What Factors Do Clinicians, Coaches, and Athletes Perceive Are Associated With Recovery From Low Back Pain in Elite Athletes? A Concept Mapping Study.

OBJECTIVE: Identify factors that elite sport clinicians, coaches, and athletes perceive are associated with low back pain (LBP) recovery. DESIGN: Concept mapping methodology. METHOD: Participants brainstormed, sorted (thematically), and rated (5-point Likert scales: importance and feasibility) statements in response to the prompt, "What factors are associated with the recovery of an elite athlete from low back pain?" Data cleaning, analysis (multidimensional scaling, hierarchical cluster analysis, and descriptive statistics), and visual representation (cluster map and Go-Zone graph) were conducted following concept mapping guidelines. RESULTS: Participants (brainstorming, n = 56; sorting, n = 34; and rating, n = 33) comprised 75% clinicians, 15% coaches, and 10% athletes and represented 13 countries and 17 sports. Eighty-two unique and relevant statements were brainstormed. Sorting resulted in 6 LBP recovery-related themes: (1) coach and clinician relationships, (2) inter-disciplinary team factors, (3) athlete psychological factors, (4) athlete rehabilitation journey, (5) athlete non-modifiable risk factors, and (6) athlete physical factors. Participants rated important recovery factors as follows: athlete empowerment and psychology, coach-athlete and athlete-clinician relationships, care team communication, return-to-sport planning, and identifying red flags. CONCLUSION: Factors perceived as important to LBP recovery in elite athletes align with the biopsychosocial model of community LBP management. Clinicians should consider that an athlete's psychology, relationships, care team communication, and rehabilitation plan may be as important to their LBP recovery as the formulation of a diagnosis or the medications or exercises prescribed. J Orthop Sports Phys Ther 2023;53(10):1-16. Epub 10 August 2023. doi:10.2519/jospt.2023.11982.

"There's definitely something wrong but we just don't know what it is": A qualitative study exploring rowers' understanding of low back pain.

OBJECTIVES: Low back pain is highly prevalent in rowing and can be associated with significant disability and premature retirement. A previous qualitative study in rowers revealed a culture of concealment of pain and injury due to fear of judgement by coaches or teammates. The aim of this study was to explore rowers' perspectives in relation to diagnosis, contributory factors, and management of low back pain. DESIGN: Qualitative secondary analysis. METHODS: We conducted a secondary analysis of interview data previously collected from 25 rowers (12 in Australia and 13 in Ireland). A reflexive thematic analysis approach was used. RESULTS: We identified three themes: 1) Rowers attribute low back pain to structural/physical factors. Most rowers referred to structural pathologies or physical impairments when asked about their diagnosis. Some participants were reassured if imaging results helped to explain their pain, but others were frustrated if findings on imaging did not correlate with their symptoms. 2) Rowing is viewed as a risky sport for low back pain. Risk factors proposed by the rowers were primarily physical and included ergometer training, individual technique, and repetitive loading. 3) Rowers focus on physical strategies for the management and prevention of low back pain. In particular, rowers considered stretching and core-strengthening exercise to be important components of treatment. CONCLUSIONS: Rowers' understanding of low back pain was predominantly biomedical and focused on physical impairments. Further education of rowers, coaches and healthcare professionals in relation to the contribution of psychosocial factors may be helpful for rowers experiencing low back pain.

2021 consensus statement for preventing and managing low back pain in elite and subelite adult rowers.

PURPOSE: To synthesise evidence on low back pain (LBP) in adult rowers and to create a consensus statement to inform clinical practice. METHODS: There were four synthesis steps that informed the consensus statement. In step one, seven expert clinicians and researchers established the scope of the consensus statement and conducted a survey of experienced and expert clinicians to explore current practice. In step two, working groups examined current evidence relating to key scope questions and summarised key issues. In step three, we synthesised evidence for each group and used a modified Delphi process to aid in the creation of the overall consensus statements. Finally, in step four, we combined information from step three with the findings of the clinician survey (and with athlete and coach input) to produce recommendations for clinical practice. RESULTS: The scope of the consensus statement included epidemiology; biomechanics; management; the athlete's voice and clinical expertise. Prevention and management of LBP in rowers should include education on risk factors, rowing biomechanics and training load. If treatment is needed, non-invasive management, including early unloading from aggravating activities, effective pain control and exercise therapy should be considered. Fitness should be maintained with load management and progression to full training and competition. The role of surgery is unclear. Management should be athlete focused and a culture of openness within the team encouraged. CONCLUSION: Recommendations are based on current evidence and consensus and aligned with international LBP guidelines in non-athletic populations, but with advice aimed specifically at rowers. We recommend that research in relation to all aspects of prevention and management of LBP in rowers be intensified.

Clinical management of acute low back pain in elite and subelite rowers: a Delphi study of experienced and expert clinicians.

OBJECTIVES: Rowing-related low back pain (LBP) is common but published management research is lacking. This study aims to establish assessment and management behaviours and beliefs of experienced and expert clinicians when elite and subelite rowers present with an acute episode of LBP; second, to investigate how management differs for developing and masters rowers. This original research is intended to be used to develop rowing-related LBP management guidelines. METHODS: A three-round Delphi survey was used. Experienced clinicians participated in an internet-based survey (round 1), answering open-ended questions about assessment and management of rowing-related LBP. Statements were generated from the survey for expert clinicians to rate (round 2) and rerate (round 3). Consensus was gained when agreement reached a mean of 7 out of 10 and disagreement was 2 SD or less. RESULTS: Thirty-one experienced clinicians participated in round 1. Thirteen of 20 invited expert clinicians responded to round 2 (response rate 65%) and 12 of the 13 participated in round 3 (response rate 92%).One hundred and fifty-three of 215 statements (71%) relating to the management of LBP in elite and subelite rowers acquired consensus status. Four of six statements (67%) concerning developing rowers and two of four (50%) concerning masters rowers gained consensus. CONCLUSION: In the absence of established evidence, these consensus-derived statements are imperative to inform the development of guidelines for the assessment and management of rowing-related LBP. Findings broadly reflect adult LBP guidelines with specific differences. Future research is needed to strengthen specific recommendations and develop best practice guidelines in this athletic population.

The relationship between rowing-related low back pain and rowing biomechanics: a systematic review.

BACKGROUND: Low back pain (LBP) is common in rowers. Understanding rowing biomechanics may help facilitate prevention and improve rehabilitation. OBJECTIVES: To define the kinematics and muscle activity of rowers and to compare with rowers with current or LBP history. DESIGN: Systematic review. DATA SOURCES: EMBASE, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Web of Science and Scopus from inception to December 2019. Grey literature was searched. STUDY ELIGIBILITY CRITERIA: Experimental and non-experimental designs. METHODS: Primary outcomes were kinematics and muscle activity. Modified Quality Index (QI) checklist was used. RESULTS: 22 studies were included (429 participants). Modified QI score had a mean of 16.7/28 points (range: 15-21). Thirteen studies investigated kinematics and nine investigated muscle activity. Rowers without LBP ('healthy') have distinct kinematics (neutral or anterior pelvic rotation at the catch, greater hip range of motion, flatter low back spinal position at the finish) and muscle activity (trunk extensor dominant with less flexor activity). Rowers with LBP had relatively greater posterior pelvic rotation at the catch, greater hip extension at the finish and less efficient trunk muscle activity. In both groups fatigue results in increased lumbar spine flexion at the catch, which is greater on the ergometer. There is insufficient evidence to recommend one ergometer type (fixed vs dynamic) over the other to avoid LBP. Trunk asymmetries are not associated with LBP in rowers. CONCLUSION: Improving clinicians' and coaches' understanding of safe and effective rowing biomechanics, particularly of the spine, pelvis and hips may be an important strategy in reducing incidence and burden of LBP.

Treating low back pain in athletes: a systematic review with meta-analysis.

OBJECTIVE: To summarise the evidence for non-pharmacological management of low back pain (LBP) in athletes, a common problem in sport that can negatively impact performance and contribute to early retirement. DATA SOURCES: Five databases (EMBASE, Medline, CINAHL, Web of Science, Scopus) were searched from inception to September 2020. The main outcomes of interest were pain, disability and return to sport (RTS). RESULTS: Among 1629 references, 14 randomised controlled trials (RCTs) involving 541 athletes were included. The trials had biases across multiple domains including performance, attrition and reporting. Treatments included exercise, biomechanical modifications and manual therapy. There were no trials evaluating the efficacy of surgery or injections. Exercise was the most frequently investigated treatment; no RTS data were reported for any exercise intervention. There was a reduction in pain and disability reported after all treatments. CONCLUSIONS: While several treatments for LBP in athletes improved pain and function, it was unclear what the most effective treatments were, and for whom. Exercise approaches generally reduced pain and improved function in athletes with LBP, but the effect on RTS is unknown. No conclusions regarding the value of manual therapy (massage, spinal manipulation) or biomechanical modifications alone could be drawn because of insufficient evidence. High-quality RCTs are urgently needed to determine the effect of commonly used interventions in treating LBP in athletes.

'You're the best liar in the world': a grounded theory study of rowing athletes' experience of low back pain.

OBJECTIVES: Low back pain (LBP) is common in rowers and leads to considerable disability and even retirement. The athlete voice can help clinicians to better understand sport-related pain disorders. We aimed to capture the lived experience of LBP in rowers. METHODS: Cross-sectional qualitative study using a grounded theory approach. Adult competitive rowers with a rowing-related LBP history were recruited in Australia and Ireland. Data were collected through interviews that explored: context around the time of onset of their LBP and their subsequent journey, experiences of management/treatment, perspectives around present beliefs, fears, barriers and expectations for the future. RESULTS: The 25 rowers (12 women/13 men) who participated were aged 18-50 years; they had a mean 12.1 years of rowing experience. They discussed a culture of concealment of pain from coaches and teammates, and fear of being judged as 'weak' because of the limitations caused by LBP. They reported fear and isolation as a result of their pain. They felt that the culture within rowing supported this. They reported inconsistent messages regarding management from medical staff. Some rowers reported being in a system where openness was encouraged-they regarded this a leading to better outcomes and influencing their LBP experience. CONCLUSIONS: Rowers' lived experience of LBP was influenced by a pervasive culture of secrecy around symptoms. Rowers and support staff should be educated regarding the benefits of early disclosure and rowers should be supported to do so without judgement.

Prevalence and risk factors for back pain in sports: a systematic review with meta-analysis.

OBJECTIVES: We aimed to determine the prevalence of low back pain (LBP) in sport, and what risk factors were associated with LBP in athletes. DESIGN: Systematic review with meta-analysis. DATA SOURCES: Literature searches from database inception to June 2019 in Medline, Embase, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Web of Science and Scopus, supplemented by grey literature searching. ELIGIBILITY CRITERIA: Studies evaluating prevalence of LBP in adult athletes across all sports. RESULTS: Eighty-six studies were included (30 732, range 20-5958, participants), of which 45 were of 'high' quality. Definitions of LBP varied widely, and in 17 studies, no definition was provided. High-quality studies were pooled and the mean point prevalence across six studies was 42%; range 18%-80% (95% CI 27% to 58%, I2=97%). Lifetime prevalence across 13 studies was 63%; range 36%-88% (95% CI 51% to 74%, I2=99%). Twelve-month LBP prevalence from 22 studies was 51%; range 12%-94% (95% CI 41% to 61%, I2=98%). Comparison across sports was limited by participant numbers, study quality and methodologies, and varying LBP definitions. Risk factors for LBP included history of a previous episode with a pooled OR of 3.5; range 1.6-4.0 (95% CI 1.9 to 6.4). Statistically significant associations were reported for high training volume, periods of load increase and years of exposure to the sport. CONCLUSION: LBP in sport is common but estimates vary. Current evidence is insufficient to identify which sports are at highest risk. A previous episode of LBP, high training volume, periods of load increase and years of exposure are common risk factors.

Epidemiology of injury and illness in 153 Australian international-level rowers over eight international seasons.

AIM: To report the epidemiology of injury and illness in elite rowers over eight seasons (two Olympiads). METHODS: All athletes selected to the Australian Rowing Team between 2009 and 2016 were monitored prospectively under surveillance for injury and illness. The incidence and burden of injury and illness were calculated per 1000 athlete days (ADs). The body area, mechanism and type of all injuries were recorded and followed until the resumption of full training. We used interrupted time series analyses to examine the association between fixed and dynamic ergometer testing on rowers' injury rates. Time lost from illness was also recorded. RESULTS: All 153 rowers selected over eight seasons were observed for 48 611 AD. 270 injuries occurred with an incidence of 4.1-6.4 injuries per 1000 AD. Training days lost totalled 4522 (9.2% AD). The most frequent area injured was the lumbar region (84 cases, 1.7% AD) but the greatest burden was from chest wall injuries (64 cases, 2.6% AD.) Overuse injuries (n=224, 83%) were more frequent than acute injuries (n=42, 15%). The most common activity at the time of injury was on-water rowing training (n=191, 68). Female rowers were at 1.4 times the relative risk of chest wall injuries than male rowers; they had half the relative risk of lumbar injuries of male rowers. The implementation of a dynamic ergometers testing policy (Concept II on sliders) was positively associated with a lower incidence and burden of low back injury compared with fixed ergometers (Concept II). Illness accounted for the greatest number of case presentations (128, 32.2% cases, 1.2% AD). CONCLUSIONS: Chest wall and lumbar injuries caused training time loss. Policy decisions regarding ergometer testing modality were associated with lumbar injury rates. As in many sports, illness burden has been under-recognised in elite Australian rowers.

Rib stress injuries in the 2012-2016 (Rio) Olympiad: a cohort study of 151 Australian Rowing Team athletes for 88 773 athlete days.

AIM: To describe the demographics, frequency, location, imaging modality and clinician-identified factors of rib stress injury in a cohort of elite rowers over the Rio Olympiad (2012-2016). METHODS: Analysis of prospectively recorded medical records for the Australian Rowing Team in 2013-2015 and the combined Australian Rowing Team and Olympic Shadow Squad in 2016, examining all rib stress injuries. RESULTS: 19 rib stress injuries (12 reactions and 7 fractures) were identified among a cohort of 151 athletes and included 12 female and 7 male cases, 11 open weight, 8 lightweight, 12 scull and 7 sweep cases. The most common locations of injury identified by imaging, were the mid-axillary line and rib 6. Period prevalence varied from 4% to 15.4% and incidence ranged from 0.27 to 0.13 per 1000 athlete days. There were no significant differences in prevalence by sex, sweep versus scull or weight class. There was a statistically significant increase in incidence in the pre-Olympic year (2015, p<0.001). MRI was the most commonly used modality for diagnosis. Stress fracture resulted in median 69 (IQR 56-157) and bone stress reaction resulted in 57 (IQR 45-78) days lost to full on water training. CONCLUSIONS: In our 4-year report of rib stress injury in elite rowing athletes, period prevalence was consistent with previous reports and time lost (median ~10 weeks) was greater than previously published literature. Rib stress injury limits training and performance in elite rowers and MRI should be considered as a first line investigation.