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Original article
Cognitive functional approach to manage low back pain in male adolescent rowers: a randomised controlled trial
  1. Leo Ng 1,
  2. J P Cañeiro 1 , 2,
  3. Amity Campbell 1,
  4. Anne Smith 1,
  5. Angus Burnett 3,
  6. Peter O'Sullivan 1 , 2
  1. 1 School of Physiotherapy and Exercise Science, Curtin University, Western Australia, Australia
  2. 2 Body Logic Physiotherapy, Perth, Western Australia, Australia
  3. 3 ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
  1. Correspondence to Leo Ng, School of Physiotherapy and Exercise Science, Curtin University, GPO Box U1987, Perth, WA 6845, Australia; Leo.Ng{at}curtin.edu.au

Abstract

Background Low back pain (LBP) is prevalent among adolescent rowers. This study evaluated the efficacy of a cognitive functional approach to reduce LBP in this population.

Methods Thirty-six adolescent male rowers reporting LBP participated. Nineteen were randomly allocated to the intervention group to receive a cognitive functional approach targeting cognitions, movement patterns, conditioning and lifestyle factors relevant to each rower for 8 weeks. The active control group (n=17) received usual care from their coaches (rowing skills and conditioning exercises). The primary outcome of the study was pain intensity as measured by the Numeric Pain Rating Scale during a 15 min ergometer trial preintervention and postintervention. Disability (Patient Specific Functional Scale and Roland Morris Disability Questionnaire) was measured preintervention/postintervention and at 12 weeks follow-up. Isometric muscle endurance of the back extensors and lower limb muscles, usual sitting posture and regional lumbar kinematic data during a 15 min ergometer row were measured preintervention/postintervention.

Results Compared with the control group, the intervention group reported significantly less pain during ergometer rowing (Numeric Pain Rating Scale −2.4, p=0.008) and reduced disability (Patient Specific Functional Scale (4.1, p=0.01); Roland Morris Disability Questionnaire (−1.7, p=0.003)) following the intervention, and at 12 weeks follow-up. They also demonstrated greater lower limb muscle endurance (20.9 s, p=0.03) and postured their lower lumbar spine in greater extension during static sitting (−9.6°, p=0.007). No significant differences were reported in back muscle endurance and regional lumbar kinematics during ergometer rowing.

Conclusion Cognitive functional approach was more effective than usual care in reducing pain and disability in adolescent male rowers.

Clinical Trial Registry Number Australian and New Zealand Clinical Trial Registry Number 12609000565246.

  • Adolescent
  • Rowing
  • Randomised controlled trial
  • Physiotherapy
  • Lumbar spine

https://doi.org/10.1136/bjsports-2014-093984

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    Introduction

    Low back pain (LBP) is common among adolescent rowers, particularly male rowers aged between 14 and 16 years (lifetime prevalence of 94% and point prevalence of 65).1 LBP is a common cause for rowers to quit rowing2 and this problem has been identified by the international rowing federation as a priority.3

    Risk factors for LBP have been reported across physical, psychological, social, neurophysiological and lifestyle domains.4 , 5 However, high training volumes—ergometer as well as on water—coupled with cyclic compressive flexion loading of the lumbar spine, are likely primary risk factors in rowers.6–12 Previous research established a relationship between time on ergometer rowing and pain,8 , 11 , 12 with reports that ergometer rowing requires greater lumbar flexion than on-water scull rowing,11 potentially leading to increased risk of back pain.

    Rowing increases the risk for LBP, but not all rowers report it, suggesting the importance of individual factors. Poor lower limb9 and back muscle endurance,9 , 10 and slump sitting during usual sitting,9 have been associated with LBP in adolescent female rowers. Slump sitting has been associated with poor back muscle endurance in a general adolescent population.13 Deficits in back and lower limb muscle endurance may increase end range flexion loading strain to the lumbar spine, resulting in pain.9

    Two non-randomised clinical trials have been conducted among adolescent female rowers using a cognitive functional approach to target rowing-related risk factors for LBP.14 , 15 In both studies, the rowers were given group-based education regarding basic spinal mechanics, motor control of the spine and potential pain mechanisms, as well as an individualised exercise programme addressing specific deficits in lumbo-pelvic motor control and conditioning.14 , 15 The outcomes demonstrated a reduction in point prevalence of LBP, pain intensity and disability in the cognitive functional approach group compared with a control group, which received no treatment.14 , 15 However, these studies were limited by participant bias due to self-selection of groups and uneven group sizes, and they did not investigate lumbar kinematics.

    We aimed to investigate the efficacy of a cognitive functional approach compared with usual care in a group of adolescent male rowers in a randomised controlled trial. The primary hypothesis was that rowers in the intervention group would row with lower levels of pain over the course of a 15 min ergometer trial compared with a control group who received usual care from their coaches with no input from the treatment physiotherapist, but remained free to seek treatment from healthcare providers external to the project, following the intervention period. Secondary hypotheses included that rowers who underwent cognitive functional approach would have reduced disability, improved lower limb and back muscle endurance, and demonstrate changes in habitual sitting posture and regional lumbar kinematics during ergometer rowing, compared with the control group.

    Methods

    Study design

    This study was a randomised controlled trial with an investigator blinded to treatment allocation, who performed all primary and secondary outcome data collection. All outcome measures were assessed at baseline and after the 8-week intervention. LBP-related disability data were also collected 4 weeks after the end of the intervention (12 weeks follow-up). Permission to conduct the study was granted by the Human Research Ethics Committee at Curtin University in Perth, Western Australia (HR197/2008). This clinical trial was registered under the Australian and New Zealand Clinical Trials Registry (ACTRN12609000565246).

    Participants

    Thirty-six adolescent male rowers aged between 14 and 19 years with between 1 and 4 years of school-level rowing experience, suffering from LBP related to rowing at the time of data collection (summer rowing season between 2009 and 2011), were recruited from school and community rowing clubs in Perth, Western Australia. The inclusion criteria were: participants rowing competitively in local rowing regattas; a self-reported LBP intensity of greater than 3/10 on the visual analogue scale, which must be reached during a typical rowing training session; and pain location within the lumbar region as drawn on a diagram. The exclusion criteria included: rowers with specific causes of LBP, including inflammatory diseases, radicular pain or neurological deficits; musculoskeletal injuries to the extremities limiting rowing training 6 weeks prior to baseline data collection. Participants were also excluded if they received any rowing-specific postural training during previous rehabilitation of their LBP, as this may have influenced their spinal kinematics during rowing. The mean and SD of the age, height, mass and body mass index of participants in each group are displayed in table 1. Power calculation estimated a sample size of 20 in each group to give 80% power to detect an overall difference in Numeric Pain Rating Scale (NPRS) scores of at least 1.5 points, based on an estimated SD of 1.5 points in both groups, measures repeated over 15 min, and a within-subject correlation of 0.8 ((Stata/IC V.12.1 for Windows (StataCorp LP, College Station, Texas, USA)).

    View this table:
    Table 1

    Baseline characteristics of participants

    All participants eligible to enter the study underwent baseline testing to determine:

    • Pain intensity during a 15 min ergometer trial;16

    • Disability as measured by the Patient Specific Functional Scale17 and by the Roland Morris Disability Questionnaires;18 , 19

    • Lower limb muscle endurance measured by an isometric squat test, which has previously been used in an adolescent population with LBP;20

    • Back muscle endurance as measured by the Biering-Sorenson test.21

    Regional lumbar postures during usual sitting and regional lumbar kinematics during a 15 min ergometer trial were collected using the 3-Space Fastrak system at 25 Hz (Polhemus Navigation Science Division, Kaiser Aerospace, Vermont, USA). This has been shown to be a valid tool with an error rate of 0.4° when collecting spinal kinematics on a modified ergometer.22 A customised Labview software program (V.8.6.1, National Instruments, Texas, USA) utilised matrix calculations23 to determine the upper lumbar angle and the lower lumbar angle (figure 1). Only sagittal plane angles from the drive phase were analysed, as there is minimal frontal and transverse plane movement during a centre-pulled ergometer,24 and greatest load occurs during the drive phase.25 All data were time-normalised using the customised Labview program and a rotary encoder that was linked to the flywheel of the rowing ergometer, with 0% defined as the beginning of the drive phase and 100% defined as the end of the drive phase in accordance with previous research.24 , 26

    Figure 1
    Figure 1

    Regional lumbar kinematics. (ULA, upper lumbar angle; LLA, lower lumbar angle).

    All measures were repeated immediately after the 8-week intervention, and only disability measures (Patient Specific Functional Scale and Roland Morris Disability Questionnaire) were reassessed 4 weeks after the intervention (12 weeks follow-up).

    Testing protocol

    The participants first completed the Patient Specific Functional Scale, Roland Morris Disability Questionnaire, lower limb muscle endurance and back muscle endurance test. These tests were conducted at a location of convenience for the rowers (local rowing club or university laboratory). Regional lumbar angles during ‘usual sitting’ and ergometer rowing were collected on the day of data collection. Each rower was asked to replicate his usual day-to-day sitting posture by holding a sitting posture for 5 min. Data were collected for 5 s at the end of this period, then the rowers were asked to change their sitting posture and return to their usual sitting posture 30 s later. This test was repeated twice and averages of the three trials were used as the participants’ usual sitting angle. Rowers were then asked to complete a warm-up of 5 min submaximal rowing on a modified Concept II ergometer (ferrous metal replaced with wood to reduce electromagnetic interference); following this they were requested to row at a very high intensity (17/20 on Rating of Perceived Exertion) at a stroke rate of 22 strokes per minute for a period of 15 min. This protocol was determined after consultation between the researchers and coaches. During the ergometer trial, the self-reported LBP intensity and the rating of perceived exertion were verbally collected at the beginning of every minute of the ergometer trial and also at the end of the 15 min ergometer trial to standardise output during ergometer rowing between groups. Participants were advised to cease the ergometer trial if their level of pain during testing exceeded that experienced during their usual ergometer rowing training or competition.

    Randomisation

    Following baseline assessment, the participants were randomly allocated to an intervention or control group (usual care) using the random number generator in Microsoft Excel 2003 (Excel version in Microsoft Office 2003 for Macintosh). Study research personnel uninvolved in data collection or recruitment assembled the randomisation schedule. Participants in both groups received a sealed, opaque envelope containing their identification number and details of their group allocation to conceal allocation from the assessor and recruiters. Once eligibility and baseline assessment were confirmed, the study assessor contacted the research personnel, who informed the participant of intervention or non-intervention allocation and arranged for treatment as necessary.

    Intervention

    Cognitive functional approach

    The cognitive functional approach was individualised to each participant based on a clinical assessment of the primary contributing factors to their LBP, including cognitions, movement patterns, conditioning and lifestyle.14 , 15 , 27 , 28 Key elements of the clinical examination are included as online supplementary material to this paper. As shown in figure 2, all rowers in the intervention group were classified as having mechanically provoked LBP with motor-control impairment. A sports physiotherapist with training in cognitive functional approach and 5 years experience with the Australian Rowing Team directed the intervention. The initial session was approximately 1 h in duration and follow-up appointments were 30 min. Rowers were seen a week after the initial session and then fortnightly after that. The key elements of the intervention are outlined in the online supplementary material.

    Figure 2
    Figure 2

    Multidimensional classification system for low back pain (LBP) in adolescent male rowers in the intervention group.27 , 28 Flexion pattern with loading is pain associated with flexion loading, not necessarily at end of range flexion.5 Flexion pattern without loading is pain associated with end of range flexion.5

    Active control group

    The control group did not receive any elements of the cognitive functional approach intervention from their coaches or the treating physiotherapist. However, they remained free to seek treatment from healthcare providers external to the project. The nature of treatment received by the control group from external healthcare providers was not recorded.

    Statistical analyses

    Primary outcome

    Linear mixed models with a random intercept and random slope for time were used to estimate group differences in the repeated NPRS measures recorded at the end of each minute of the post-treatment 15-min ergometer rowing trial. To examine if the difference in pain between groups became larger over the 15 min of rowing, a group×minute interaction term was evaluated, and the model was adjusted for maximum pain recorded during the preintervention ergometer trial.

    Secondary outcomes

    Linear mixed models with a random intercept were used to estimate group differences in disability at 8 and 12 weeks. Linear regression models were also used to estimate group differences in muscle endurance and usual sitting posture angles. Kinematic data collected over the 15 min of rowing were evaluated for group differences using two measures. First, the excursion of the upper and lower lumbar angles over the drive phase was calculated as the difference between the minimum and maximum flexion angle measures taken at percentiles of the drive phase from three completed strokes, at the 1st, 7th and 15th minute of rowing. Two linear mixed-effects models (for upper and lower lumbar angle) were used to evaluate treatment group differences in excursion adjusted for minute. Group×minute interactions were also assessed to examine if group differences varied with time. Second, flexion angle measures taken at percentiles of the drive phase from three completed strokes were averaged to produce a single flexion angle (for both upper and lower lumbar) for the early (0–20th centile), mid (30–70th centile) and late (80–100th centile) drive phase, at the end of the 1st, 7th and 15th minute of rowing. Two linear mixed-effects models (for upper and lower lumbar angle) were used to evaluate treatment group differences adjusted for minute, phase, baseline values and age. Group×minute and group×phase interactions were also assessed to examine if treatment group differences varied according to these factors. Models were adjusted for the baseline measure of the outcome under consideration and also for age, as the intervention group was 1.2 years older than the control group and age was significantly associated with disability, endurance and kinematic measures. All models were examined to confirm the absence of influential outlying observations. Statistical analysis was performed using Stata/IC V.12.1 for Windows (StataCorp LP, College Station, Texas, USA).

    Results

    Of the 153 rowers who were assessed for eligibility, 36 rowers consented to participate. Randomisation allocated 17 rowers to the control group and 19 to the intervention group. The outline of the participants’ involvement is displayed in figure 3.

    Figure 3
    Figure 3

    Flow chart depicting participant recruitment, randomisation allocation to cognitive functional approach intervention and control group and retention of participants.

    Treatment fidelity

    Treatment fidelity was ensured by documenting clinical notes for each session, and providing exercise sheets to each rower in the intervention group containing written and drawn information specifying exercise repetition, sets and frequency. For dynamic exercises, such as changes in lumbar kinematics during ergometer rowing, videos were taken (on the participants’ smart phone device). A parent or their coach always accompanied the rower during each treatment session and were asked to encourage the rower to follow the management plan. The mean number of treatments was 3.6 out of four sessions (range 2–5; SD 1.1). Five rowers discontinued treatment after three treatment sessions as the therapist deemed the participants had no further need for treatment. Fifteen participants were more than 50% compliant with the home exercise programme in the intervention group as determined by an exercise diary.

    Primary outcome

    Figure 4 presents the preintervention and postintervention group means for NPRS over the 15 min ergometer trial. Not all rowers were able to complete the 15 min ergometer trial due to their pain level during testing. At baseline, one rower was unable to complete the 15 min ergometer trial (ceased at 9th minute due to LBP) in the control group and five rowers were unable to complete the trial (two ceased at 7th minute due to LBP; two at 9th minute due to LBP; and one at 10th minute due to muscle cramping) in the intervention group due to LBP. At 8-week follow-up, one rower ceased rowing at 10th minute due to LBP in the control group. In the intervention group one rower ceased at 7th minute due to LBP; one at 7th minute due to reported fatigue; and one at 10th minute due to reported muscle cramping in the back. Rowers who were not able to complete the ergometer trial at 8-week follow-up were also rowers who could not complete the trial at baseline.

    Figure 4
    Figure 4

    Numeric Pain Rating Scale (NPRS) during ergometer rowing at preintervention laboratory analysis and postintervention laboratory analysis, between the control (CTRL) and the intervention (INT) groups.

    Following the intervention, rowers in the intervention group had a significantly lower rate of increase in pain during the ergometer trial (0.15 points per minute, 95% CI 0.07 to 0.23 vs 0.27 points per minute, 95% CI 0.19 to 0.36, p<0.001). There was a significant difference in the slope coefficient between groups (−0.12, 95% CI −0.24 to −0.01, p=0.035). Rowers in the intervention group reported significantly lower NPRS from the 3rd minute of the trial onward (3rd min: −0.9, 95% CI −1.8 to −0.1, p=0.048), with the difference between groups increasing throughout the 15 min (15th minute: −2.4, 95% CI −4.1 to −0.63, p<0.01).

    Secondary outcomes

    Rowers in the intervention group had significantly less disability immediately following intervention compared to the control group, as measured by the Patient Specific Functional Scale and the Roland Morris Disability Questionnaire (table 2), which was maintained at the 12-week follow-up (table 2). Rowers in the intervention group had significantly improved lower limb muscle endurance, and postured their lower lumbar angle during static sitting in less flexion following intervention compared with the control group (table 2). However, no statistically significant difference was observed in back muscle endurance, upper lumbar angle during static sitting, and regional lumbar angle kinematics during rowing between the intervention and control group (table 2). Further, no interactions between treatment group and minute, or treatment group and phase were detected in the lower lumbar angle and upper lumbar angle kinematics during ergometer rowing.

    View this table:
    Table 2

    Unadjusted secondary outcomes at baseline, 8-week follow-up and 12-week follow-up, and estimated group difference adjusted for baseline measures and age

    Discussion

    This is the first randomised controlled trial to assess the efficacy of a LBP intervention in rowers. Rowers who received the cognitive functional approach had less intense pain during ergometer rowing and reduced disability levels compared with the control group. Rowers in the intervention group demonstrated an increase in lower limb muscle endurance and demonstrated greater lower lumbar extension during usual sitting, compared with the control group. However, there were no differences between groups in back muscle endurance or in regional lumbar kinematics during ergometer rowing following the intervention.

    How did the intervention work?

    All participants reported a gradual increase of self-reported pain intensity levels during the preintervention 15 min ergometer row data collection, corroborating with previous findings that prolonged ergometer rowing is associated with LBP.2 , 11 , 12 This may reflect a repetition-induced summation of activity-related pain, where repetitive stimulation of pain-sensitive structures amplifies pain perception, as reported previously in repeated lifting tasks.29 , 30 Following the intervention, the intervention group had significantly less increase in pain intensity levels during rowing in comparison to the control group. It is possible these findings reflect a reduction in the sensitisation of lumbar spine structures to repeated flexion loading following the intervention. This may have been facilitated by increased load tolerance and/or reduced sensitivity of the spinal structures to flexion loading following the intervention.

    While both groups experienced reduced disability, the reductions were statistically greater in the intervention group than the control group. Furthermore, the intervention group reported ‘clinically’ meaningful reductions in the Roland Morris Disability Questionnaire, Patient Specific Functional Scale and the rowing item of the Patient Specific Functional Scale, according to previously outlined criteria.17 , 19

    Our findings in the context of other studies

    These findings match those of two non-randomised trials in female adolescent rowers.14 While the reduction in disability may be secondary to less pain experienced during rowing influencing other aspects of daily function, it is also possible that the cognitive functional approach provided active pain coping strategies via the functionally targeted training, which enhanced their ability to carry out other functional tasks with greater pain control and self-efficacy.

    The improved lower limb muscle endurance in the intervention group is consistent with the targeted nature of the rowing-specific conditioning exercises and corroborates the previous findings in female adolescent rowers.14 We postulate that poor lower limb muscle endurance may increase flexion loading of the lumbar spine as it results in increased lumbar flexion during repeated lifting tasks in adult workers.31 Although the intervention group appeared to perform better in back muscle endurance tests following the intervention, the difference between groups was not significant (28.2 s; 95% CI −0.5 to 56.9; p=0.054). This may be due to insufficient statistical power, as a previous study with a larger sample size (n=56) found that similar-sized differences (28.9 s) differentiated between adolescents with and without LBP.20 Improved back muscle endurance and lower limb muscle endurance may increase load tolerance across the lumbar spine during rowing. Increased back muscle endurance has also previously been linked to increased self-efficacy and reduced pain sensitivity.32

    The lower lumbar angle during usual sitting was more extended following cognitive functional approach compared with the control group, consistent with previous research in female adolescent rowers.14 Rowers were instructed to sit in a neutral lordosis if they were sensitised to flexion loading. Sitting in a position near end of range of lumbar flexion has also been associated with reduced back extensor muscle activity, poor back muscle endurance and LBP.32–34 It is possible that more upright sitting was associated with the trend towards greater back muscle endurance observed in the cognitive functional approach group while reducing static flexion loading during sitting.

    Contrary to our hypothesis, no differences in spinal kinematics during ergometer rowing were observed between groups following the intervention period. This suggests that the reductions in pain and disability observed following the cognitive functional approach intervention were due to other factors. However, it is possible that some individuals did indeed change their kinematics as we have previously reported,35 but that these changes were washed out in the group analysis.

    Strengths and limitations

    This is the first randomised controlled trial to investigate the effectiveness of an intervention to reduce LBP in a rowing population, in which the international rowing federation has identified LBP to be a common issue. However, this study has several limitations. First, the control group did not receive active treatment, potentially biasing the results, as the participants were not blinded from their group allocation. Although the control group was able to receive treatment for LBP by other clinicians during the intervention period, this was not formally monitored. Although all the data were considered in the analysis, not all rowers were able to complete the ergometer trials before and after the intervention due to LBP. While the study was powered to detect a difference in NPRS ratings over the 15 min ergometer trial, sample size may have been insufficient to detect differences in kinematics between the groups. Further, the type and intensity of sports participation outside of rowing was not captured. Finally, work rate during ergometer testing was only standardised between groups using self-reported rating of perceived exertion, rather than objective criteria. However, this approach has been used in previous ergometer studies.12 , 26

    Summary and conclusion

    A cognitive functional approach reduced pain during ergometer rowing and disability in male adolescent rowers compared with usual care. The intervention was associated with increased lower limb muscle endurance and a more extended lower lumbar posture during usual sitting. However, there were no differences between groups in spinal kinematics during ergometer rowing after the intervention.

    What are the new findings?

    • A cognitive functional approach was effective in reducing pain summation during ergometer rowing and disability levels in adolescent male rowers using a randomised controlled trial design.

    • Reduction in pain and disability were associated with changes in lower limb muscle endurance and lower lumbar sitting posture.

    • Improvement was not associated with regional spinal kinematics during rowing.

    How might it impact on clinical practice in the near future?

    • Low back pain (LBP) in rowers should be assessed through a multidimensional approach to determine the underlying mechanism of their LBP.

    • Treatment of LBP in rowers should target the factors contributing to the individual rower's LBP.

    • Cognitive functional approach should be considered in the treatment of athletes in other sports with LBP.

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    Supplementary materials

    • Supplementary Data

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    Footnotes

    • Contributors All authors were fully involved with this study and manuscript preparation. LN secured the funding for this project, planned the project and was the blind assessor who collected all outcome variables for the study. LN was also responsible for writing the manuscript drafts and submission of the article. JPC provided the CFA intervention and was responsible for writing the online supplementary appendix and assisted with creating figures 2 and 3. AC was responsible for designing the study, in particular the collection of the spinal kinematics variable. AC was also involved in editing the entire manuscript. AS was responsible for the data and statistical analysis of the manuscript, and wrote the results section of the manuscript. AB was involved with the design of the study and communicated with coaches to design the research protocol. PO is the primary supervisor who oversaw this project. He was involved with the design of the study and monitored the treatment protocol, and was involved with editing the final draft of the manuscript.

    • Funding This study was supported by research grants from the Physiotherapy Research Foundation tagged Sports Physiotherapy Australia grant (T09-THE/SPA001).

    • Competing interests JPC received honoraria from the Physiotherapy Research Foundation tagged Sports Physiotherapy Australia grant for administering the cognitive functional approach (T09-THE/SPA001).

    • Patient consent Obtained.

    • Ethics approval Human Research Ethics Committee at Curtin University in Perth, Western Australia.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement All data collected were published in this article.