Sports Medicine Australia’s State Council Member Luke Nelson reviews SMA’s Athletic lower back pain symposium held at Melbourne University on Sunday  February 9.

It was an action packed day featuring a multidisciplinary lineup of speakers which aimed to help attendees better manage low back pain in the athletic population. In this blog he shares with you his key takeaways from the event!

The day kicked off with a bang with Associate Professor Tasha Stanton who leads the Pain and Perception Group in Adelaide at the University of South Australia, on the topic “Just get more active? Psychosocial considerations (and their biological implications) for the athlete with low back pain”

Some of the misconceptions those suffering from low back pain include:

• “I have back pain because I’ve injured my back”
• “I have back pain because my back is weak and it hasn’t healed properly”

The INCORRECT assumption in the above statement is that pain reflects tissue damage.

The reliance on imaging for the diagnosis of low back pain:

“Abnormal” findings are commonly seen on MRI in pain-free individuals: As we age, we get the equivalent of “wrinkles” on our scans.

Your knowledge influences pain: Things hurt more when you aren’t sure they are safe. Wiech et al J Neurosci 2010

• Anything that suggests you need protecting (danger cues) increases pain.
• Anything that suggests you don’t (safety cues) reduces pain

“We are all bioplastic- this means our systems can always adapt and change…right until the very end.

“These scan changes look as I would expect for someone who is an elite athlete. Many of these changes are a bit like wrinkles- what we expect to see”

Message: our systems are designed to adapt and change. Some changes on scans are normal- they don’t tell us what you are capable of. Adapted from O’Sullivan & Lin 2014

Giving good information to people with back pain matters!

• Enhanced reporting (altering the terminology of the report summary and including epidemiological information) improved back related perceptions & was found to be more reassuring. Karran et al 2017

• Ask your athletes about why they think they are hurting‬: what is their understanding of their condition?
• ‪Ask about more than just the pain‬: think of all the things that can influence pain (sleep, stress, anxiety, fear etc..)
• ‪Measure the functional state of the pain system: assessing temporal summation via exercise reps (ie movement evoked pain)‬

Psychological factors: athletes with pain/injury.

“When players knew the length of time they were out of the game, and were informed about the extensive nature of the rehabilitation process, they recalled how this was the most depressing time of all”

“Players described how sometimes it seemed that no one cared about their injury or how they were progressing through their rehab… focus on on-field performance”

“Feel isolated from the group”

Ensure that the athlete feels a part of the team when they are injured!

Ruddock-Hudson 2012

Do athletes with pain have increased fear avoidance and pain catastrophising?? YES

Increase fear avoidance is associated with decreased physical functioning

Increased pain catastrophising is associated with increased pain intensity.

Tasha used Butler & Moseley’s analogy from “Explain Pain” of climbing a mountain. Our bodies are designed to protect and warn us of danger. Pain protects us from exceeding our capacity, this is our “safety buffer”. However for some people post injury, their “safety buffer” increases to where their system becomes “overprotective”. We can educate these patients that they can be “sore but safe”: they can experience pain, whilst not exceeding their tissue capacity.

Treatments informed by pain science with psychological & movement ramifications that can be utilized for those with athletic low back pain include:

• Increasing pain knowledge
• Talking about scan results
• Pain science based movement prescription

Should athletes with back pain just get more active??

Expanding on the previously written article by O’Sullivan et al 2019, the advice we should be giving our athletes with back pain include:

1. Keep active

2. But respect the influence of training load on pain

3. Be aware of movement avoidance- they may need to become more active in terms of specific movements.

Athletes with low back pain: keep physically active but avoiding specific movements

• A thorough objective assessment of their back
• Assessing for movement changes or alterations that result in protecting the back from movement
• Aim to rescue protective movements/postures by: increasing safety cues, decreasing danger cues

Unhelpful words

• “stop immediately if it hurts”
• “Don’t want to blow out a disc”
• “Be very careful when you do that movement”

Message from all of the above is that movement is bad and could injure you further.

Adapted from O’Sullivan & Lin 2014

Instead (and evidence based)

• “movement will be painful at first- like a sprained ankle- but will get better as you get more active”
• “Our tissues heal best through loading – gradually increasing your activity is the very best thing you can do”
• “Movement decreases the size of our protective safety buffer.”
• “Your back is strong & robust”

Message: movement is the best thing for you to help you heal, and you are safe to move.

Applying these principles during rehab

Unpairing movements that hurt with that EXACT movement

• If back movement during a kick is painful, find new ways of achieving back & leg movement that do not mirror the exact kicking motion: Pilates reformer, dance, tai chi
• Use a different movement pattern to create a new representation and to promote increased diversity in representation
• We are NOT correcting vulnerability, we are helping the system to relearn that certain movements are safe

SUMMARY

1. Pain is there to protect, it doesn’t necessarily tell us about damage: just because you feel pain doesn’t mean you are injured. Our systems can become over-protective

2. Consider psychological factors (anxiety, fear avoidance and pain catastrophizing) in athletes with low back pain

3. Use education to increase athlete’s pain knowledge to target fears about movement and re-injury.

4. Our words matter!!

5. We can help athletes to interpret scans to promote reassurance & safety, not fear & danger

6. We can use movement to help our system “unlearn” associations between pain & activity.

7. Stay as active as possible, focus “increased activity” on movements being avoided, promoting robustness not vulnerability.

Paul Marks: MRI lumbar spine- advanced techniques

Radiologist Paul Marks then delved into a discussion on imaging and athletic low back pain in his talk “MRI lumbar spine- advanced techniques”

Indications for CT

• useful if MRI not available/safe
• Pacemaker/spinal stimulator
• Spinal intervention
• Metalware

Indications for MRI

• One stop shop
• Efficient use of time
• Normal MRI reassuring
• Specialist Centre and radiologist for scan and interpretation to minimize errors
• 3T better than 1.5T
• Fat sat: important for Inflammation, bone oedema. Some imaging centers don’t perform this.
• THRIVE or VIBE: allows to get thinner image slices

High intensity zone (HIZ) lesions

86% positive predictive value for symptomatic disc. April & Bogduk 1992

Despite the frequency of other pathological imaging findings in asymptomatic individuals, Disc extrusions are NOT a common finding in asymptomatic people.

Alex Kountouris – “Managing lumbar bone stress in athletes”

Alex Kountouris, Cricket Australia’s Sports Science and Sports Medicine Manager, then led a discussion of the management of lumbar spine stress injuries.

Very rare to see spondylolisthesis in elite cricket: they may be career ending?

Where do they occur? they can occur all around the posterior neural arch but just more common at pars interarticularis

Mechanism: repetitive axial loading

Risk factor: age is the most important.

• <22 years old has 4x risk of bone stress injury
• <25 years of age: 3.1x more likely to suffer bone injury in the next month
• <25 and played in a first class match: 4.9 x more likely bone injury in the next month
• <25 and you bowled >40overs in a game: 9.5 x more likely bone injury in the next month

Grading bone stress

There are 3 stages of the bone stress continuum

Bone strain=pre-symptomatic bone stress (micro-fractures)

Stress reaction= early stage (macro fractures)

Stress fracture=cortical/trabecular breach

Chronic defects=non united fractures

Clinically

• Easy to detect later in the process, more challenging to pick up early
• Can usually diagnose from the history: in those at risk (young active, fast bowlers) and with some recent history of loading, usually localized pain & specific movement that will aggravate it. With palpation can often identify the level of the lesion.
• Clinical test: extend, rotate and lateral flex/ ensure you get to end range and not letting them cheat (bending knee)

4 tips:

1. Get them early!

• Difference of 100 days in return to play between managing a stress reaction versus a stress fracture
• MRI: fat sat is a MUST, with THRIVE/VIBE images
• Bone marrow oedema: if you had in the preseason you were 5x more likely to develop stress reaction in season
• Lag of 100 days between seeing oedema and then appearance of symptoms

Cricket Australia is now screening all at risk players at the END of the season. They were finding that most stress fractures occur in early season and by then they probably haven’t done enough to create a new stress reaction, it was likely already occurring at the end of the previous season.

2. Bone marrow oedema is Real: use MRI not CT

Yet to be published study of 31 stress fractures: the size of fracture and BMO was proportionate to healing time.

Mean healing time 200 days for stress fracture.

3. They heal

Non union will result if there are management errors

Early: continue to load and they become asymptomatic

Avoid reloading too quickly

Recurrence rate

Those who suffered a recurrence commenced bowling mean 12.1weeks post injury (range 9-18wks) versus those did not suffer a recurrence commenced bowling at 21.8 (range 16-25 weeks)

Management stages

Week 0-8

• Fracture protection stage
• Protect fracture

Week 9-20

Protected reloading

Commence running/strength

Week >20

• Transition to RTP
• Commence bowling
• RTP>30weeks

4. Do the time

• Pre-symptomatic bone stress: no bowling 4-8weeks
• Stress reaction: no bowling 8-10 weeks
• Stress fracture: 20-30 weeks of no bowling

Management- previous non union

• fibrous tissue at the non-union site is enthesis like histologically
• Eventually can become symptomatic
• Treat as tendinopathy or joint injury (NSAIDs, cortisone injections, local anaesthetic to determine source of pain)
• Need a period of unloading to allow pain & inflammation to settle (2-4weeks)
• Gradual reloading (high & low load days) are important.

Stephen King- “Objective data to get the back on track”

Physiotherapist & Osteopath Stephen King next led a discussion on the importance of objective data in the management of athletic low back pain. This includes the use of patient reported outcomes and objective physical tests (range of motion and strength).

The plank hold (front and side plank) and Biering-Sørensen test are 2 simple low tech options that can be used to test strength, with normals for each of these tests: 1:1 for front plank and back extensor hold, side plank= 45 seconds for untrained, 180 secs for elite athletes.

Stephen also presented a unique test, the Star Excursion Sitting test for use in those with low back pain. Click here to view a video of this test

Sophie Emery- “The Mobile Spine”

Next up, Australia Ballet’s Sophie Emery discussed the challenges in those with

In the Australian Ballet, there are few stress fractures

Spinal issues are the most common injury that causes missed time in ballet. More common in males

What makes dancers unique?

Range of movement:

• increased sagittal plane
• Equal transverse plane
• Altered spinal curvature
• increased rate of scoliosis/trunk asymmetry (dancers 24-50%, general population 1.5-10%)

A lot of dancers have flattened curves. In the male dancers those with flattened curves tend to have issues with absorbing impact forces- need to work on low back and hip strength.

Joint hypermobility syndrome (JHS)

No link between back pain and hypermobility

Brighton criteria

• dancers 26-49%
• General population <19.5%

Does it increase injury risk?

• female dancers with JHS more likely to report arthralgia than those without
• This correlation not found in males
• Less likely to progress in career
• Those with joint hypermobility syndromes might take a little longer to return

What Makes dancers unique when it comes to low back pain?

• Increased pain catastrophizing compared to non dancers with LBP
• Different perception of dangerous movements (extension tends to be feared more than flexion)
• Imagery improves dampening
• Decreased multifidus size

Individual assessment & treatment

Initial profiling on entry to company including:

• Beighton
• Brighton
• ROM
• Posture
• Key muscle strength, endurance
• Balance

From this an individualized education & exercise program is developed

Modified according to upcoming roles

Assessment tips:

• subjective: determine irritability
• Ask to see their aggravating movement
• Is it stiff or does it feel stiff? Ask for them to show you where the pain is on the movement
• Look whole picture at their movement

Treatment

• Hands on? Try mini treatment. Some don’t respond well to heavy hands on treatment. Mobilization of joints: they might feel good initially but then the next day feel not great
• Education and language
• Use motor imagery
• May need to modify time expectations
• Management is ongoing: may need more prolonged treatment

Strengthening

• strength through range
• Add an element of positional awareness
• Strengthen above and below the spine

Take home messages

1. Dancers are at high risk of spine pain and injury

2. Dancers are typically mobile but this may not cause symptoms or injury

3. Dancers may have decreased spinal curvature in the sagittal plane and increased date of scoliosis however the impact of this is uncertain

4. Care with soft tissue release and joint mobilisations, be specific

5. Individualize you’re treatment & strength program based on assessment findings

6. Include dynamic strengthening, including outer range

Martyn Girvan: “Modifying programs for those with spine issues: Practical application from a strength & conditioning perspective.”

The symposium then shifted to rehabilitation and strength and conditioning for athletes with low back pain. First up a presentation by Strength & Conditioning coach, Martyn Girvan on modifying exercise for those with low back pain.

• Injury is an opportunity to bring up weak points
• Look to develop posterior chain through hip extension, many ways to do this
• Minimize spinal compression (no bar on the back or in the hands)
• Go back to basics, fundamental movement patterns
• Start on the floor, reinforce bracing, neutral spine
• Address hip & ankle mobility

Have a good relationship with medical staff:

• Collaborate
• Ask the right question, what to avoidGoals
• Develop confidence
• Build resilience not dependence
• Get buy in

Exercises that tend to be well tolerated by those with low back pain:

• Bird dog
• Plank single leg lift
• Side bridge
• Bridge
• Single leg bridge
• Hip complex
• Lateral band walk
• Belt squat walk (will depend on level of physical literacy)

Body weight key competencies:

• Step down
• Single Leg deadlift
• Box squat
• Split squat

Loaded progressions:

• Belt squat
• Back attack: machine without bar
• Power runner
• 45 degrees back raise
• 90 deg back raise
• Glut ham raise
• Inverse leg curl
• Reverse hyper
• Sled dragging (forward, backwards & lateral)

Program considerations:

• Increase upper back volume/link the shoulder to the hip
• 3/2/1 ratio: 3 horizontal, 2 vertical and 1 straight arm pulls to target lats
• All rows supported
• Chest supported row
• Lat pull down
• Straight arm pull downs

Beth Chiuchiarelli – “Rehab for low back pain”

Keeping with the rehab theme, next up was Exercise Physiologist Beth Chiuchiarelli on rehab progressions for those with low back pain.

Restoring normal movements:

1. Flexion or extension first (dependent on directional preference)

2. Progress with static lateral flexion/rotation

3. Then dynamic lateral flexion/rotation

4. Finally include a combination of all

Consider:

• Normal joint range for the athlete and their sport (dancers & gymnast)
• Required strength/power needs for their sport compared to their body weight

How much should athletes lift?

Depends on:

• based on bodyweight and requirements for sport
• Weight training age

Example for team field sport:

• be able to deadlift their body weight
• Be able to squat their body weight (front/back)

Optional requirement goals:

• be able to deadlift upto 1.8-2x BW for 1RM
• be able to squat upto 1.8-2 x BW for 1RM

Which exercise is best for low back pain? No evidence of superiority for one versus the other ie Pilates, resistance training.

Assess hip hinge/start loading to improve tissue tolerance

• 30 degree hip hinge or less= poor eccentric/concentric extension control
• Hip hinge good morning with broomstick
• Progress to weight if able after 10reps, no weight
• Regress to banded hip hinge tall kneeling or bridge if needed
• 45-60 deg hip hinge
• Above knee rack pull or below knee rack pull: start with 10RM to decide on load, monitoring for fatigue, technique, pain/irritation
• 60-80 deg hip hinge
• Deadlifts: start with 10RM to decide on load, monitoring for fatigue, technique, pain/irritation

When hip hinge is an irritant try these first:

• Goblet squats
• Trap bar
• Sumo deadlift
• Hip thrusters

Trunk series: static bracing

• ADD a heavier load as able ie 15kg plate on back for plank holding 30seconds
• Plank 30sec
• Side plank 15-20sec
• Curl ups
• Pallof press
• Climbers
• Get ups
• Kettlebell snatches, swings

Unilateral loading:

• Lumbar spine: better to have heavier load on that side
• pelvic issues: better to have heavier load on contralateral side
• Examples include: suitcase & farmers carries, unilateral rack pulls, overhead carries

Matt Fernandez- “Manual therapy and maintenance care for back pain – can it work”

Next up was Chiropractor & Exercise Physiologist Matt Fernandez discussing the research behind a potential role of manual therapy and maintenance care in the management of persistent low back pain, namely the recent work on the Nordic maintenance program by Ekland et al.

This study was a pragmatic, investigator-blinded, two arm randomized controlled trial included 328 consecutive patients (18–65 years old) with non-specific LBP, who had an early favorable response to chiropractic care. After an initial course of treatment, eligible subjects were randomized to either maintenance care or control (symptom-guided treatment) and followed for 12 months. The maintenance care group had visits scheduled between 1-3 months (determined by treating practitioner), whereas the control group sought treatment when symptoms arose.

What this study found was that the maintenance care group reported 12.8 fewer days in total with bothersome LBP compared to the control group and received 1.7 more treatments.

Examining the pain trajectory: Maintenance care improved faster, steady state was achieved earlier and lower levels of pain were achieved at long term follow up.

Summary

• Maintenance care experienced 13 days fewer back pain for an extra 2 visits
• Is the 13 days fewer back pain a large or small difference?
• Some robust evidence for close to 2weeks of less bothersome LBP
• Select patients according to inclusion criteria
• Maintenance care is one form of prevention- encourage exercise & education first

However:

• Maintenance care can compliment exercise
• Maintenance care is an alternative if exercise is not an option ie patient compliance
• Maintenance care may be preferable for some patients
• Some will and some won’t benefit: but who?

A second study Ekland’s group looked examined Psychological sub grouping and came up with 3 groups:

Adaptive copers:

• less pain severity
• Low interference everyday life (pain)
• Low life distress
• High activity level
• High perception of life control
• “Getting on with it” and have the lowest level of distress & disability
• Best prognosis & low risk

Interpersonally distressed

• high distrust of others (blame)
• Low social support (close ones)
• Often irritated/frustrated/angry
• “More focus on lack of support, feel isolated & helpless in their pain”
• Worst prognosis & highest risk

Dysfunctional

• High pain severity (everyday life)
• High interference everyday life (pain)
• High affective distress
• Low perception of life control
• Low activity levels
• “Highly distressed, depressed, fearful with disability”
• Worst prognosis & highest risk

Not all benefit from maintenance care!

• Important to individualize care
• Active copers did worse on maintenance care
• Dysfunctional responded well- average 30 days less pain

Greg Malham- Surgery: the why and when

The final speaker for the day was neurosurgeon Mr Greg Malham, who presented on the various surgical options when conservative management fails.

Athlete panel with Mason Cox

The day concluded with Osteopath Nick Brasher interviewing Collingwood Football Club player Mason Cox, who has had a unique journey to AFL, and suffered his fair share of injuries including low back pain.

Some of the key takeaways from Mason’s interview were:

• It’s important to give the player a voice in their rehab, sometimes we as clinicians don’t know best
• You need to build trust with the player so they will trust you on when to push/hold back
• How to build trust? different between athletes, some earn quickly others will take time. Honesty, ensuring that the athletes best interests are behind every decision

References

• C. Aprill and N. Bogduk. High-intensity zone: a diagnostic sign of painful lumbar disc on magnetic resonance imaging, The British Journal of Radiology 1992 65:773, 361-369
• Branco RC, da Costa Fontenelle CR, Miranda LM, Junior YA, Vianna EM. COMPARATIVE STUDY BETWEEN THE PUBIS OF ASYMPTOMATIC ATHLETES AND NON-ATHLETES WITH MRI. Rev Bras Ortop. 2015;45(6):596–600.
• Eklund, A., et al. (2018). “The Nordic Maintenance Care program: Effectiveness of chiropractic maintenance care versus symptom-guided treatment for recurrent and persistent low back pain-A pragmatic randomized controlled trial.” PLoS One 13(9): e0203029.
• Eklund, A., et al. (2019). “The Nordic Maintenance Care Program: Does psychological profile modify the treatment effect of a preventive manual therapy intervention? A secondary analysis of a pragmatic randomized controlled trial.” PLoS One 14(10): e0223349.
• Karran EL, Medalian Y, Hillier SL, Moseley GL. The impact of choosing words carefully: an online investigation into imaging reporting strategies and best practice care for low back pain. PeerJ. 2017;5:e4151. Published 2017 Dec 6. doi:10.7717/peerj.4151
• O’Sullivan K, O’Sullivan PB, Gabbett TJ, et al. Advice to athletes with back pain—get active! Seriously?British Journal of Sports Medicine 2019;53:324-325.
  O’Sullivan, Peter & Lin, Ivan. (2014). Acute low back pain: Beyond drug therapies. Pain Management Today. 1. 8.
• Ruddock-Hudson, Mandy & O’Halloran, Paul & Murphy, Greg. (2012). Exploring Psychological Reactions to Injury in the Australian Football League (AFL). Journal of Applied Sport Psychology – J APPL SPORT PSYCHOL. 24. 10.1080/10413200.2011.654172.
• Wiech K, Lin CS, Brodersen KH, Bingel U, Ploner M, Tracey I. Anterior insula integrates information about salience into perceptual decisions about pain. J Neurosci. 2010 Dec 1;30(48):16324-31