 years, SE=3.34 years (Table 1). Patients eth-
nicities included 57 white/non-Hispanic; 30 Hispanic; 8
black/non-Hispanic; 3 Asian/Pacic Islander, and 1 other.
Their mean height was 166.7 cm (range, 134.6 to 198.1 cm)
and weight was 70 kg (range, 44.3 to 127.3 kg). Calculated
BMIs of ALL survivors identied 43.6% as being over-
weight or obese.
The siblings of ALL survivors were similar to the ALL
survivors with regards to sex, age, ethnicity, height, and
weight. The sibling comparison group included 31 females
(58.5%; P=0.15); mean age =17.6 years, SE=3.1 years
(P=0.32). Siblings ethnicities included 37 white/non-
Hispanic; 11 Hispanic; and 2 black/non-Hispanic (P=
0.28). Their mean height was 167.7 cm (range, 152.4 to
188 cm; P=0.61) and weight was 69.0 kg (range, 50 to
136.4 kg, P=0.76). Calculated BMIs of siblings of ALL
survivors identied 18.2% as being overweight or obese,
which was signicantly less than the ALL survivors
(P=0.01).
Forty-four of 99 (44.4%) ALL survivors reported
experiencing back pain compared with 11 of 53 (21.2%)
siblings experiencing back pain (P=0.007; RR: 2.01; 95%
CI, 1.15-3.56; Table 2). Twenty-six of 99 (26.3%) ALL
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survivors reported experiencing back pain of longer than
6-month duration compared with 6 of 50 (12%) siblings
experiencing back pain of longer than 6-month duration
(P=0.037; RR: 2.26; 95% CI, 0.99-5.12). In contrast, 10 of
99 (10.1%) ALL survivors reported experiencing hip pain
compared with 1 of 50 (2%) siblings experiencing hip pain
(P value =0.07; RR: 4.95; 95% CI, 0.65-37.57).
Variables examined for an association with back pain
among leukemia survivors included sex, coexisting obesity
(determined by self-reported BMI), physical activities
(determined by CDC recommendations of moderate and
vigorous activity), and treatment with radiation therapy
(Table 3). Back pain was reported by 26 of 43 (60.5%)
female survivors compared with 18 of 56 (32.1%) of male
survivors (P=0.005). Back pain was more frequently
reported among female ALL survivors than male survivors
when compared with siblings of the same sex. 60.5% of
female ALL survivors reported back pain compared with
only 14.3% of female siblings (Pr0.001; RR=4.23; 95%
CI, 1.66-10.82). In comparison, 32.1% of male ALL sur-
vivors reported back pain compared with 31.8% of male
siblings (P=0.978; RR=1.01; 95% CI, 0.049-2.08).
Of 44 ALL survivors who reported back pain, 4 (9%)
met CDC recommendations for moderate activity, 9
(20.5%) survivors met CDC recommendations for vigorous
activity, and 3 (7%) met CDC recommendations for both
vigorous and moderate activity. Of 55 ALL survivors who
denied back pain, 4 (10.8%) met CDC recommendations
for moderate activity and 11 (35.1%) met CDC recom-
mendations for vigorous activity, and 13 (32.4%) met CDC
recommendations for both vigorous and moderate activity
(P=0.17). Although ALL survivors were more likely to be
classied as overweight or obese compared with their
siblings (Table 1, P=0.01), survivors who were identied
as being overweight or obese were not more likely to report
back pain (Table 3; P=0.54). Finally, treatment with
radiation therapy was not associated with back pain
(P=0.18). Self-reported causes of back pain among 41
respondents included lumbar punctures and/or treatment
eects [n =14 (34.1%)], other [n =13 (31.7%)], and
trauma [n =7 (17.1%)].
DISCUSSION
This is the rst study examining the prevalence of self-
reported back pain among long-term survivors of
TABLE 1. Description of Study Subjects and Their Participating
Siblings
Survivor No.
(%)
Sibling No.
(%) P
No. participants 99 50
Sex
Female 43 (43.4%) 28 (56.0%) 0.15
Ethnicity
Black, non-Hispanic 8 (8.1%) 2 (4.0%) 0.28
White, non-Hispanic 57 (57.6%) 37 (74.0%)
Asian or Pacic
Islander
3 (3.0%) 0
Hispanic 30 (30.3%) 11 (22%)
Other 1 (1.05) 0
Mean age (y) 18.1 (3.34) 17.6 (3.1) 0.32
Height (cm) 166.7 (11.1) 167.7 (9.8) 0.61
Weight (kg) 70.0 (15.5) 69.0 (17.1) 0.76
BMI category (kg/m
2
)
Underweight (<18.5) 7 (8.0) 2 (4.5) 0.01
Normal weight (18.5-
24.9)
42 (48.3) 34 (77.3)
Overweight (25-30) 27 (31.0) 4 (9.1)
Obese (>30) 11 (12.6) 4 (9.1)
Smoking 3 (3.0) 1 (9.1) 0.33
BMI indicates body mass index.
TABLE 2. Presence of Hip Pain and Back Pain Among Survivors
and Siblings
Survivor
No. (%)
Siblings
No. (%) P
No. participants 99 50
Reported back pain 44 (44.4%) 11 (22%) 0.007
RR=2.01
(1.15-3.56)
Reported back pain
>6 mo
26 (26.3) 6 (12.0) 0.037
RR=2.26
(0.99-5.12)
Mean duration of back
pain (mo)
11.4 3.7
Reported hip pain 10 (10.1) 1 (2.0) 0.07
RR=4.95
(0.65-37.57)
Reported hip pain
>6 mo
6 (6.1) 1 (2.0) 0.28
RR=2.97
(0.37-23.99)
Mean duration of hip
pain (mo)
1.6 2.4
RR indicates relative risk.
TABLE 3. Variables Associated With Back Pain Among Leukemia
Survivors
Variable
Reported Back
Pain No. (%)
Denied Back
Pain No. (%) P
No. participants 44 55
Females 26 (59.1) 17 (30.9) 0.005
Males 18 (40.9) 38 (69.1)
BMI (kg/m
2
)
Underweight
(<18.5)
3 (7.9) 4 (8.2) 0.56
Normal weight
(18.5-24.9)
17 (44.7) 25 (51)
Overweight (25-30.9) 11 (28.9) 16 (32.7)
Obese (>30) 7 (18.4) 4 (8.2)
Physical activity
Not met 11 (44%) 9 (21.6%) 0.17
Moderate only 3 (12) 4 (10.8)
Vigorous only 8 (32) 13 (35.1)
Both moderate and
vigorous
3 (12) 12 (32.4)
Treatment with
radiation therapy
9 (20.5) 18 (32.7) 0.18
Self-reported cause of back pain
Lumbar puncture or
treatment-related
14
Other 13
Trauma 7
Do not know 7
BMI indicates body mass index.
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childhood ALL. This study identies a statistically sig-
nicant increased frequency of back pain among long-term
survivors of childhood ALL when compared with their
sibling cohort. This study also identies ALL survivors as
being more likely to report chronic back pain, dened as
experiencing back pain for longer than 6-month duration.
In contrast, this study did not identify an increased
frequency of hip pain among ALL survivors compared with
their siblings. Interestingly, the excess cases of self-reported
back pain occurred among females. There was a non-
signicant trend between the amount of physical activity
and reported back pain. Overweight and obese survivors
did not appear to be at increased risk of back pain and a
history of radiation therapy did not appear to be associated
with subsequent back pain.
There is little literature describing pain among child-
hood leukemia survivors. One such study from Elmantaser
et al
8
reported musculoskeletal pain among 26% of 186
ALL survivors. The most common sites of pain were the
lower extremities (54%), spine and pelvis (26%), and upper
extremities (11%). A study by Goldsby et al
5
from the
CCSS examined late occurring neurological decits among
4151 childhood ALL survivors and 3899 of their siblings.
Relative to the sibling control group, the ALL survivors
were at a signicantly increased risk of late pain
sensation. The RR of reporting pain compared with their
sibling cohort was 3.0 (P=0.001). Although this study has
a very large number of study subjects, this study is limited
because of lacking details of the pain, including the location
and cause of pain, and thus is not able to comment upon
back pain among ALL survivors.
This study identies a higher prevalence of back pain
among female ALL survivors than male ALL survivors. A
recent study examining neuromuscular impairments among
ALL survivors by Ness et al
9
determined that female ALL
survivors were more likely to have balance problems
(P=0.005) and limited mobility (P<0.001) than male
ALL survivors, which may contribute to back pain. In
contrast, a study by Elmantaser et al
8
described an equal
rates (29%) of musculoskeletal pain between male and
female ALL survivors treated on UK ALL trials. In their
study, musculoskeletal morbidity was associated with
treatment with dexamethasone and older age at diagnosis,
but not sex. The study from the CCSS by Goldsby et al
5
classied pain, including back pain, as focal neurologic
dysfunction and did not identify a dierence in prevalence
of focal neurological dysfunction between male and female
survivors of childhood ALL. Studies of back pain in the
general population have mixed results. This study identied
a higher prevalence of back pain among the male siblings
than female siblings. A study by Auvinen et al
10
reported an
increased frequency of lower back pain among females than
males, but a report by Feldman et al
11
did not identify an
association of back pain and sex.
Possible mechanisms for back pain among ALL sur-
vivors include compression fractures, bone demineraliza-
tion, physical inactivity, obesity, and repetitive trauma
from lumbar punctures. Halton et al
12
prospectively eval-
uated 186 children with ALL at time of initial diagnosis and
found a 16% rate of vertebral compression fractures. The
location of the compression fractures included the T6, T7,
and L2 vertebrae. Furthermore, compression fractures were
often painful. The investigators were not able to identify a
correlation between compression fractures and age at
diagnosis, sex, leukemia subdiagnosis, white blood count,
leukemia risk category, height, weight, pubertal stage, bone
age, or family history of osteoporosis. However, this study
was not able to comment upon the long-term outcome of
children with compression fractures and whether these
fractures improved after completion of therapy and
through new bone growth.
Decreased bone mineralization may lead to osteopo-
rosis and osteonecrosis, which can contribute to back
pain.
8,13,14
Furthermore, it seems that bone demineraliza-
tion may continue after completion of therapy.
1416
Warner
et al
17
also reported that ALL survivors had an increased
risk of decreased bone mineral density, which appeared to
be associated with decreased physical activity and obesity.
A recent prospective study by te Winkel et al
18
identied a
6.1% rate of osteonecrosis among survivors of childhood
ALL. Older age at initial diagnosis and female sex were
associated with the development of osteonecrosis, but not
BMI and risk group. Importantly, and consistent with prior
reports, osteonecrosis involved the weight bearing bones of
the lower extremities but not the vertebral bones. Strauss
et al
19
reported that children with ALL have a prevalence of
fractures and osteonecrosis of 30%. In their study, older
children, males, and patients treated with dexamethasone
(vs. prednisone) were at increased risk of bony morbidities.
In their study, the vast majority of fractures and osteo-
necrosis occurred in long bones; only 4 of 176 children had
fractures involving vertebrae. The authors attributed
steroid therapy as the most likely cause of the bony mor-
bidities, but also recognized that the underlying disease
process
20
and other chemotherapy agents (methotrexate
and doxorubicin)
19
have been implicated in bone injury. A
report by Abbas et al
21
described 6 children with ALL who
complained of severe back pain. In their report, the onset of
back pain occurred at a median of 2 years after completion
of therapy (range: end of induction4 y after completion of
therapy). Examination of bone mineral density by com-
puted tomographic scan revealed severe osteoporosis. All
patients responded well to treatment with oral calcium and
vitamin D supplementation.
Decreased physical activity may contribute to back
pain and possibly explain the observed increased risk of
back pain among female ALL survivors. A study by Heath
et al
22
reported no dierence in reports of moderate to
vigorous physical activity among ALL survivors when
compared with healthy children. However, females were
much less likely to engage in moderate to vigorous physical
activity than males (P=0.029). A study by Florin et al
23
identied ALL survivors as being more likely to not meet
CDC recommendations for physical activity when com-
pared with siblings (52.8% vs. 48.2%; P<0.001) and
females were more likely than males to not meet CDC
recommendations for physical activity (P=0.006). How-
ever, in our study, there was no association (P=0.17)
between patients reporting no physical activity and back
pain. We also considered a potential contributing role of
obesity in ALL survivors to subsequent back pain among
ALL survivors. For example, female ALL survivors treated
with >20 Gy cranial radiation therapy are at increased risk
of obesity.
24
However, our study found the rates of obesity
(P=0.56) and treatment with radiation therapy (P=0.18)
were not dierent among ALL survivors with back pain
and without back pain.
Interestingly, in this study, 14 of 44 (31.8%) survivors
who reported back pain identied the repetitive lumbar
punctures received as part of ALL treatment as the cause of
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their back pain. It seems reasonable that repetitive trauma
to the supraspinous and interspinous ligaments may lead to
instability and inammation and subsequently to back
pain, though this study does not establish a cause-and-eect
relationship between lumbar punctures and subsequent
back pain.
Several limitations of this study should be considered
when interpreting its ndings. First, data for this study was
prospectively collected from a self-reported survey. How-
ever, the rates of back pain in the sibling comparison group
in this study (22%) is similar to that reported in other
studies examining back pain among young adults (17% to
20.5%) in the general population,
7,11,25,26
thus suggesting
that the rate of self-reported back pain among participants
siblings in this study is reasonably accurate. Second, we
acknowledge that the survey we used in this study has not
been externally validated, but we believe that the question,
Do you have back pain? is not a leading question, espe-
cially when deliberately paired with Do you have hip
pain? that serves as an internal control question and was
found to have an equal prevalence in both groups. Third,
this study did not examine and validate participants med-
ical records to determine whether dierences in therapy,
such as type and cumulative dose of corticosteroids or
number of lumbar punctures or number of traumatic
lumbar punctures, contributed to back pain. Also, BMIs
and physical activity calculations are based on self-reported
heights and weights, which Garmey et al
27
argues are gen-
erally accurate and do not contribute signicantly to error
of BMI calculations. Finally, we recognize that non-
responding ALL survivors were older at time of study than
participating ALL survivors (19.8 vs. 18.6 y), which is
perhaps explained by older ALL survivors being less likely
to be living with their parents and not receiving the mailed
survey or being busy with college or careers and less willing
to take the time to respond to the survey. Nevertheless, this
dierence is relatively small and does not substantially
inuence the results or conclusions of the study.
In summary, this is the rst study to demonstrate an
increased frequency of back pain among survivors of
childhood ALL. In our study, females seem to be at higher
risk of back pain than males. Although some patients
believe repetitive lumbar punctures may be the cause of
their back pain, future studies are needed to better under-
stand the causes of back pain among ALL survivors and
possibly modify ALL therapy to reduce the rates of back
pain. Furthermore, we recommend that all clinicians pro-
viding care for young adult survivors of childhood ALL
inquire about the presence of back pain. For those survi-
vors identied as having back pain, there is a need for
pediatric oncologists, cancer survivors specialists, physical
medicine and rehabilitation specialists, and physical thera-
pists to develop strategies to improve exibility, promote
weight loss, and enhance physical activity, as it may reduce
the occurrence of back pain among ALL survivors.
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