Really the research in sport hasn't defined what the injury is. It really has researched single interventions which we don't do when we treat. We have multiple interventions going on across that return to sport time frame and it really hasn't targeted at what point in the return to sport time frame that you apply an intervention.
SPEAKER_00:Training athletes with low back pain can present its own unique challenges. So today we have Kelly Wilkie on the podcast. Now, Kelly is a postgraduate from La Trobe University and she was at the 2012 and 2016 Olympic Games helping the Australian rowing team. Kelly's just completed research in a 2021 BJSM paper exploring rowers with low back pain. And she spoke to us today about the findings, the prevalence, the risk factors, and if there were any learnings that we could take a to the general population. I really enjoyed this one. My name is Michael Risk and this is Physio Explained. Welcome, Kelly. Thank you for joining us.
SPEAKER_01:It's really nice to be here, Michael. Thank you.
SPEAKER_00:We're going to talk about athletic low back pain. And what we were talking about off air is firstly, how do we define that? What does that look like to you in the research?
SPEAKER_01:It's a great question because unlike other injuries, low back pain hasn't got such a specific definition. So we talk about having pain in the low back area, but when does it define as an injury in our sporting population? And when we were looking at doing research, looking at low back pain in rowing and trying to look at the prevalence and the incidence of low back pain in rowing, it became really obvious that there wasn't a common definition for athletic low back pain in the literature. And so what we've hoped to do throughout through developing a consensus statement around the treatment of low back pain in rowing in particular, is trying to find that and try and say that we should think of it as an incidence when an athlete has to either modify their training or stop training because of it. So we can certainly have an ache in our low back area or we might even get quite sore from using it in sport, but we really need agreed definition on what it actually is so that we can really define the prevalence and incidence across sport.
SPEAKER_00:I like that. So instead of it being... pain-based or pathology-based, it was more a criteria if you had to stop sport or reduce your sport?
SPEAKER_01:Yeah, absolutely. And that helps us really work out what the burden of the injury is. Because for an athlete, we know that the more training that they miss, or the more training that they have to modify, the worse the performance at the end of the day. And so essentially what we're trying to do with athletes is get them training consistently and have consistent training load, and therefore injuries like low back pain that are very much repetitive in nature and insidious in onset become a whole lot less when you can have your high training loads tolerated in a really consistent way.
SPEAKER_00:Was that, because I know you've been involved in a lot of the research, Was that the outcome of some of the research or did the researchers agree, let's use this as the definition and then go forward with research?
SPEAKER_01:Yeah, so we did a systematic review and meta-analysis on the incidence and prevalence of low back pain in sport, for starters, and certainly the definition of low back pain was really varied and therefore it was really difficult to have a look at a cross-sport burden. And so what we ended up doing and the study that I led as part of writing a consensus statement for low back pain in rowing was a big Delphi study where we interviewed expert and experienced clinicians looking at number one, how they manage low back pain in the sport of rowing, but also how they define low back pain. And so from that and from putting the systematic review definition of low back pain together, that's what we've come up with and recommended with regards to research going forward with low back pain in sport.
SPEAKER_00:That sounds super helpful, a really helpful thing to do. Were there any other findings from that research or little sidebars that you found along the way?
SPEAKER_01:Yeah, well, certainly when we look at rowing-related low back pain, there's only ever been one study that's looked at the management of rowing-related low back pain in athletes. And that was in Schoolgirl Roberts that showed that if you screen them at the beginning of a season and you gave them exercises and advice around posture, that you could reduce their incidence of low back pain throughout the season. But There was no other research in rowing population, even though we know it is the biggest, most prevalent injury in rowing, but also has the greatest burden in rowing as well. And so... We ended up having to extend our systematic review and we're looking at the management of low back pain to all sport. And what we found when we looked at the research across sport is that the research is very pocketed. We really have looked at single intervention studies with athletic populations and we haven't defined at what point along the continuum that they may have suffered low back pain or are getting intervention. So for instance, is the person with low back pain in their first six weeks of treatment and would we consider that to be acute? Are they at week 10 and would we consider that to be chronic like we do in the adult low back pain literature? Or is that because it's ongoing and we're trying to tolerate it with the training load? So really the research in sport hasn't defined what the injury is. It really has researched single interventions, which we don't do when we treat. We have multiple interventions going on across that return to sport timeframe. And it really hasn't targeted at what point in the return to sport timeframe that you apply an intervention. And that's why we ended up running this large DLP study to be able to go, okay, if we talk to experienced and expert clinicians in a sport that has a lot of low back pain, what do they do in the initial triage phase? What do they do in the subacute phase in that first week after triage, after you've ruled out your red and yellow flags and you've really done a lovely big aggressive unload, what do you do in the first week? Then what do you do in that subacute phase, getting them back to sport? But more importantly, what do we do in that next phase, in that rehab phase to get them back to performance so there's something about getting them back to sport that's important but actually getting our athletes back to performing at their highest level and doing their full training load is really important and there is just no research that covers that whole return to sport continuum with regards to low back pain and spinal pain in fact across sport.
SPEAKER_00:And so no good research currently, but it was more experience-based. What did you find that those experienced practitioners were doing through those phases?
SPEAKER_01:Yeah, so we're hoping that the views of the experienced and expert clinicians will drive further research in this area. So we certainly found that there was significant agreement with early aggressive unload, really unloading people very quickly, figuring out what they can do without pain to be able to cross-train and keep the athlete fit, if you like, so that their training load doesn't decrease too much in might be reducing the tissue load of the area that's injured being the low back but for instance with rowing you might actually get the athlete to be sitting on a bike so yes they're seated and they might be loading the low back but it's not as loaded as rowing and be able to keep their training load up so being able to cross train keep them fit while you unload the tissue and allow it to recover and then build the athlete back into their sport gradually but also know when things aren't going in the right direction be able to identify red flags in terms of radicular pain and radiculopathy in particular particular, or even by social stresses that actually might prolong a recovery, which are just as prevalent in athletes as what they are in the general population, and be able to head that athlete down a pathway if you identify a red or yellow flag anywhere along the whole return to sport continuum. So look, not too different from what we would say with the management of adult low back pain, but there's urgency with athletes to get back as soon as they possibly can and to remain fit. And they're always asking you to be the best version of your rehab self to be able to make sure they don't slide too far, you know, down that sort of losing time continuum. So really, you know, it's making a plan, it's sticking to a plan and when the plan's not going right, continuing to ask questions about why it might not be going right and to intervene and refer on when necessary.
SPEAKER_00:I like that. And something you said at the start was aggressively unload. And I'll bring in my own faults and errors as a clinician here. Something I found with athletes, particularly, if I unloaded them slowly, it tended to just really hang around versus, say, the weekend warrior runner. I could bring them from 10Ks to 8Ks and get a good result. Did you use that word by choice there, that with the athlete, you really pull them back quickly and soon?
SPEAKER_01:Yeah, we absolutely do. And that's the way that we've found working with the Australian rowing team to be able to turn episodes of low back pain around a whole lot quicker. That if you just unload them a little bit, they still have pain, but while they still have pain, they're not performing well because we know in the presence of pain, you actually have upregulation of some muscles and you actually have some inhibition of other muscles. And so their movement patterns aren't ideal. And I think that probably contributes to an ongoing, you know, sustainment, if you like, of pain. And so what we would do in the Australian rowing team when athlete would suffer an acute episode of low back pain where we would have to modify them or stop them training you say okay for the next you know two days you're only going to walk you're not going to ride a bike at all we're actually going to unload you a significant amount we're not going to let you sit down to each if sitting is an aggravator so really identifying all of the aggravators and limiting those as quickly as you can and then you get this lovely turnaround in a very very quick way in most non-specific low back pain cases.
SPEAKER_00:That's a really good pearl because I think what I'm noticing in young clinicians is the opposite. They maybe don't want to be the physio that rules someone out. And particularly with an athlete, that pressure of being the physio to keep someone there. So I like just reversing that thought. You'll get a better result by missing a week or two or unloading for a
SPEAKER_01:Yeah, yeah. And then you're lessening, you can sell it to the athlete in terms of lessening the burden. So if we do this early aggressive unload, we can get you back to full training a whole lot quicker and therefore performance is going to come, you know, come back a whole lot quicker as well. So it is an easy sell, but athletes don't like to stop. So you really have to be quite confident with actually letting them know that this is the best way to go about it, to really unload your tissues, turn things around really quickly and get you back to what you should be doing really quickly as well. And there was a huge amount of agreement in our group in that Delphi study right across the world. And we ended up with 31 practitioners spread throughout the world answering this survey that took between an hour and an hour and a half to do. So we had this really rich amount of data that came in our direction, high amount of grants. And, you know, the average years that clinicians, whether they be physiotherapists or doctors in particular, had worked with rowing athletes and therefore had seen a lot of low back pain was 15%. which was pretty fabulous.
SPEAKER_00:Yeah, that's huge. Something that's just kind of bubbling for me, I've been thinking about this, is I'd love to get your thought on the prevalence and the risk factors, if anything shone through. And if we start with prevalence, is there a difference between general pop and, say, the rowers that you've looked at?
SPEAKER_01:Yeah. So what's really interesting is the elite and sub-elite level rowing low back pain prevalence is about 30% to 60%. So different studies basically rated at different levels. And so the adult low back pain prevalence is about 30% as well when we're looking at point prevalence at any one time. So it's not that different. But when we're thinking about this, we're talking about young adults being elite and sub-elite level rowers compared to general population adults who are a lot younger. older, that we would expect to probably have more episodes of low back pain. So we've got to start to be worried about that. But the thing that's most interesting is how different the risk factors are. So the main risk factors for adult low back pain are low socioeconomic status, smoking, obesity, and lack of exercise. And our elite and sub-elite level rowers do not have any of those risk factors. And in fact, it's probably an increased amount of exercise. So there might be a U-shaped proportion, if you like, or U-shaped relationship with regards to low back pain and risk and exercise, maybe. We don't know that, but it sort of makes a whole lot of sense that if you're rowing a lot of kilometres and you're loading your back a lot, too much exercise may be a risk factor in itself. So rowing may be a risk factor for low back pain in itself. But really the risk factors for rowing are not anything to do with socioeconomic status or obesity or smoking. So our young athletes are getting this injury at a much great, well, the same prevalence as our adult population, but without those same risk factors, which is really concerning.
SPEAKER_00:I have two thoughts there. I'd love your perspective, is that the U-shaped distribution, like you touched on that, not enough exercise could lead to it, but maybe too much, which we see in a lot of elite sport. But then... Do you think there's some biomechanical factor at play there? Like when we look at the rower and the stress and the velocity they put through their back, do you think that plays into it?
SPEAKER_01:Absolutely. So Alison McGregor is a researcher that has published a lot in the biomechanics area for rowing. And most of it's been done on the rowing ergometer because it's really hard to study biomechanics out on the water. But the movement of the body is fairly similar. And one of the things that's come up in the research is that it's very much around lumbopelvic biomechanics. So if you don't have enough hip range of motion and you can't get to the front of the catch in a rowing stroke in quite a vertical pelvic position, a very flat low back position, which is a strong low back position and a curved thoracic spine position. So if you get to the catch in the opposite, in a bit of posterior pelvic tilt, increased lumbar flexion, then you're more likely to get low back pain. So it requires about 130 degrees of flexion to be able to get into that position, which there's actually a significant amount of movement in your hips. And that comes up in the research most of the time when we look at the risk factors for low back pain in rowing. Now, we're not really sure whether that's chicken and egg because at the moment we actually have a look at the biomechanics and we talk to rowers about whether they've had back pain or not. So we haven't really followed rowers prospectively when they're young to be able to go, you haven't had back pain, you're rowing in this way and you ended up getting back pain. So that's research that still needs to be done. But certainly it looks like that there is an association with getting into a better position to load your back with rowing and reducing your risk.
SPEAKER_00:It's also that single intervention, right, is I guess once a rower comes and you address some of those biomechanical factors, you're probably also giving them loading advice. Yes. And so a few things are changing there. It's interesting because I guess this shift away from biomechanics, though, does biomechanics become more relevant when you're sitting, when you're flexing the same joint, when you're doing it hundreds of times, when you're doing it at that velocity?
UNKNOWN:Yes.
SPEAKER_01:It makes sense that it does, right? And I think the really unique thing about rowing compared to other sports is you're loading your tissues in exactly the same way in a cyclical movement all the time. There's no lateral or rotational variability. It is the same pattern loading the same tissues all the time. And we know with load-related data that if you have a period of unload and then a period of reload very quickly, you're more likely to get pain. And certainly we acknowledge that definitely happens with low back pain in rowing. We also know that It's not always the total load. We know athletes can tolerate quite high levels of load without getting pain, but you really need to sit up at that load for a good three months to be able to adapt to it from a tissue loading perspective. So I think we've thrown the biomechanics and the tissue load out of the baby with the bathwater a little bit, but really we need to be considering those as part of the risk factors when we're looking at how the spine gets loaded in sport most definitely.
SPEAKER_00:Kelly, thank you so much for sharing this. That has flown by. Where can we find the research that you're speaking to and the title and the year?
SPEAKER_01:Yeah, so the research, the Roaring Low Back Pain Consensus Statement was published in the British Journal of Sports Medicine this year in 2021. And the five papers that informed that, so that came together to actually form that piece of research, are all referenced within that paper. So having a look at that paper is the best way to go. And yeah, certainly the Delphi study formed a really large part of the actual clinical expertise recommendation within that paper. And all five studies were published in BJSM over the last 18 months.
SPEAKER_00:That is really good that it's modern and recent research. Kelly, thank you so much for your time. I've taken some pills away myself from this chat.
SPEAKER_01:No worries at all, Michael. Thank you.