Physiotherapists JP Caneiro and Dr. Leo Ng outline how individualised plans are needed in the management of low back pain in an issue of the Sport Health magazine. JP Caneiro is a Specialist Sports Physiotherapist (as awarded by the Australian College of Physiotherapists in 2013) who consults at Body Logic in Perth and lectures in the Clinical Masters in Physiotherapy at Curtin University. He is undertaking a PhD investigating the process of change in people with LBP and high fear undergoing a personalised CFT intervention. Dr. Leo Ng is a musculoskeletal physiotherapist and a lecturer at the School of Physiotherapy and Exercise Science at Curtin University. He completed his PhD on the use of Cognitie Functional Therapy to manage low back pain in rowers.
Low back pain (LBP) affects a large proportion of the general and athletic population; being considered a common reason for activity avoidance and retirement from sport. The story of a young Western Australian footballer troubled by persistent back pain is used to illustrate the impact of back pain in sport.
This footballer’s back pain started with no specific incident, but at a time of reduced sleep and increased stress. His pain persisted over 12 months becoming a major impairment in his life. An MRI scan organised soon after the onset of symptoms reported disc degeneration of the lower lumbar spine (L5/S1), with no evidence of a disc prolapse or neural compromise. This advice given by a health care practitioner was to avoid bending and lifting and to follow a program that aimed at strengthening the core muscles to protect the back. Despite compliance with the program for over three months the athlete had minimal improvement, presented increased levels of distress, became avoidant of physical activities, had unhelpful beliefs about his back (“my back is weak and damaged”, “bending will cause more damage”) and the possibility of playing football again and stopped training.
This case is a common example of an athlete that struggles to achieve their goals while living with persistent back pain. Historically, the rehabilitation of athletic populations has been directed at targeting biomechanical faults with consideration of pathology. The search for an accurate imaging diagnosis, guiding medical interventions (spinal injections, medication and surgical procedures) and physical approaches that aim to reduce biomechanical impairments such as core stability, have been a major focus of biomedical practice. However, there is evidence that biomedical approaches have led to a significant increase in healthcare costs and an increase in pain related disability. The limited intergration of a biopsychosocial understanding that directs clinical practice combined with the lack of individualised care are two factors considered to underpin this.
Biopsychosocial factors related to pain
The understanding of the mechanisms by which pain can occur have evolved over recent years. While originally pain was understood solely as an alarm system to indicate the amount of tissue damage, contemporary knowledge defines pain more broadly as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” (as defined by the International Society for the Study of Pain – IASP).
Strong evidence supporting this definition indicates the nature of pain is multifactorial and may include interactions between patho-anatomical, physical (training load, lifestyle, biomechanics, movement patterns, physical conditioning) and non-physical (beliefs, emotions, lifestyle, social stressors, culture) factors. The complex interplay of these factors in some cases, can lead to a negative cycle that perpetuates pain and disability.
Patho-anatomical factors
Specific pathologies account for 10-15 percent of the population with LBP. In the sporting population the most common are: stress fractures, spondylolisthesis and, disc prolapse with radiculopathy. Serious pathologies (e.g. fractures, tumours, infections) account for one to two percent of people with LBP. The large majority will present pain in the absence of pathology (non-specific LBP). Radiological findings such as disc bulges, protrusions, annular tears and facet joint arthropaties are commonly seen in asymptomatic individuals and not well correlated with pain and disability; therefore, when present, need to be considered within the context of the athlete’s presentation and communicated skilfully.
Physical factors
Certain sports that perform sustained (e.g. cycling) or repetitive loading of the spine, especially when coupled with rotation (e.g. sweep rowing) or lateral bending (e.g. gymnastics and tennis), can be associated with an increased risk for LBP. Factors such as cumulative training load and sport-specific technique have been linked to higher incidence of LBP in rowing. Similarly, lifestyle factors related to physical activity (under and over activity) can influence pain sensitivity and disability.
Deficits in back muscle endurance have also been linked to increased risk of LCP in sports (i.e. rowing), and improvements in back and leg muscle endurance have reduced the risk of LBP.
Non-physical factors
Beliefs about pain can have a strong impact on an individual’s response to pain, and are influenced by a person’s past experiences, contextual factors, culture, and information provided by treating therapists. LBP is commonly seen as “easy to harm and hard to heal”. Negative beliefs have been associated with increased pain sensitivity and together with fear of movement are highly predictive of disability. Emotional factors such as high levels of stress, low mood and anxiety influence pain, disability and distress, and have been described as predictors of injury in athletes.
Lifestyle factors such as sleep deficits, abdominal obesity and alcohol consumption can affect spinal tissue sensitivity. Social factors such as demands of the sport, expectations from coaches, team mates and fans, family stresses, and cultural factors can influence stress load, pain coping and vulnerability.
A person-centered approach to the management of LBP in sport
In light of the limitations of the biomedical approach, Cognitive Functional Therapy (CFT) emerged as an integrated person-centered, goal orientated behavioural approach for the management of LBP once serious pathology has been ruled out. CFT uses a clinical reasoning framework to consider the multiple factors associated with the LBP disorder. This enables the identification of the key modifiable risk factors for the athlete and subsequent development of an individualised management plan.
CFT aims to provide biopsychosocial understanding of pain, promote functional re-training while confronting mal-adaptive cognitions and behaviours in avoided and/or provocative activities to return people to desired functional goals. A thorough interview that is reflective and motivational in nature is followed by a targeted physical examination to determine the key drivers of the athlete’s disorder, assisting the athlete to make sense of his pain and developing a targeted rehabilitation program.
Managing the young footballer
Some of the key aspects for the management of the young footballer was to understand the beliefs underlying his behaviour. He believed that pain was a sign of damage, and that avoiding bending forward and tensing his muscles while moving would protect his back from further damage (pointed to him on the MRI). These beliefs were challenged not only through de-threatning his radiology with sensible and evidence-based information, but also through behavioural learning. Behavioural experiements during the performance of valued activities (bending to pick the football, lifting weights) showed that his pain could be controlled by changing his behavioural response (breathing and relaxing his abdominal muscles while bending forward and lifting through his legs). Based on that, a targeted functional re-training program was designed to restore his confidence in his back, conditioning of his legs and physical capacity to return gradually to valued activities and sports training.
The efficacy of CFT has been tested in the athletic and non-athletic population with non-specific LBP, showing promising results. However, this approach is still novel and further testing is underway.
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