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Low back pain (LBP) is a common problem among cyclists. However, the efficacy of a specific rehabilitation approach for reducing LBP during cycling has not been evaluated. In this case study, a cognitive functional therapy (CFT) intervention including biofeedback was used to modify lumbo-pelvic posture and to reduce LBP during cycling. The cyclist had a clear “Flexion Pattern” LBP disorder and completed a two-hour outdoor cycling task before and after the CFT intervention. Lumbo-pelvic posture was measured using a wireless monitoring system (BodyGuardTM). The numerical pain rating scale was used to measure the level of pain. The CFT intervention was provided over a one-month period. The use of CFT including biofeedback significantly reduced lumbo-pelvic flexion and the LBP reported during cycling (p=0.01). The results from this case study suggest that a specific CFT intervention including biofeedback on lumbo-pelvic posture could be a useful rehabilitation strategy for reducing LBP in this subgroup of cyclists.
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20 Sport & Geneeskunde | oktober 2011 | nummer 4
Sportmedische praktijk
Introduction
Cycling is one of the most po-
pular recreational sports throu-
ghout the world. The incidence
of low back pain (LBP) among
cyclists appears to range from
32-60%.1-3 Most LBP lacks a spe-
cific diagnosis, and has been
described as non-specific chro-
nic low back pain (NS-CLBP).4,5
The NS-CLBP population is a
very heterogeneous group re-
quiring sub-classification.5 One
of the proposed subgroups in
NS-CLBP is the Flexion Pattern
(FP) which is the most common
pattern4 within the ‘maladap-
tive motor control impairment’
subgroup.4 It is suggested that
a well selected subgroup of cy-
clists with NS-CLBP present
with inherent maladaptive mo-
tor control (FP) at the lower
lumbar spine resulting in a
more flexed lumbo-pelvic pos-
ture during cycling that is rela-
ted to a significant increase in
pain.6-8
For the general LBP population
several researchers have sug-
gested that enhancing the lum-
bar lordosis can help to reduce
the incidence of LBP.9,10 There-
fore, for a subgroup of cyclists
where the LBP is related to a
maladaptive flexed position on
the bicycle,2,11-14 trying to alter
Samenvatting
Lage rugpijn (LRP) is een veelvoorkomend probleem bij fietsers. Desalniettemin is de
effectiviteit van een specifiek gerichte revalidatie voor het verminderen van LRP tijdens het
fietsen niet onderzocht. In deze casuïstiek werd een cognitieve functionele therapeutische
(CFT) interventie met biofeedback uitgevoerd voor het verbeteren van de lumbo-pelvische
houding en voor het verminderen van de geassocieerde LRP tijdens het fietsen. De
fietser had LRP, gesubclassificeerd als een duidelijk “Flexie Patroon” en voltooide een
twee uur durende ‘outdoor’ fietsproef voor en na de CFT interventie. De lumbo-pelvische
houding werd gemeten met behulp van een draadloos meetsysteem (BodyGuardTM). De
‘numerical pain rating scale’ werd gebruikt om de intensiteit van de pijn te meten. De CFT
interventie werd uitgevoerd gedurende een periode van één maand. Het gebruik van de
CFT interventie met biofeedback verminderde significant de lumbo-pelvische flexie en
de gerapporteerde LRP tijdens het fietsen (p = 0.01). De resultaten van deze case studie
suggereren dat een specifieke CFT interventie met biofeedback van de lumbo-pelvische
houding als een nuttige en effectieve strategie kan gebruikt worden om de LRP in deze
subgroep van fietsers te verminderen.
Summary
Low back pain (LBP) is a common problem among cyclists. However, the efficacy of a
specific rehabilitation approach for reducing LBP during cycling has not been evaluated.
In this case study, a cognitive functional therapy (CFT) intervention including biofeedback
was used to modify lumbo-pelvic posture and to reduce LBP during cycling. The cyclist
had a clear “Flexion Pattern” LBP disorder and completed a two-hour outdoor cycling
task before and after the CFT intervention. Lumbo-pelvic posture was measured using a
wireless monitoring system (BodyGuardTM). The numerical pain rating scale was used to
measure the level of pain. The CFT intervention was provided over a one-month period.
The use of CFT including biofeedback significantly reduced lumbo-pelvic flexion and the
LBP reported during cycling (p=0.01). The results from this case study suggest that a
specific CFT intervention including biofeedback on lumbo-pelvic posture could be a useful
rehabilitation strategy for reducing LBP in this subgroup of cyclists.
Keywords: Low Back Pain (LBP), cycling, lumbar postural control, Flexion
Pattern, rehabilitation
Trefwoorden: Lage rugpijn, fietsen, lumbale postural controle, Flexie Patroon,
revalidatie
W. Van Hoof, K. Volkaerts, K. O’Sullivan, S. Verschueren, W. Dankaerts
Cognitive functional therapy
intervention including biofeedback
for LBP during cycling
A Single Case Study
Dingt mee naar Aanmoedigingsprijs Sport & Geneeskunde
21nummer 4 | oktober 2011 | Sport & Geneeskunde
ate effect of a rehabilitative approach on reducing LBP in
cycling. Therefore, the aim of this case study was to evalu-
ate the effect of a specific CFT intervention including BFB
on lumbo-pelvic posture to influence both the postural
control at the symptomatic lumbar region and the associ-
ated levels of LBP during cycling.
Case
A 19 year old male (mass 72.2kg, height 186cm, Body Mass
Index: 20.9) was independently evaluated and subclassified
based on O’Sullivan’s classification system4 by two physio-
therapists.
The subject presented with bilateral LBP located at the lo-
wer lumbar spine (L4-5 region). The LBP was described as a
dull and diffuse ache. Cycling and prolonged sitting aggra-
vated his LBP. Walking and stretching the lower back into
extension during cycling relieved his pain. He had a 5 year
history of LBP. His average cycling pain was 5/10 (numerical
pain rating scale: NPRS) and average pain during activities
of daily living (ADL) was 2/10(NPRS). He had a low level of
disability (Revised-oswestry disability index (R-ODI) = 6%)
and moderate level of kinesiophobia (Tampa Scale for Kine-
siophobia (TSK) = 38/68). He was otherwise healthy and
took no medication.
Subject had a slouched usual sitting posture with a poste-
rior rotated pelvis. Self-correcting his posture resulted in
upper lumbar and thoracic extension. A loss of lumbo-pel-
vic lordosis and anterior pelvic rotation and increase in
thoracic extension was also seen during different functio-
nal tasks (forward bending, squatting and sit-to-stand). The
L4-5 segment was found hyper-mobile into flexion during
passive motion testing and LBP was reproduced during pal-
pation of the L4-5 segment.
Subject cycled with his race bike 5 days/week and an aver-
age distance of 400 km/week. He was a competitive cyclist
who already cycled for 6 years, but because of the LBP he
recently decided to stop competitive cycling. He had no
specific structural spinal pathology, no spinal surgery and
no neurological symptoms. Based on this musculoskeletal
screening the subject was subclassified (by the two physio-
therapists) as having a ‘Flexion Pattern LBP disorder’ that
was considered directly attributable to the activities of cy-
cling and sitting.
Subject’s personal race bike had a medial cut-out saddle
and a 1° anterior tilted saddle angle (measured with a long
arm goniometer (Gymna, Belgium).
the adopted lumbo-pelvic position could be a relevant re-
habilitation intervention. Testing this hypothesis can be
classified in two domains.
Firstly, the low back position can be improved by addres-
sing the
non-personal modifiable factors
, namely the geo-
metric bike related variables. These includes factors such
as saddle angle,2 type of saddle,15 saddle height,11 pedal
unit position,16 type of bike2 and reach.11 Making changes
to these variables have been proposed as a method to re-
duce LBP. Two studies examined the influence of such alte-
rations. Bressel and Larson15 demonstrated that some sad-
dles could increase anterior pelvic tilt and hypothesized
this could reduce LBP during cycling. They concluded
further investigation into saddle alteration and LBP are re-
quired. Further, Salai et al.2 revealed that appropriate ad-
justment of saddle angle inclination caused a major reduc-
tion (72%) in the incidence and magnitude of LBP
experienced during cycling.
Secondly, the low back position can be improved by addres-
sing personal modifiable factors, namely regaining postural
control through active repositioning of the symptomatic lower
lumbar spine,17 without modifying the settings of the bike.
A multi-dimensional Cognitive Functional Therapy (CFT)
intervention could be an appropriate and useful rehabilita-
tion/prevention strategy for LBP in cyclists.18 The general
aim of the intervention would be to alter the personal mo-
difiable factors in order to reduce the LBP experienced du-
ring cycling, taking into account the complex multi-facto-
rial nature of LBP in sports.19 This CFT should be specifically
directed to regain postural control over the symptomatic
lumbo-pelvic region and to facilitate a less end range flexed
cycling posture.
While in clinical practice this postural control retraining
has been shown to be effective in the management of NS-
CLBP disorders,20,21 its relationship to LBP during cycling has
not been investigated rigorously.
Biofeedback (BFB) might be a useful tool to increase sub-
jects’ awareness of their lumbo-pelvic posture during cy-
cling, helping them to avoid provocative end-range postu-
res and reduce the risk of recurrent and chronic LBP. There
is evidence of reduced proprioceptive awareness in NS-CL-
BP22 and further evidence that postural feedback may be a
useful adjunct to conventional management of NS-CLBP.23
Despite the potential that regaining postural control could
be a useful rehabilitation intervention for LBP during cy-
cling, until now no cycling field studies have investigated
this issue. Nor are there documented cases of the immedi-
22 Sport & Geneeskunde | oktober 2011 | nummer 4
during cycling. To avoid any potential diurnal effects27,28 the
start time was the same (13.30pm). Non-personal modifia-
ble factors were unchanged.
Outcome measures and statistics
Lumbo-pelvic posture was measured using the BodyGuardTM
(Sels Instruments nv, Belgium) (http://www.sels-instru-
ments.be), as described in detail elsewhere.14,29 The subject
was positioned on his personal race bike and the maximal
lower lumbar lordosis still allowing to cycle was deter-
mined. Based on pilot testing and clinical observation, an
individualised threshold was set at 62% flexion range of
motion (Fl ROM), 20% below his average lower lumbar pos-
ture (82.2% Fl ROM) during the first cycling task. External
auditory and somato-sensory BFB was provided when the
subject exceeded this threshold by assuming excessive
lumbo-pelvic flexion.
The NPRS was used to measure the level of LBP, as described
in detail elsewhere.14 The subject’s level of pain was measu-
red at the start, every 15 minutes during cycling and at 30
minutes, one, two and 24 hours after cycling. R-ODI30 and
TSK31,32 were re-evaluated after the second cycling task.
Comfort level of sitting was recorded using the Category
Partitioning scale (CP-50), as described in detail else-
where.33 This comfort level of sitting was measured since it
has been suggested that an anterior pelvic rotation during
cycling could increase perineal pressure15, leading to sitting
discomfort. Scores were filled in at the start and immedia-
tely after the two hours of cycling.
BodyGuardTM data were downloaded to a personal compu-
ter, uploaded to Microsoft Excel and compressed from 20Hz
to an average value for each minute and per ten minutes
of cycling. Paired t-tests were used to determine differences
in lumbo-pelvic posture and level of pain between the two
cycling tasks. A one-way repeated measures ANOVA was
used to determine if the lumbo-pelvic posture changed bet-
ween the two conditions across the 12 intervals of ten mi-
nutes. All statistical analyses were performed using SPSS
Version 16.0. The significance level was set at p<0.05.
The subject was contacted by telephone for further follow-
up after 2½ months and asked to report on his LBP during
cycling and ADL activities.
Clinical outcome
The CFT/BFB intervention significantly reduced (p<0.001)
the mean(±SD)% of total lumbo-pelvic flexion from
82.2(±5.2)% during the first cycling task (no-CFT/BFB) to
Intervention – Cognitive Functional Therapy (CFT)
In order to improve postural control and reduce LBP at the
lumbo-pelvic region during cycling, the subject underwent
a specific CFT intervention including BFB. This consisted of
several steps.
Firstly, the underlying mechanism behind the patient’s LBP
was clearly explained by an experienced physiotherapist
during an educational session on LBP. This cognitive com-
ponent was deemed essential to give the subject a clear
understanding of the relationship between his (prolonged)
excessively flexed sitting posture and LBP, and the develop-
ment and further provocation of peripheral nociceptive
pain generation leading to LBP. This session was given by
an experienced musculoskeletal physiotherapist (WD) and
contained the basic principles on spinal loading, the impor-
tance of neutral posture and the concept of neuromuscular
control strategies (as a personal modifiable factor) and its
influence on pain control.
Thereafter, the subject was taught to regain postural con-
trol over his symptomatic lumbo-pelvic region. In practice,
this control can be achieved by instructing and learning the
subject to rotate the pelvis anteriorly, which has a critical
role in facilitating the lumbo-pelvic musculature24,25 and
preventing excessive flexion at the lumbar spine.
Finally, the subject was taught individual exercises aiming
to control anterior tilting of the pelvis in different positions
(sitting and in four-point kneeling). Subject was asked to
practice on a daily basis and to integrate the motor control
strategies during ADL and cycling. A sheet with clear in-
structions for exercises was provided.
To test the effectiveness of this CFT intervention, the sub-
ject had to perform two cycling tasks, which are explained
below.
Cycling task 1 (no-CFT/BFB) was performed before the start
of the CFT intervention. The subject performed a two hour
outdoor cycling task on a flat parcourse with his personal
race bike. He was instructed to cycle as usual and was gui-
ded by a heart rate monitor (Polar, Belgium) to maintain a
heart rate between 60-70% of his age-predicted maximum
heart rate.6,26
Cycling task 2 (CFT/BFB) was performed one month after
the start of the CFT intervention. The task was identical,
except for the following two aspects. To facilitate a less
end-range cycling posture, the subject was instructed to
actively rotate his pelvis anteriorly as practiced during the
CFT. Further, he was provided with external auditory and
somato-sensory (vibration) BFB of his lumbo-pelvic posture
Sportmedische praktijk
23nummer 4 | oktober 2011 | Sport & Geneeskunde
The average pain during cycling (average pain over the last
week) prior to the first cycling task had decreased from
5/10 to 2/10 over the last week before the second cycling
task (one month later). Similarly, the average pain during
ADL (average pain over the last week) decreased from 2/10
to 1.5/10 before the first and the second cycling task res-
pectively. R-ODI and TSK scores improved from 6 to 2% and
from 38 to 30 respectively after the CFT intervention.
Discussion
This single case study revealed that a cycling specific CFT
intervention including BFB significantly decreased lumbo-
pelvic flexion over the entire two hours of cycling. This was
accompanied by a significant reduction in cycling related
LBP. During the initial cycling task, the level of pain gradu-
ally increased over time without increase of lumbo-pelvic
flexion. In contrast, after the CFT intervention and using
the BFB, the cyclist was able to maintain a more towards
neutral lower lumbar lordosis during cycling. The LBP de-
veloped during cycling was significantly delayed and redu-
ced compared to the initial cycling task. This suggests that
an inherent maladaptive motor control dysfunction (FP
disorder), resulting in a more end-range flexed posture, can
be a key factor in the development of LBP in this cyclist.
Consistent with these findings, similar cognitive and active
rehabilitation strategies have been recommended in sports
like cycling11,12,34 and rowing.35,36 Recently this type of inter-
vention has been shown to be effective in reducing the in-
cidence and level of LBP and disability in rowers.19,36 For
instance, Thorpe et al.36 compared an experimental with a
control group through the rowing season till 10 weeks post
season. The experimental group received a LBP education
session, a physical conditioning program and a specific in-
dividualised prescribed physiotherapy intervention (based
on a thorough musculoskeletal screening). The control
group only received a LBP education session and a physical
conditioning program. The findings revealed that a specific
individually prescribed physiotherapy intervention was as-
sociated with a reduction in the prevalence of LBP in ado-
lescent female rowers across the rowing season. More re-
cently, Perich et al.19 revealed that a multi-dimensional
intervention program (during the season) consisting of a
LBP education session, a screening based individualised
specific exercise intervention, combined with off-water
strength and conditioning sessions resulted in a decreased
incidence of LBP and the levels of pain en disability in
schoolgirl rowers at mid- and end-season compared with a
control group. In clinical practice this CFT intervention has
56.6(±3.6)% during the second cycling task (CFT/BFB) (Fi-
gure 1). This was associated with significantly less pain
reported during cycling (p=0.01) (Figure 2). During the ini-
tial cycling task (no-CFT/BFB), the level of pain gradually
increased to 7/10 while the lumbo-pelvic position remained
the same. During the second cycling task, when the cyclist
adopted a less end-range lumbo-pelvic lordosis using BFB,
the level of pain was significantly reduced as it remained
at 0/10 up till 90 minutes and then increased to a maxi-
mum level of 2/10 for a short period of time during cycling,
returning back to 0/10 at the end (Figure 2).
Figure 1: Percentage (±SD) of total lumbo-pelvic flexion (% Fl ROM)
over entire period per 12 intervals of ten minutes of the LBP case
subject provided with (CFT/BFB) and without CFT and BFB (no-
CFT/BFB). SD: standard deviation, CFT: cognitive functional thera-
py, BFB: biofeedback.
Figure 2: The average pain scores (NPRS; 0-10) during and after
cycling of the LBP case subject provided with (CFT/BFB) and wit-
hout CFT and BFB (no-CFT/BFB). Significant difference over entire
two hours of cycling (p=0.01). The vertical dotted black line indica-
tes the end of the two hours cycling task and the start of the 24h
follow-up period. NPRS: numerical pain rating scale, CFT: cognitive
functional therapy, BFB: biofeedback, ‘: minutes, h: hours.
The level of sitting comfort during cycling was the same
(5/50), on both cycling tasks, indicating very low pressure/
slight discomfort.
22 Sport & Geneeskunde | oktober 2011 | nummer 4
The reduction in maximum pain during cycling from 7/10
during the first cycling task to 2/10 during the second cy-
cling task exceeds the minimal clinically important diffe-
rence (MCID) (2/10) for the NPRS. Further, the cyclist repor-
ted feeling more comfortable on the bike and being able to
subjectively produce more power with the lower limbs.
Interestingly, follow-up after 2½ months (telephone con-
tact) revealed the subject still could cycling without LBP
and that he was able to resume competitive cycling after
an absence of one year because of LBP. He also reported
significant decrease in LBP in daily life (e.g. during pro-
longed sitting), and improvements for the TSK and the R-
ODI. The score on the TSK improved to a value (30/68) be-
low the cut-off score of 37/68,31 meaning that the cyclist
had less fear of movement after the CFT intervention.
Limitations and recommendations for further
research
To confirm these case-study based findings, a well-powered
RCT in a similar NS-CLBP population, with adequate follow-
up, is required. Further research is necessary to discern the
relative contribution of changing personal and/or non-per-
sonal modifiable factors in reducing LBP in cyclists. It is not
unlikely that a combination targeting both factors may help.
Finally, from this case study it is not possible to draw con-
clusions regarding the specific contribution of the BFB de-
vice in improving the lumbo-pelvic posture. During the CFT
intervention period (without BFB) the subject’s average LBP
during cycling (over the last week) had reduced from 5/10
(prior to cycling task 1) to 2/10 (prior to cycling task 2).
Further research, comparing FP subgroups of cyclists recei-
ving CFT with or without BFB is required to evaluate the
specific contribution of the BFB during the CFT intervention.
Conclusion
This is the first cycling field study revealing that a specific
CFT intervention including BFB on lumbo-pelvic posture
could significantly change lumbo-pelvic posture and reduce
LBP during cycling. The results of this case study suggest
that this intervention could be an appropriate and useful
rehabilitation strategy for LBP in cyclists. Further research
using a larger sample size is warranted.
Acknowledgements, funding
We would like to thank Sels Instruments nv, Belgium
(http://www.sels-instruments.be) for the provision of the
BodyGuard measuring systems.
been shown to be effective in the management of CLBP
disorders,18,20 and lifting tasks.37 For instance, Fersum et al.
compared a 12-week classification based CFT intervention
with a Manual therapy and exercise intervention in a ran-
domised controlled clinical trial with 12 month follow-up.
The results support the efficacy of the CFT intervention.
While the CFT/BFB approach was highly effective, it is inte-
resting to mention that initially the subject experienced a
“stiff and fatigued feeling in the lower back” during cycling
when adopting a more anteriorly tilted pelvis. This pheno-
menon could be related to muscle fatigue and reduced back
muscle endurance in this cyclist, and has been described in
other LBP populations.35,38,39 In addition, upright sitting
(like instructed during the CFT) is positively correlated with
activating key muscles and stimulating back muscle
endurance.24,38,40,41 In contrast, posterior pelvic tilt is cor-
related with flexion-relaxation42 (myo-electrical silence in
the back extensor muscles at the mid-to end-range of trunk
flexion) and inversely correlated with back muscle
endurance.38 In this study lumbo-pelvic posture did not de-
teriorate over time during cycling but instead stayed rela-
tively consistent. This suggests that an altered motor con-
trol pattern could be the primary driver for LBP during
cycling, rather than simply reduced endurance. Since LBP
subjects with a Flexion Pattern dysfunction presents with
altered motor control patterns resulting with deficits in the
spinal stabilizing muscles43 and adopting a more ‘passive’
posture with relative inactivity of these muscles,44 the mo-
tor control deficit itself may contribute to the reduced
endurance.42 This may suggest that for these paraspinal
muscles, controlling the lumbo-pelvic region, propriocep-
tive and endurance training may be an important factor in
the rehabilitation of chronic LBP. Further research is neces-
sary to test this hypothesis in cyclists.
In this case-study, non-personal modifiable factors were not
altered. It is noteworthy that the case subject was cycling
on a medial cut-out saddle and a 1° anterior tilted saddle
angle. Both factors can facilitate an anterior pelvic tilt wit-
hout increasing perineal discomfort.15 While tilting the
pelvis anteriorly may increase perineal pressure,15 in this
case study the sitting discomfort levels remained the same,
maybe by the tilt and type of the saddle. Most interes-
tingly, it was only after the CFT/BFB intervention that the
cyclist was able to actively control the lumbo-pelvic region.
This finding further supports the major role of motor con-
trol in cycling.
Sportmedische praktijk
25nummer 4 | oktober 2011 | Sport & Geneeskunde
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Sportmedische praktijk
About the authors
W. Van Hoof a,
K. Volkaerts a,
K. O’Sullivan b,
Prof. Dr. S. Verschueren a,
Prof. Dr. W. Dankaerts a,
a) Musculoskeletal Research Unit,
Department of Rehabilitation
Sciences, Faculty of Kinesiology
and
Rehabilitation sciences, Katholieke
Universiteit Leuven, Leuven,
Belgium
b) Department of Physiotherapy,
Faculty of Education and Health
Sciences, University of Limerick,
Limerick, Ireland
Van Hoof W., MSc. is a part-time
researcher at the Faculty of
Kinesiology and
Rehabilitation sciences
(Musculoskeletal Research Unit),
Katholieke Universiteit Leuven,
Belgium. He also works as a
musculoskeletal physiotherapist in
private practice.
Volkaerts K., MSc. is a full-time
musculoskeletal physiotherapist.
O’Sullivan K. is a full-time
researcher at the Faculty of
Education and Health Sciences,
University of Limerick, Ireland.
Prof. Dr. Verschueren S. is
professor at the Faculty of
Kinesiology and Rehabilitation
sciences (Musculoskeletal
Research Unit), Katholieke
Universiteit Leuven, Belgium.
Prof. Dr. Dankaerts W. is professor
at the Faculty of Kinesiology and
Rehabilitation
sciences (Musculoskeletal
Research Unit), Katholieke
Universiteit Leuven, Belgium. He
also works as a musculoskeletal
physiotherapist in private practice
in Tienen, Belgium.
Corresponding author:
Wim Dankaerts, Musculoskeletal
Research Unit, Department of
Rehabilitation Sciences, Faculty of
Kinesiology and Rehabilitation
sciences, Katholieke Universiteit
Leuven
Tervuursevest 101, B-3001
Leuven, Belgium
Tel: +32 16 32 90 70
Fax: +32 16 32 91 97
E-mail: wim.dankaerts@faber.
kuleuven.be
... Four studies utilized a withinparticipant study design, 3 a case-control design, and 1 was a single case study. Six studies included participants with cycling experience, ranging from elite, 25 master, 25 professional, 23 professional competitive off-road, 30 competitive, 34 and unspecified, 4 with no definitions provided for these categories. Two studies 3,9 included participants without cycling experience. ...
... Two studies 3,9 included participants without cycling experience. Four studies 23,25,33,34 reported cycling experience ranging from 6 to 17 years. Three studies 4,30,33 compared participants with and without LBP. ...
... 23,25 Measures used to assess pain also varied across studies and included the Rehabilitation Bioengineering Group pain scale 3 and the Numeric Pain Rating Scale. 33,34 Bicycle Fit, Muscle Activity, and Low Back Pain Two studies 3,4 applied sEMG to spinal and arm musculature to measure muscle fatigue. Subjects with LBP experienced fatigue in arm and spinal musculature associated with postural support and stability. ...
Article
Context: Low back pain is reported by more than half of cyclists. The pathomechanics and association of risk factors of lumbar spine overuse injuries in cycling are not clearly understood. Objective: To determine whether relationships exist between body positioning, spinal kinematics, and muscle activity in active cyclists with nontraumatic low back pain. Data sources: In August of 2015 and April of 2016, a comprehensive search of the PubMed, CINAHL, Ovid MEDLINE, and Scopus databases was performed independently by 5 reviewers. Study selection: Included articles consisted of biomechanical studies examining factors relating to low back pain in cyclists as agreed upon by group consensus. Study design: Systematic review. Level of evidence: Level 4. Data extraction: Five reviewers appraised by consensus each article using the Downs and Black checklist. Results: Eight studies met criteria for this review. There is evidence that cyclists with lower handlebar heights displayed increased lumbosacral flexion angles during cycling. Core muscle activation imbalances, back extensor endurance deficits, and increased lumbar flexion while cycling were found to be present in cyclists with low back pain. Conclusion: Spinal and core muscle activation imbalances in a prolonged flexed posture associated with cycling may lead to maladaptive spinal kinematics and increased spinal stresses contributing to overuse low back pain.
... 2 Also, Feedback exercises have been used as part of training in Cognitive Functional Training. 3 Cognitive issues such as fear of movement affect kinematics and muscle activity. Increased levels of both fears of movement and pain intensity were independently associated with a decreased level of muscle activation. ...
Article
We thank Julia Castro and her colleagues for their interest in our study. We will respond, briefly, to some of the matters raised. One of the strengths of our study was the use of different experts in the study. In our study used a Clinical Psychologist expert who has been work- ing in this field for many years. Also, the authors of the article received the necessary educations in the Cognitive Functional Therapy intervention. It should be noted that the authors of the article already have a history of research in Cognitive Functional Training and their articles have been published in this field.1 Due to a large number of trial variables, it was not possible to report them in one article, therefore, other trial variables, includ- ing disability and other factors will be reported in another article. Before starting Cognitive Functional Training, during an interview, psychological factors includ- ing cause/meaning, consequences, vigilance, self- efficacy, pain interference/disability, coping with pain, catastrophic thoughts, emotional response to pain, anxiety, frustration/anger, the influence of emotions on pain, fear of damage, fear of pain, pain predictability, and pain controllability were exam- ined. The exercises were performed Individually and based on individual characteristics. Our approach in Cognitive Functional Training was based on previous studies of people with low back pain. Patients in our study had neck pain and defects in the scapula. Therefore, it was necessary to design exercises for them. Functional movement exercises are one of the main components of the Cognitive Functional Training training.2 Also, Feedback exercises have been used as part of train- ing in Cognitive Functional Training.3 Cognitive issues such as fear of movement affect kinematics and muscle activity. Increased levels of both fears of movement and pain intensity were independently associated with a decreased level of muscle activation.4 It is likely that the decrease in muscle activation level is aimed at “avoiding” the use of painful muscles.4 Individuals with high pain-related fear had smaller peak velocities, accelerations, and motion of the spine joints.5 Smaller, slower, and jerkier cervical motion was most frequently correlated with increased fear of movement, and occasionally with pain intensity and disability.6 Therefore, changes in muscle activity and kinematic can be one of the consequences of reducing pain inten- sity and kinesiophobia after using Cognitive Functional Training. Two models, the neurophysiological “pain adaptation” model and the “fear-avoidance” model, explain the reorganization of muscle activation pat- terns in musculoskeletal pain syndromes. In the pain adaptation model, the assumption is that noci- ceptive interneurons induce reciprocal inhibition at the segmental level.7 In the long term, avoidance of movement can produce maladaptive changes in the musculoskeletal system such as physical decondi- tioning and impairments in muscle coordination.8
... 39 That previous trial also demonstrated that the CFT group were 3 times less likely to take sick leave for their LBP at 12 months. Further, among people with moderately to highly disabling PLBP 40,41 and in cyclists 83 and rowers 84 with PLBP, CFT has been shown to significantly reduce pain and disability. Together, these data support that CFT is a flexible integrated behavioral approach for individualizing the management of PLBP and may be widely applicable in the LBP population and across other painful musculoskeletal disorders. ...
Article
Objective: Persistent low back pain (PLBP) is a common and costly health problem worldwide. Better strategies to manage it are required. The purpose of this study was to longitudinally evaluate absenteeism, pain, and disability in nurses with PLBP following a cognitive functional therapy (CFT) intervention. Methods: In this case-series pilot study, 33 eligible nurses with PLBP were recruited. During the baseline phase A (no intervention) outcome measures were collected on 2 occasions 6 months apart (A1 and A2). During phase B, subjects participated in an individualized CFT intervention for 14 weeks. During phase C (no intervention), outcomes were measured immediately after the intervention, as well as 3, 6, 9, 12 and 36 months after the intervention (secondary outcomes only until 12 months). LBP-related work absenteeism, pain intensity (Numeric Rating Scale) and disability (Oswestry Disability Index) were the primary outcomes. Health care seeking, a range of psychological and lifestyle variables, and global perceived effect were secondary outcomes. Results: Days of absenteeism due to LBP were significantly reduced in the first and second calendar year after the CFT intervention, but not the third and fourth. Disability was significantly reduced immediately after (-4.4; 95%CI = -6.5 to -2.2) and at 3 months (-4.3; 95%CI = -6.6 to -2.0), 9 months (-6.0; 95%CI = -8.1 to -3.9), and 12 months (-4.9; 95%CI = -7.0 to -2.8) after the intervention. Pain was significantly reduced immediately after (-1.2; 95%CI = -1.7 to -0.8) and at 3 months (-1.5; 95%CI = -2.0 to -0.9), 9 months (-1.1; 95%CI = -1.9 to -0.3) and 12 months (-0.9; 95%CI = -1.5 to -0.2) after the intervention. Total health care seeking (consults and proportion of participants) was significantly reduced after the intervention. All psychosocial variables, except for 1, demonstrated significant improvements at all follow-ups. Conclusions: This case-series pilot study demonstrated significant reductions in LBP-related absenteeism, pain intensity, disability, health care seeking, and several psychological and lifestyle behaviors until 1 year follow-up among nurses with PLBP following an individualized CFT intervention. Further evaluation of the efficacy.
... 24 It is possible that the cognitive functional therapy intervention provided an alternative movement strategy and enhanced load distribution across the spine, thereby reducing focal strain and loading of the spine. 25 It is also likely that the intervention reduced his fear by reframing his beliefs about pain and teaching adaptive movement strategies. 26 In this study, cognitive functional therapy included a strong cognitive component, such as a change in the perception of pain and the education about the multidimensional nature of chronic pain, management of pain fluctuations and worsening, functional postural training and mirror feedback. ...
Article
Objective The aim of this study was to compare the effectiveness of scapular exercises alone and combined with cognitive functional therapy in treating patients with chronic neck pain and scapular downward rotation impairment. Design Single-blind randomized controlled trial. Setting Outpatient. Subjects A total of 72 patients (20–45 years old) with chronic neck pain were studied. Intervention Allocation was undertaken into three groups: scapular exercise ( n = 24), scapular exercise with cognitive functional therapy ( n = 24) and control ( n = 24) groups. Each programme lasted three times a week for six weeks. Main outcomes The primary outcome measure was pain intensity measured by the visual analogue scale scores. The secondary outcome measures included kinesiophobia and muscles activity. Results Statistically significant differences in pain intensity were found when multidisciplinary physiotherapy group including a cognitive functional approach was compared with the scapular exercise alone group at six weeks (effect size (95% CI) = −2.56 (−3.32 to −1.80); P = 0.019). Regarding kinesiophobia, a significant between-group difference was observed at six-week (effect size (95% CI) = −2.20 (−2.92 to −1.49); P = 0.005), with the superiority of effect in multidisciplinary physiotherapy group. A significant between-group differences was observed in muscle activity. Also, there were significant between-group differences favouring experimental groups versus control. Conclusion A group-based multidisciplinary rehabilitation programme including scapular exercise plus cognitive functional therapy was superior to group-based scapular exercise alone for improving pain intensity, kinesiophobia and muscle activation in participants with chronic neck pain.
... Identifying these behaviors and their contributions to pain development might refine the application of the classification-based cognitive functional therapy (CB-CFT) (14) in FP and AEP subgroups. A postural biofeedback training to facilitate proper lumbosacral kinematics away from the end-range sitting postures, could be relevant in spine rehabilitation for these subgroups (14,36). Also, incorporation the findings to intervention approaches for these subgroups might advance NSCLBP management. ...
Preprint
Background: Although, non-specific chronic low back pain (NSCLBP) has been associated with abnormal lumbosacral kinematics, little is known about the possible driving mechanisms of pain development overtime during prolonged sitting period. Therefore, the purpose of this study was to examine the differences in lumbosacral postures in adults with and without NSCLBP, and their role on pain development during a 1-hour of prolonged sitting task. Methods: Twenty NSCLBP subjects with motor control impairment (MCI) [10 classified as having flexion pattern (FP) disorder, and 10 with active extension pattern (AEP) disorder], and 10 healthy controls participated in the study. Subjects underwent a 1-hour sitting protocol on a standard office chair. Lumbosacral postures including: sacral tilt (ST), third lumbar vertebrae (L3) position, and relative lower lumbar angle (RLLA) were recorded using a two-dimensional inclinometer over the 1-hour period. Perceived back pain intensity was recorded using a numeric pain rating scale every 10 minutes throughout the sitting period. Results: All study groups presented with significantly distinctive lumbosacral kinematics at the lowest level of pain (the beginning of the sitting period) (p
... Helping people to adopt more relaxed postures, while reassuring them that these postures are safe, can provide symptom relief. 4,7,10,12 Comfortable postures vary between individuals, so it is useful to explore different postures. The clinician might consider how to expose people to postures and ways of moving that they have avoided, and how to encourage change in habits that may be provocative. ...
Article
Full-text available
Posture is a frequent topic of discussion for patients, clinicians, the media, and society. A common belief is that spinal pain is caused by sitting, standing, or bending "incorrectly." Despite the absence of strong evidence to support these common beliefs, a large posture industry has flourished, with many interventions and products claiming to "correct" posture and prevent pain. Unfortunately, many health care professionals provide advice in line with this non-evidence-based perspective. In this Viewpoint, the authors reflect on common beliefs regarding posture and spinal health and why they are so widely held, and consider how clinicians can positively influence these beliefs. J Orthop Sports Phys Ther 2019;49(8):562-564. doi:10.2519/jospt.2019.0610.
...  Cyclist with flexion pattern LBP drive with more flexion of the lower lumbar than the controls. Coaches should consider helping such athletes to reduce the excessive lower lumbar flexion during riding, through biofeedback (42) or by adjusting the saddle angle (43).  Dancers with LBP have poorer lumbopelvic motor control strategies. ...
Article
Full-text available
Low back pain (LBP) is also one of the most common medical conditions in athletes. There is little doubt that patients with LBP use from their body differently than pain free individuals. The purpose of this review was to investigate changes in motor control which may be present in athletes with LBP. The search strategy for this review consisted of an electronic database search of full text in MEDLINE database. 28 studies met the eligibility criteria, most of which were cross-sectional in nature. The studies were analyzed separately according to the specific sports involved. The studies demonstrate that athletes with LBP exhibit a range of MCI in the trunk, lumbopelvic region and lower extremities. However, inconsistencies were apparent between the results. Athletes with LBP demonstrate MCI during functional and non-functional tasks, similar to non-athletes. More studies, especially large prospective studies which control for non-mechanical factors which may also differ among athletes with LBP are required to determine the relationship between LBP and MCI in athletes. KEY WORDS: Low Back Pain, Motor Control, Athletes, Biomechanics, Electromyography, Range of Motion
... Since the findings of this study suggest that LBP during cycling is related to maladaptive lower lumbar kinematics, trying to regain control over the lower lumbar region during cycling could be relevant in the rehabilitation/prevention of LBP in this subgroup. A cognitive functional training intervention including biofeedback to monitor the lower lumbar kinematics, to facilitate a less end-range flexed cycling posture has been recently explored by our research group (Van Hoof et al., 2011). The results revealed that an intervention targeting this maladaptive control at the symptomatic lower lumbar region resulted in a significant decrease of the near end-range lower lumbar flexion and a substantial reduction of LBP during cycling. ...
Article
Full-text available
Objective: To examine lumbar postural control during cycling and it's relation with low back pain (LBP). Material and methods: Eight cyclists with non-specific chronic LBP (NS-CLBP) and a Flexion Pattern (FP) and nine asymptomatic cyclists participated in a two hour outdoor cycling task. Spinal kinematics (expressed as a percentage of the total lumbo-pelvic flexion) were measured with a wireless remote monitoring system (BodyGuard). Levels of pain were measured at start, every 15 minutes during and at 0.5, 1, 2 en 24 hours after cycling using a numerical pain rating scale (0-10). The average lumbo-pelvic posture, the posture per 12 intervals of 10 minutes and the postural variation of this posture were analysed and compared between the 2 groups. Results: NS-CLBP (FP) subjects were significantly more flexed at the lower lumbar spine during cycling compared to healthy controls (p=0.018), and reported a significant increase in pain during cycling (p<0.001). Conclusion: In a specific subgroup of cyclists with NS-CLBP (FP) the inherent underlying maladaptive motor control pattern (FP) results in a more flexed lumbo-pelvic posture during cycling that is related to a significant increase in pain.
... Case studies would indicate that cognitive functional therapy interventions that focus on hip flexion and minimise end range of lumbar flexion during rowing and cycling reduce pain in these athletes. 68,69 Interestingly, portable wireless biofeedback devices that provide reliable and valid feedback on lumbar posture are now being integrated into sports training. 70,71 Physiotherapists also need to consider lumbar posture when developing rehabilitation exercises for low back pain patients. ...
Article
Full-text available
Background: Lumbar posture has a significant impact on the functional biomechanics of the erector spinae and multifidus muscles, which has implications for the loads placed on the tissues of the lumbar spine. Objectives: The objective of this review is to discuss the effects of lumbar posture on the functional biomechanics of the different divisions of the erector spinae and the multifidus muscle and its importance when developing clinical interventions. Methods: This review used the search engines PubMed, EBSCO, CINAHL and SCOPUS to identify studies investigating erector spinae and multifidus muscle architecture and the influence of lumbar posture on the biomechanical properties of these muscles and the resulting impact on spinal loading. Results: Changes in lumbar curvature alter muscle fascicle obliquity, lever arm distances, the length–tension relationships and muscle volume of the different divisions of erector spinae and multifidus, which impact on the spine's ability to resist moments and shear forces. Conclusion: Changes in lumbar posture influence the functional biomechanics of the different divisions of erector spinae and the multifidus muscles. Therapists should develop low back interventions that avoid end range of lumbar postures and optimise the functional biomechanics of the erector spinae and multi-fidus muscles and minimise loading on the lumbar spine.
Article
Full-text available
Abstract Aim and Background: There is little doubt that low back pain (LBP) patients use from their body differently than healthy individuals. The purpose of this review was to investigate changes in biomechanical perspective which may be present in athletes with LBP. Materials and Methods: The search strategy for this review consisted of an electronic database search of full text in PUBMED database. Findings: From 461 records that were initially identified through the PUBMED database, 28 studies met the eligibility criteria, most of which were cross-sectional in nature. The studies demonstrate that athletes with LBP exhibit a range of biomechanical perspective changes in the trunk, lumbar spine, pelvis and lower extremities. However, inconsistencies were apparent between the results. Conclusions: Athletes with LBP demonstrate some biomechanical perspective changes during sport specific and non-sport specific functions. More studies, especially large prospective studies which control for non-mechanical factors are required to determine the relationship between LBP and biomechanical perspective changes in athletes. Keywords: Low Back Pain, Motor Control, Athletes, Biomechanics, Electromyography, Range of Motion
Article
Full-text available
A randomized prospective cohort study of participants with chronic low back pain, seeking physical therapy, with follow-up at weeks 6 and 28. Effects of conventional physiotherapy and physiotherapy with the addition of postural biofeedback were compared. To evaluate the benefits of postural biofeedback in chronic low back pain participants. Biofeedback using electromyographic signals has been used in chronic low back pain with mixed results. Postural feedback had not been previously used. Demographic and psychological baseline data along with range of motion were analyzed from a sample of 47 chronic participants with low back pain randomized into conventional physiotherapy with or without the addition of postural biofeedback. After 6 months, there were 21 dropouts. The participants with biofeedback had markedly improved status in visual analog pain scales, short form-36, and range of motion. The study strongly suggests that postural feedback is a useful adjunct to conventional physiotherapy of chronic low back pain participants.
Article
Full-text available
Lower back pain (LBP) appears to be a common overuse injury in cycling. However, there are few scientific studies that report on the epidemiology and risk factors associated with LBP in cyclists. The prolonged flexed posture that a cyclist maintains may lead to increased mechanical strain of the lumbar spine, causing LBP. In this article, the epidemiology, pathomechanics and risk factors associated with LBP in cyclists will be critically reviewed. An extensive literature review was conducted using an evidence-based approach. Using selective keywords (lower back pain, cyclists, bicycle set-up, risk factors) a search was undertaken on the PubMed database to identify all research publications that relate to lower back pain in cyclists. Although epidemiological studies were limited, LBP was shown to be a common cycling overuse injury. The point prevalence of LBP in cyclists ranged from 10-60%. It has been suggested that LBP in cyclists may be prevented by adjusting certain bicycle parameters to match the anthropometric measurements of the cyclist. Pathomechanical hypotheses for the development of LBP in cyclists are poorly supported, and most studies were conducted over time periods shorter than one hour. Monitoring cyclists over a longer period of cycling may yield more accurate data. There is strong evidence supporting the incorrect saddle angle as an intrinsic risk factor is associated with LBP in cyclists. In conclusion, additional research on the epidemiology of LBP in cyclists is necessary. Further research studies, such as case control and intervention studies are necessary to study pathomechanics and risk factors associated with LBP in cyclists
Article
The time course of full lumbar flexion under a prolonged flexion moment, lasting 20 min, was documented in 27 male and 20 female subjects. Peak flexion increased by 5.5° over the 20 min. The flexion-creep data was fitted with a first-order step input response having a time constant of 9.4 min. Maximum flexion was also documented over the recovery phase, lasting 30 min, indicating that subjects regained approximately 50% of their resting joint stiffness within 2 min of resuming relaxed lordosis, although full recovery took longer than the flexion-creep, indicating the presence of viscoelastic hysteresis. For this reason it may be prudent to advise those who experience prolonged full flexion postures (as might a seated warehouse shipper/receiver, gardener, or construction worker) to stand and walk for a few minutes prior to performing demanding manual exertions. Indeed, temporary joint flexion laxity, following a bout of full flexion, may increase the risk of hyperflexion injury to certain tissues.
Article
Bending and lifting activities are associated with injury to the lumbar discs and ligaments, and cadaveric experiments suggest that this damage is most attributable to a high bending moment (bending stress) acting on the osteoligamentous spine. We examined the hypothesis that people with poor sagittal mobility in the lumbar spine and hips apply higher bending stresses to their spines during everyday lifting activities. Forty-nine subjects performed a series of simple forward bending and lifting exercises while their lumbar flexion was measured continuously using a skin-surface technique (3-space isotrak). Peak flexion angles were compared with the bending properties of cadaveric osteoligamentous spines in order to calculate the peak bending moment (bending stress) acting on the lumbar spine during each exercise. All subjects flattened or reversed their lumbar lordosis when lifting, and most came close to or exceeded their static in vivo limit of lumbar flexion in many of the activities. The bending moment acting on the lumbosacral junction rose to about 30 Nm, which is about 50% of that required to cause injury in a single lift. Bending moments were significantly lower in subjects who had good sagittal mobility in the lumbar spine. Good hip mobility was similarly associated with a reduction in bending moment, but this reached significance only in subjects who reported a history of low back pain.
Article
The objective of this study was to determine muscle fatigue in cyclists with and without low back pain (LBP) using bilateral surface electromyography (sEMG). sEMG was acquired bilaterally from biceps brachii medial, trapezius medial, latissimus dorsi medial, and erector spinae medial muscles. Fourteen male volunteers split equally into two groups (with and without LBP) participated in this study. sEMG was recorded before, after 15 and 30 min of cycling when the subjects performed psychophysical tests to elicit maximal voluntary contraction of the relevant muscles. Statistical tests to determine fatigue difference using mean power frequency were performed. LBP group showed a significantly higher fatigue (P < 0.05) in right trapezius medial and erector spinae when compared to the without LBP group. The high fatigue in the back muscles in the LBP group is suggestive of the possibility for worsening of their condition due to cycling.
Article
The effect of posture on spinal compressive strength was examined in a series of three experiments on cadaveric material. Lumbar 'motion segments', consisting of two vertebrae and the intervening disc and ligaments, were compressed while positioned in various angles of flexion and extension. In the first experiment load sharing between the disc, the apophyseal joint surfaces, and the intervertebral ligaments was inferred from measurements of intradiscal pressure (IDP). Results showed that extension caused the apophyseal joints to become load-bearing, and damage could occur at compressive loads as low as 500 N. Flexion angles greater than about 75% of the full range of flexion (as defined by the posterior ligaments) generated high tensile forces in these ligaments, and caused substantial increases in IDP. The optimum range for resisting compression therefore appeared to be 0-75% flexion. The second experiment compared the distribution of compressive stress within the disc at the endpoints of this range, and showed that at O% flexion high stress concentrations occur in the posterior annulus of many discs, whereas an even distribution of stress was usually found at 75% flexion. However, the third experiment showed that there was no significant difference in the compressive strength of motion segments positioned in 0% and 75% flexion. A comparison of the range of flexion/extension movements in vivo and in vitro led us to conclude that in life a position of moderate flexion is to be preferred when the lumbar spine is subjected to high compressive forces.
Article
To investigate seated pressure discomfort requires a valid and reliable technique to measure discomfort. The aims of this study were to test the validity and reliability of several rating scales and select the best for investigation of pressure discomfort. Six scales were tested: a category partitioning scale, the Borg CR-10 scale, the Corlett discomfort scale, an 8-point ordinal scale, a modified intensity and discomfort scale, and a 21-point ratio scale. Twelve subjects took part in the repeated measures test in two sessions, one week apart. A test seating device generated interface pressure from underneath a foam cushion. Four levels of stimulus, 60, 85, 120, and 165 mmHg, were presented to the seated mid-thigh region. Perceived pressure intensity, discomfort level due to the pressure, and overall discomfort were reported using each of the six scales. Reliability was examined by test-retest correlation, relative rating change and coefficient of variations, and validity examined by absoluteness of rating and the functional consistency. Generally, subjects were capable of reporting their sensation of pressure intensity and discomfort by using the rating scale technique. However, the accuracy of rating strongly depended upon the properties of the scale. The category partitioning scale was found to be highly reliable and most valid for rating pressure intensity and perceived discomfort. This scale was also preferred by subjects when compared with the other five scales. Properties of all the six scales were defined and summarised.