1. 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

2. 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

3. 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. 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

5. What is Prevention? TERTIARY PREVENTION Strategies to limit the impact of advanced conditions SECONDARY PREVENTION Strategies to prevent transition from acute symptoms to chronicity PRIMARY PREVENTION Strategies to prevent the occurrence of the condition

6. “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

7. Primary Prevention in Athletes Correct technique – avoiding postures and positions of stress Flexibility Strength – Core stabilization Education

8. Correct Technique Factors that may contribute to spine pain or injury include: –Over-rotation –Repeated end-range extension –Hyper flexion during lifting

9. High amplitude trunk rotation

10. 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

11. 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

12. Weight Belts? ↑ intra-abdominal pressure unclear impact on spinal compression Some report increased comfort with a belt No evidence of injury reduction

13. 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: 149 0 Total hamstring length asymptomatic: 144 0 Nourbakhsh and Arab (JOSPT, 2002)

14. 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

15. 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).

16. 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

17. 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

18. 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)

19. 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 ”

20. Onset time of TrA was significantly delayed for patients with LBP in each direction

21. 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

22. Evidence Roland Morris Scores Pain Scores

23. Evidence Recurrent Episodes

24. 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

25. 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)

26. 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