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Managing back pain in rowers: local research

Dr Leo Ng, APAM, JP Cañeiro, FACP, Professor Peter O’Sullivan, FACP
1 September 2016


Sports participation in school is a very important part of adolescent development, providing physical and mental benefits. Rowing is considered one of the most physically demanding sports and, as a result, it is thought to provide many benefits. In Perth, the Head of the River regatta is a highlight of the sporting calendar, considered one of the most prestigious school events.

However, adolescent rowers are at greater risk of developing low back pain (LBP) than non-rowers. A survey of adolescent rowers in Perth reported that more than 90 per cent of adolescent male and 60 per cent of adolescent female rowers suffered from at least one episode of LBP. This is much higher than the 40 per cent that is reported in the general adolescent population (Ng et al 2014). These rowers also reported moderate levels of pain while they were rowing and performing daily activities.

It has been reported that in the late teen years, 20–30 per cent of the general population report an episode of LBP, which can lead to medication intake, care-seeking, and modification of physical activity and daily activities, negatively impacting the inividual’s lives (O’Sullivan et al 2012). This is concerning because LBP during adolescence is associated with LBP in adulthood, which is considered the leading cause of years lived with disability globally (Vos et al 2012).

A survey of adolescent rowers in Perth reported that more than 90 per cent of adolescent male and 60 per cent of adolescent female rowers suffered from at least one episode of low back pain

There are several factors that need consideration when dealing with LBP. Rowing has high inherent physical demands due to the repetitive nature of the sport and the potential for combined movement, which can place greater load in the spine.

Spikes in training load are another factor that impacts on the fluctuation of LBP symptoms (Wilson, Gissane & McGregor 2014). Ng et al (2015) showed that adolescent rowers with LBP spend more time in lumbar flexion not only when rowing, but also when sitting. In addition, boys and girls with LBP have demonstrated reduced levels of lower limb and back extensor muscle conditioning (Ng et al 2015; Perich et al 2011).

A person’s beliefs and emotions are also important factors to consider. There is a belief that the back is easy to harm and hard to heal, therefore demanding protection. Such beliefs may be heightened in a sport such as rowing, where athletes are often reminded of their posture, to tense their core and the need to protect the spine from ‘injury’. This has to be considered alongside the adolescent’s lifestyle and contextual demands such as school workload, sleep (considering school work and early morning training), culture, social and home environment, time spent watching TV (Fernandes et al 2015), stress levels, mood and general health. All these factors may play a role in the onset and persistence of pain.

Historically, a biomedical approach has guided the management of LBP in sport, where pain is thought to be a consequence of pathoanatomical abnormality or joint and muscle dysfunctions, and the back is seen as a vulnerable structure that needs protection. This narrow view on LBP, which often directs treatment at signs and symptoms, has not provided long-term benefits; in fact, it’s led to increased costs and further disability (Darlow & O’Sullivan 2016; Balague et al 2012).

Approaches that consider the multidimensional nature of LBP in sport have been called for. Therefore, a team of researchers at Curtin University assessed the efficacy of a cognitive functional approach (CFT) to manage LBP in adolescent rowers (Ng et al 2015). In this study, 36 adolescent male rowers with LBP participated in a randomised controlled study to determine the efficacy of CFT to manage pain and disability. Nineteen rowers were randomly assigned to the CFT group, and they received an eight-week patient-centred intervention that targeted the multidimensional nature of their pain. The factors that were addressed included: education regarding the relevant multi-dimensional factors associated with their LBP (ie, beliefs and behaviors); lumbo-pelvic control and conditioning during sitting, squatting, lifting and rowing; and addressing lifestyle factors.
Figure 1 – Self-reported pain intensity (numeric pain rating scale) during a 15-minute ergometer. This graph illustrates the comparison between preintervention (dashed lines) and post-intervention (continuous lines) results for both groups: CFT (red) and usual care (blue). Figure adapted from Ng et al 2015.

The results of the study showed that the CFT group demonstrated a reduction in pain during ergometer rowing (Figure 1) and disability to daily activities compared to the control group, who received usual care (eg, massage, usual physiotherapy and normal rowing coaching). CFT also demonstrated an improvement in lower limb endurance and sitting posture (not at end of range flexion) compared to the control group. No differences were observed in the rowers’ spinal posture during rowing. While the exact mechanism for change is not clear, we think it is likely that the CFT intervention reduced their sense of threat and built their confidence and load tolerance to rowing.

In summary, managing rowers with LBP should follow guidelines that recognise that multiple factors need to be considered, such as physical, training load, psychosocial and lifestyle. Aligning management of back pain in rowing with the evidence may promote better outcomes for this population.

 

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