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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