20 Sport & Geneeskunde | oktober 2011 | nummer 4
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
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
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.
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
Trefwoorden: Lage rugpijn, ﬁetsen, lumbale postural controle, Flexie Patroon,
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.
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-
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-
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
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
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.
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
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
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
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
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.
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/
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
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.
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.
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.
25nummer 4 | oktober 2011 | Sport & Geneeskunde
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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
Rehabilitation sciences, Katholieke
Universiteit Leuven, Leuven,
b) Department of Physiotherapy,
Faculty of Education and Health
Sciences, University of Limerick,
Van Hoof W., MSc. is a part-time
researcher at the Faculty of
(Musculoskeletal Research Unit),
Katholieke Universiteit Leuven,
Belgium. He also works as a
musculoskeletal physiotherapist in
Volkaerts K., MSc. is a full-time
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
Research Unit), Katholieke
Universiteit Leuven, Belgium.
Prof. Dr. Dankaerts W. is professor
at the Faculty of Kinesiology and
Research Unit), Katholieke
Universiteit Leuven, Belgium. He
also works as a musculoskeletal
physiotherapist in private practice
in Tienen, Belgium.
Wim Dankaerts, Musculoskeletal
Research Unit, Department of
Rehabilitation Sciences, Faculty of
Kinesiology and Rehabilitation
sciences, Katholieke Universiteit
Tervuursevest 101, B-3001
Tel: +32 16 32 90 70
Fax: +32 16 32 91 97