10/16/2017 ATHLETIC LOW BACK PAIN: RISK FACTORS AND PRINCIPLES FOR EFFECTIVE RETURN TO SPORT. How Do Patients Present? The Journey to Return to Sport

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1 ATHLETIC LOW BACK PAIN: RISK FACTORS AND PRINCIPLES FOR EFFECTIVE RETURN TO SPORT Phil Glasgow PhD, MCSP How Do Patients Present? Technique Sport Specific Mobility Effective Force Generation Strength Subqualities Efficient Force Transfer Control Whole Body Integration The Journey to Return to Sport We don t receive wisdom; we must discover it for ourselves after a journey that no one can take for us or spare us. Marcel Proust Psychosocial Factors Sport Specific Mobility Control Technique Strength (Subqualities) Beliefs Anxiety Sport-specific Factors Hip Rotation (particularly rotational sports) Trunk Mobility Combined movements (Tension Arcs) Torso-pelvic dissociation Lumbopelvic-hip dissociation Response to unpredictable variations Focus on coaching of correct sport specific movements Eccentric extensors Reactivity: Rate of Force Development Length Tension relationship Strength Endurance Whole Body Integration Torso-pelvic (de)coupling Lines of Force Global Driven Management should be directed at PHYSICAL and associated COGNITIVE factors underlying the disorder. Every emotional state corresponds a personal conditioned pattern of muscular contraction without which it has no existence. (Moshe Feldenkrais, Awareness Through, 1977) Quality and Control Which factors are important? How do you measure them? Cognitive Factors Altered beliefs Altered experiences How we measure learning? We have a brain for one reason and one reason only -- that s to produce adaptable and complex movements. is the only way we have of affecting the world around us (Daniel Wolpert, Neuroscientist, Cambridge University) 1

2 Cognitive Factors Which factors are important? How do we measure them? From Gifford LS 1998 Pain the tissues and the nervous system: a conceptual model. Physiotherapy 84(1):27-36 Conflicting Beliefs But I ve a bad back and the trapped nerve hurts when I exercise. The pain is excruciating - I can't possibly do that, I might cause permanent damage fear of pain and injury may be more disabling than pain itself "You have pulled a muscle in your back so it needs exercise to help it heal Barriers to Successful RTP Psychological distress Social factors Lack of trust Inappropriate beliefs about back pain Illness behaviour Fear avoidance Psychological Factors Anxiety Fear Anger Depression Stress Depression Hypervigilance Cognitive Factors Changed beliefs Changed experiences How do we measure learning? Beliefs Serious pathology Fearavoidance to control pain Iatrogenesis Coping Strategies Confronter vs. Avoider Inability to objectify pain Pacing Goal-setting Patterns of learned behaviour Social Factors Social and inter-personal circumstances Relationships Support Economic Position on team Experience Neurophysiolo -gical changes Perception Performance Self-efficacy Fersum et al. EurJ Pain (2013) O Sullivan. Man Ther (2005) Storheim et al, J Rehabil Med (2005) Poor understanding of condition Oswestry Disability Index (ODI) Back Beliefs Questionnaire (BBQ), Fear-Avoidance Beliefs Questionnaire (FABQ), Pain Catastrophizing Scale (PCS) Pain Self-Efficacy Questionnaire (PSEQ), STarT Back screening tool, Tampa Scale of Kinesiophobia (TSK), Pain Scales 2

3 Quality and Control Which qualities? How do you measure/train them? Sport Specific Mobility Hip Rotation (particularly rotational sports) Trunk Mobility Combined movements (Tension Arcs) Sport- Specific Mobiiity Control Technique Strength Whole Body Integration Direction specific Kinetic Chain Tension arc Hip ROM Overhead athletes Response to unpredictabl e variability Torso-pelvic dissociation Lumbopelvic-hip dissociation Sportspecific skill: coach input Performance variables: time, speed, accuracy, repeatability Reactive agility Eccentric extensors Reactivity: RFD Length Tension relationship Strength Endurance Torso-pelvic (de)coupling Lines of Force Global Patterns Repeatability Whole Body Mobility: Tension Arcs 3

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5 Clinical Threshold 10/16/2017 Control Torso-pelvic dissociation Lumbopelvic-hip dissociation Response to unpredictable variations Some Problems Are Easy To See Clinical Presentation Painfree Adaptable motor system Occasional Pain Dysfunctional movement patterns Reduced adaptability Regular Pain Dysfunctional movement patterns Reduced adaptability Significant Pain Unable to compete in sport Chronic Motor Control Adaptable, Responsive System Sub-clinical Quality / Adaptability Clinical Unresponsive System Acyclic Power Delivery of Force Whole body / kinetic chain integration Force Transfer Re-establishing Quality in LBP Br J Sports Med 2013 Vol 47 No 2 Injury / Underperformance Constraints: Environment Task difficulty Previous injury Performance Zone Constraints: Environment Task difficulty Previous injury Balanced System Performance Zone Address specific limitations of function Break association between specific movement patterns and pain** Simple motor skills Stimulate peripheral afferents Encourage re-education of normal movement 5

6 Intervention: Early Stage Painfree Correct patterning Single-segment Uni-planar Familiar, predictable and smooth known movement patterns Manual assistance or facilitation may be useful More Variations vs. More Exercises? Train Adaptability Hip Extension / PPT 6

7 Progressions Increase complexity of the task: Multiple segments Multiple planes of movement Focus on facilitating effective loading of tissues through functional patterns Force production and attenuation Build endurance Whole Body Integration Torso-pelvic (de)coupling Lines of Force Global Tension Arc Training 7

8 Strength (Subqualities) Eccentric extensors Reactivity: Rate of Force Development Length Tension relationship Strength Endurance Retraining Adaptability Adaptability Training Perturbations: Internal and External facilitates reactive neuromuscular adaptations Unanticipated movements essential for effective restoration of function Monitor movement quality How can we determine if someone with LBP is ready to RTP? What are the Key Dependencies? How will you assess them? 8

9 Clinical Threshold 10/16/2017 Creighton et al 2010 RTS Physiotherapy Intervention Activity (sport) Specific Dysfunction Specific Sport-specific Patterns Efficient force transfer Multi joint / segment Responsiveness / variability Unpredictable Challenging Psychosocial Factors Basic Patterns Direction and location of dysfunction Painfree position / posture Activation Sequencing Predictable Clinical Presentation Painfree Adaptable motor system Occasional Pain Dysfunctional movement patterns Reduced adaptability Regular Pain Dysfunctional movement patterns Reduced adaptability Significant Pain Unable to compete in sport Chronic Sub-clinical Motor Adaptable, Control Responsive System Quality / Adaptability Clinical Unresponsive System Key take home points that I can use in my practice on Monday Thank-you Sport-related LBP is different to normal LBP Restore lumbopelvic-hip decoupling: both ROM & Control Focus on elongated trunk Include posterior pelvic tilt training Integrate tension arc training Restore adaptability 9