PREVENTION of COMMON ACUTE ATHLETIC INJURIES

The Spine

Julie M. Fritz, PT, PhD, FAPTA

Professor, Associate Dean for Research University of Utah

Salt Lake City, Utah, USA

• Yearly prevalence 20-50%

• About 20% of athletic injuries involve the spine

• One of the most common reasons for lost playing time

• Most common injury among:– Golfers

– Divers

– Gymnasts

Low Back Pain in Athletes

Magnitude of the Problem

•Reported prevalence of LBP among athletes:

– Wrestlers 59% (Granhed and Morelli)

– Rowers 15-25% (Hickey et al)

– Elite Gymasts 79% (Sward et al)

– Tennis 32% (Lundin et al)

4

Magnitude of the Problem - Youth• Conflicting evidence on relationship between

physical activity levels and back pain in school-age children.

• Most studies report increased LBP related to sports participation

• Increased for competitive sports vs. recreational activity

• Increases with amount of participation

• Dependent on the type of sport

What is Prevention?

“Virtually nothing is known about the primary prevention of low back pain.”

(Spitzer et al, BMJ, 1993)

Still mostly true

True for athletes and non-athletes alike

Identifying risk factors ≠ Effective prevention strategy

Primary Prevention in Athletes

• Correct technique – avoiding postures and positions of stress

• Flexibility

• Strength – Core stabilization

• Education

Correct Technique

• Factors that may contribute to spine pain or injury include:

– Over-rotation

– Repeated end-range extension

– Hyper flexion during lifting

High amplitude trunk rotation

High Amplitude Rotation

• Athletes in tennis, golf with LBP tend to have:

– Asymmetry of hip flexibility, particularly rotation

– Reduced lead hip internal rotation

– Different patterns of lumbar – hip rotation movement (more dominant lumbar rotation early in movements)

From Harris-Hayes et al, J Sport Rehabil, 2014, Vad et al, J Sci Med Sports, 2003

Proper Lifting Technique

• Sports/occupations with frequent lifting have higher rates of back injury.

– No evidence that advice or instruction in lifting techniques can reduce injury (Cochrane review, 2011)

– No evidence that back belts prevent injury

Weight Belts?

↑ intra-abdominal pressure

unclear impact on spinal compression

Some report increased comfort with a belt

No evidence of injury reduction

Flexibility• Presumed cause of back pain and injury

• Stretching advocated as key to preventing injury

• Some associations between flexibility and back pain in cross sectional studies.

– Individuals with LBP have less hamstring flexibility• 600 subjects (300 LBP, 300 control)

• Total hamstring length LBP patients: 1490

• Total hamstring length asymptomatic: 1440

Nourbakhsh and Arab (JOSPT, 2002)

• 2,377 individuals over 18 who do vigorous physical activity at least 1 day per week.

– Excluded those with activity-limiting leg or back pain

– Recruited over the internet

• Randomized to stretch 7 muscles before and after vigorous activity for 12 weeks

– gastrocnemius, hip adductors, hip flexors, hamstrings, rectus femoris, hip external rotators and trunk rotators

– Compared to control group

Jamtvedt et al. A pragmatic randomised trial of stretching before and after physical activity to prevent injury and soreness. Br J Sport Med 2010: 1002-1009

Jamtvedt et al. A pragmatic randomised trial of stretching before and after physical activity to prevent injury and soreness. Br J Sport Med 2010: 1002-1009

• Stretching did not produce clinically important or statistically significant reductions in all-injury risk (HR=0.97, 95% CI 0.84 to 1.13)

• Stretching did reduce the risk of bothersome soreness (mean risk of bothersome soreness in a week was 24.6% in the stretch group and 32.3% in the control group; OR=0.69, 95% CI 0.59 to 0.82)

• Stretching reduced the risk of injuries to muscles, ligaments and tendons (incidence rate of 0.66 injuries per person-year in the stretch group and 0.88 injuries per person-year in the control group; HR=0.75, 95% CI 0.59 to 0.96).

• 600 patients with recurrent LBP– 18 years or older

– At least 2 LBP episodes in past 12 months

• Randomized to one of 4 treatment groups (performed daily for 30 minutes):

– Strengthening (trunk isometrics)

– Stretching (post-isometric relaxation for trunk muscles)

– With or without abdominal bracing (instructed to incorporate into daily activities)

Alexsiev et al. Ten-Year Follow-up of Strengthening Versus Flexibility Exercises With or Without Abdominal Bracing in Recurrent Low Back Pain. Spine 2014: 997-1003

• All groups improved through year 2 then worsened through year 10.

• No differences in stretching or strengthening• Bracing improved outcomes

Alexsiev et al. Ten-Year Follow-up of Strengthening Versus Flexibility Exercises With or Without Abdominal Bracing in Recurrent Low Back Pain. Spine 2014: 997-1003

Number of recurrences per year

Core Stabilization– Core stabilization, dynamic abdominal bracing

and maintaining neutral position can be used to increase lumbopelvic-hip stability

– Increased stability helps the athlete maintain the spine and pelvis in a comfortable and acceptable mechanical position (prevents microtrauma)

Core Stabilization - Theory

•Hodges & Richardson, (Spine, 1996)

– Fine-wire EMG recordings

– 30 subjects (15 control, 15 with history of LBP)

– Performed arm movements in response to a visual stimulus “as fast as possible”

Onset time of TrA was significantly delayed for patients

with LBP in each direction

Evidence

• Hides et al (Spine, 1996, 2001)– 41 patients with acute LBP

• 18-45 years old

• First episode of unilateral LBP

• Excluded patients involved in lumbar strengthening

– Randomized to receive:

• Medical management

• Medical management and specific exercise training

Evidence

Roland Morris Scores Pain Scores

Evidence

0

2

46

8

10

1214

16

18

Control Exper.

Moderate

Severe

Recurrent Episodes

George et al. Brief psychosocial education, not core stabilization, reduced incidence of low back pain: results from the Prevention of Low Back Pain in the Military (POLM) cluster randomized trial BMC Med 2011: 9:128

• Cluster randomized trial of military basic trainees (n=7,616)

• Factorial design:

– Exercise Program: traditional or core stabilization

– Psychosocial Education: single 45-minute sessions covering back pain prognosis, importance of maintaining activity

George et al. Brief psychosocial education, not core stabilization, reduced incidence of low back pain: results from the Prevention of Low Back Pain in the Military (POLM) cluster randomized trial BMC Med 2011: 9:128

• No differences in LBP incidence resulting in seeking health care based on type of exercise

• Brief psychosocial education reduced risk of a LBP episode regardless of exercise program.

(NNT = 30.3; 95% CI: 18.2, 90.9)

Summary

• Primary prevention of back pain is an elusive yet important goal.

• Many strategies have been tried without clear evidence of effect.

• Likely role for:

– Technique modifications

– Flexibility

– Strength – core stabilization

– Education