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ATHLETIC LOW BACK PAIN: STRATEGIES TO

ENHANCE MOVEMENT QUALITY AND

CONTROL

Phil Glasgow PhD, MCSP

Volu

me 5

1 Issu

e 1

3 Pages 9

85–1046

BRIT

ISH

JOU

RN

AL O

F SPO

RTS M

ED

ICIN

E

July

2017

51

13

July 2017 Volume 51 Issue 13

2nd World Congress

of Sports Physical Therapy

Belfast, 6th–7th October 2017

Optimal Loading in Sport

www.telegraph.co.uk

INJURY vs.

PAIN?

Low Back Pain in Sport: A Common Problem

• Great Britain Olympic athletes 2009 - 2012

• 11 Olympic sports

• Thoracic and lumbar spine injury 14.2% of all injuries

• 737 days missed from training and competition

Palmer-Green et al. J Sports Med 2013

Low Back Pain in Sport: A Common Problem

• Rowing: Most common problem (Smoljanovic et al AJSM, 2009; Hickey et al MSSE 1997; Wilson et al

BJSM 2010)

• Cross country skiing: 63% 1 yr prevalence (Bahr et al 2004)

• Judo: 35-62% prevalence of non-specific low back pain (Yamaji et al, 1992; Okada et al, 2007)

• Tennis: Most common problem in adolescent players (Hutchinson et al 1995). Most common chronic complaint (Dines et al 2015; Abrams et al BJSM)

• Cricket: 8-14% incidence (> fast bowlers) (Orchard et al BJSM 2002)

• Beach Volleyball: Most common overuse injury (19%) followed by shoulder (17%) (Bahr et al 2003)

• Golf: Most common injury, 25–36% of all injuries (Fradkin et al, 2005; Gluck et al, 2008; Gosheger et al, 2003)

• Field Hockey: Reported by 59% of athletes (Murtagh, Med. Sci. Sports Exerc. 2001)

• Juvenille Athletes: More treatment but less improvement in disability than matched controls…worse prognosis? (Fritz & Clifford, JAT, 2010)

Athletic LBP: Is The Pain…

Pathology DrivenPsychosocially

DrivenMovement Driven

Management Decisions Should Reflect Impact of the Key Drivers

Red flags*

Pathoanatomical disorders e.g.:

• IVD prolapse

• Spinal and foraminalstenosis with Radicular pain

• Neurological deficits

• Internal disc disruption • Inflammatory pain

Anxiety, Fear, Anger

DepressionNegative beliefs

Emotional issues

Poor coping strategies Negative social and

interpersonal circumstances

Painful…aberrant movement

patternsMuscle imbalances

Rigidity – reduced

adaptabilityDevelop 20 altered beliefs

and experience of movement

Increased maladaptive movement patterns

Turk, 2005; Boersma and Linton, 2006; Hill et al., 2010; Dankaerts et al., 2009;

Smart et al., 2011; Bjorck-van Dijken et al., 2008; Mitchell et al., 2010

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Movement Quality

and Control

Which factors are

important?

How do you manage

them?

Athletic Performance

Effective Force

Generation

Efficient Force

Transfer

HOW?

Posture

Sport Specific Mobility

Movement Control

Strength Subqualities

Whole Body

Integration

Why Do Athletes Get Back Pain?

Flexibility Strength

EnduranceActivities

Re

pe

titive

Motor Control

Movement Quality

Kinetic Chain Integration

Technical ProblemsHip

Mo

bility

Rota

tion

Proprioception

PsychologicalS

ocia

l

Posture

Training Volume

Level of Competition

Wear & Tear

Accelerated Degenerative Cascade?

“The prevelance of radiographic evidence of

disc degeneration is higher in athletes than it

is in non athletes…..however it remains

unclear whether this correlates with a higher

rate of back pain.”

Bono, JBJS 2004

MRI Findings In The Lumbar Spines Of Asymptomatic, Adolescent, Elite

Tennis Players

• 33 asymptomatic elite adolescent tennis players

• 5 (15.2%) had a normal MRI

• 23 showed signs of early facet arthropathy

• 13 showed disc desiccation and disc bulging

• 9 players had pars lesions (3 complete fractures)

F Alyas, M Turner and D Connell Br J Sports Med 2007 41: 836-841Role of Imaging?

• Majority of LBP (up to 85%) classified ‘non-specific’ as no

diagnostic imaging correlated with LBP (Dillingham, 1995; Deyo and Phillips, 1996;

Nachemson, 1999; Pearce, 2000)

• Abnormal findings in asymptomatic individuals are common (Jensen

et al., 1994; Boos and Hodler, 1998; Stadnik et al., 1998; Pfirrmann et al., 1999; Borenstein et al., 2001; Humphreys et al., 2002)

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Key Factors

Volume +/- Level of Participation

• Australian football: linear increase in LBP from non-athletic, to the semi-

elite and elite groups

• Elite subjects more likely to experience more frequent and severe LBP (Hoskins et al, 2009)

• Rowing: Ergometer training sessions >30min is a risk factor for LBP (Wilson

et al, 2014)

• Tennis: Playing > 6 h/week is a risk factor for LBP in junior players (Hjelm et

al, 2012)

Athletic LBP: Key Factors

Movement Patterns:

• Extremes of flexion or extension (Bahr et al, 2004).

• Rotation sports (Chimenti et al, 2013)

• Endurance (Foss et al 2012)

How Does This Relate to Sport?

Sporting Movements

• Habitual & Repetitive

• Large ranges of motion

• Often High Forces

• Repetitive stress on

tissues

• Increased mechanical

loading

• Reinforcement of aberrant

patterns of movement

• Reinforcement of pain

perception & association

Spinal Mechanics and Effective Sporting Function

Cf. Spinal Engine (Gracovetsky, 1985)

Cyclical Movements

Energy efficiency

Torso-pelvic integration

Energy conservation

Acyclic Movements: Rotation

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Energy Flow

• Mechanical energy transferred between segments

• Transferred or absorbed by joints

• Proximodistal sequence

• If the amount or rate of energy transfer > tissue

threshold it will result in damage.

• If the action of one joint in the chain is altered, the

contribution of the other joints will increase to

accommodate loss of energy

• Can lead to increased joint loading and overuse

injuries

Throwing

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The Spine in Kicking

Acknowledgement: Rob Langhout

Acyclic Power

Delivery of Force

Whole body / kinetic chain

integration

Force Transfer

High Speed Running Increased vertical force…

…applied in the right place

…as quickly as possible

F= ma

Rapid hip flexion more important

As speed increases

duration of hip flexion

increases

Saito et al, 1974; Kunz and Kaufmann, 1981; Mann et

al, 1980a, 1980b, 1984, 1989; Mann and Herman,

1985; Moran et al, 1986; Schache et al, 1998

Elite sprinters: less

hip extension at

toe-off

High Speed Running

Effective Muscle-tendon Unit Function

Cyclic Power Delivery

Force Transfer

Control Rotational Forces

(counter-rotation)

Ground Reaction Forces

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Energy Flow: A Potential Key Component in Athletic LBP?

• Prospective Study: Upper limb injuries

• Non-injured players:

• Higher rate of energy output from the trunk to arm

• Higher quality energy flow (correlated to ball velocity)

• More efficient energy transfer

• Pattern for athletes with LBP?

LBP & Torso-pelvic (De)Coupling

Still present in runners 6 months after resolution of LBP

(Lamoth et al, 2005; Seay et al, Clin Biomech, 2011)

Reduced Decoupling with LBP

Still present in runners 6 months after RTS

Neuromuscular Control & LBP

• Altered recruitment patterns (Cholewicki et al, 2005)

• Reduced proprioception (Brumagne et al., 2000; O’Sullivan et al, 2003)

• Increased postural sway (Hamaoui et al, 2004)

• Reduced responsiveness to environmental perturbations (Radebold et al,

2001)

• Impaired activation of deep stabilising muscles (TVA, mulitifidus(Hodges et al, 1996, 1998).

• Increased likelihood of LBI x2.8 when a history of LBI

•↑ x3% with each ms of abdominal muscle shut-off latency.

Prospective study:

• 292 athletes

• 20% h/o LBP

• 22 sports)

• 2-3-year follow-

up

Why Do Athletes Get Back Pain?

Flexibility Strength

EnduranceActivities

Re

pe

titive

Motor Control

Movement Quality

Kinetic Chain Integration

Technical ProblemsHip

Mo

bility

Rota

tion

Proprioception

Psychological

So

cia

l

Posture

Training Volume

Level of Competition

Spinal-Limb Integration

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Lumbopelvic – Hip (De)Coupling

• Reduced in patients with LBP

• Predictive of development of LBP in dancers (Roussel et al., 2009)

Hoffman et al, Rehabil Res Pract (2012)

Esola et al.,1996; McClure et al.,1997;

Burnett et al., 2004; Shumet al., 2005;

Luomajoki et al., 2008

LPH Integration & LBP in Sport

• Reduced active and passive hip joint rotation ROM important marker

of LBP in range of sports

Golf(Murray et al, 2009;

Lejkowski & Poulsen, 2013;

Grimshaw & Burden, 2000; Vad et al 2004),

Judo(Almeida et al, 2012)

Tennis (Vad et al, 2003)

LPH Integration & LBP in Sport

• LBP group:

• Less overall passive hip rotation

• More asymmetry of total rotation, right

hip versus left hip

• Left total hip rotation was more

limited in the LBP group

• No LBP group:

• no significant differences

• Van Dillen et al, Phys Ther in Sp, 2008

Rotation-related sports: racquetball, squash, golf, tennis

What about the Shoulder?

Key Factors:• Shoulder flexibility

• Age

BJSM, 2014

Suggested Interventions :

• Prevent hyperextension of the lumbar region during water entry

• Enhance shoulder flexibility

Overhead SportsWhy Do Athletes Get Back Pain?

Flexibility Strength

EnduranceActivities

Re

pe

titive

Motor Control

Movement Quality

Kinetic Chain Integration

Technical ProblemsHip

Mo

bility

Rota

tion

Propriocetion

Psychological

Socia

l

Posture

Training Volume

Level of Competition

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Strength & LBP

• Reduced strength important general population

• Improvements in strength effectively reduces CLBP in

non-athletic populations (Bruce-Low et al, Ergonomics, 2012; Smith, et al J Back

Musculoskelet Rehabil, 2011; Bayramoğlu et al Am J Phys Med Rehabil 2001; Taimela et al, J

Spinal Disord, 1996)

• Eccentric strength may be more important (Shirado et al, Arch

Phys Med Rehab, 1995)

Strength & LBP: Athletic Populations

Football (Maus et al 2010)

• Isometric strength: Flexion, Rotation, Lateral Flexion

• No significant difference between players with and without LBP

Wrestling (Iwai et al, Med Sci Sports Exerc, 2004)

• No correlation between radiological abnormality (RA) and trunk strength

• No trunk flexor parameters correlated with disability or level of LBP

Strength & Athletic LBP

Field Hockey

•No difference trunk flexor strength LBP vs. No

LBP (concentric & eccentric)

• Reduced peak eccentric extensor strength in

players with LBP

Strength & Athletic LBP

Max isometric trunk Ext

strength:

• NO relationship to LBP or

• Neuromuscular imbalance of

erector spinae

Isometric Extension:

• Neuromuscular imbalance

of erector spinae (L:R) in

LBP group

Tennis

(Renkawitz et al, The Spine Journal, 2006)

How Do Patients Present?

Effective Force

Generation

Efficient Force

Transfer

Sport Specific Mobility

Movement Control

Strength Subqualities

Whole Body

Integration

Technique

Strength

Pelvic Control

Sequencing

Tissue Health

EnduranceRange of Motion

Kinetic Chain

IntegrationTiming

Energy conservation

Force transfer /

generation

Force attenuation

Torso-pelvic (de)coupling:

Rotational

Coronal

Sagittal

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•Beliefs

•Anxiety

•Sport-specific FactorsPsychosocial Factors

•Hip Rotation (particularly rotational sports)

•Trunk Mobility

•Combined movements (Tension Arcs)

Sport Specific Mobility

•Torso-pelvic decoupling

•Lumbopelvic-hip decoupling

•Response to unpredictable variationsMovement Control

•Focus on coaching of correct sport specific movementsTechnique

•Eccentric extensors

•Reactivity: Rate of Force Development

•Length – Tension relationship

•Strength Endurance

Strength (Subqualities)

•Torso-pelvic (de)coupling

•Lines of Force

•Global Movement

Whole Body Integration

Thank-you