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Study design: Case report. Background: Contemporary low back pain models propose that the experience of and responses to pain result from a complex interaction of biopsychosocial factors. This supports the need for a management approach that addresses the biological, psychological, and social components that may be related to the pain disorder. This case report demonstrates the application of, and outcomes associated with, a cognitive functional intervention that considers neurophysiological, physical, psychosocial, cognitive, and lifestyle dimensions for the management of a rower with nonspecific chronic low back pain. Case description: An adolescent male club-level rower with nonspecific chronic low back pain was classified as having a motor control impairment with a lower lumbar compressive-loading pattern in flexion. Evaluation of this patient included ergometer rowing analysis (clinical and laboratory) before and after an 8-week intervention, and outcome measures at a 12-week follow-up. The intervention consisted of a cognitive functional approach that targeted optimization of movement behavior, providing the rower with alternative movement strategies to minimize sustained flexion loading. Outcomes: Reduced temporal summation of pain while ergometer rowing and reduced functional disability were observed preintervention to 12 weeks postintervention by changes in Roland-Morris Disability Questionnaire score (12/24 to 1/24) and the Patient-Specific Functional Scale (4/30 to 26/30), and associated improvements in lower-limb and back muscle endurance and changes in hip and spinopelvic kinematics during ergometer rowing. In particular, there was a greater use of available range of movement in the lumbar spine postintervention. Discussion: The cognitive functional intervention for this patient resulted in reduced pain and functional disability related to ergometer rowing, which was associated with a change in lumbar kinematics and improved lower-limb and back muscle endurance. The results suggest that providing the rower with greater use of his available range of movement may enhance load distribution during the drive phase of rowing. Registered at Australian New Zealand Clinical Trials Registry (ACTRN12609000565246). Level of evidence: Therapy, level 4.
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542  |  august 2013  |  volume 43  |  number 8  |  journal of orthopaedic & sports physical therapy
case report
Low back pain (LBP) is a common complaint among
rowers.4,18,39,47,50,58 Research has suggested that there is a higher
prevalence of LBP in elite male rowers, with 25% of total injuries
reported in the low back, compared to 15.2% in female rowers.18
Adolescent rowers also appear to be
at particular risk, with up to 47.5% of
schoolgirl rowers reporting back pain
and higher level of disability compared
to 15.5% of age-matched controls,39 sug-
gesting that rowing-related factors are as-
sociated with pain and disability.
Previous research has found that row-
ers with LBP report a gradual increase
of pain during ergometer rowing.32 It
has also been reported that rowers with
LBP maintain their lumbar spine posture
closer to end-range flexion and use less
of their available range across the drive
phase when compared to rowers without
pain.32 It is proposed that these motor
control patterns could be maladaptive
and pain provocative, resulting in sus-
tained flexion loading (ie, strain) to the
lumbar spine, which may, in turn, lead to
pain.35 Patients with LBP have been re-
ported to present with altered movement
patterns and body schema, which raises
the possibility that retraining movement
patterns through interventions that ad-
dress both cognitive and functional do-
mains may assist with managing chronic
spinal pain.24,29,34,56 However, to date, it
is not known whether targeted interven-
tions are able to influence these patterns.
It has been proposed that accurate
diagnosis and classification of an LBP
STUDY DESIGN: Case report.
BACKGROUND: Contemporary low back pain
models propose that the experience of and re-
sponses to pain result from a complex interaction
of biopsychosocial factors. This supports the need
for a management approach that addresses the
biological, psychological, and social components
that may be related to the pain disorder. This
case report demonstrates the application of, and
outcomes associated with, a cognitive functional
intervention that considers neurophysiological,
physical, psychosocial, cognitive, and lifestyle
dimensions for the management of a rower with
nonspecific chronic low back pain.
CASE DESCRIPTION: An adolescent male
club-level rower with nonspecific chronic low back
pain was classified as having a motor control
impairment with a lower lumbar compressive-
loading pattern in flexion. Evaluation of this patient
included ergometer rowing analysis (clinical and
laboratory) before and after an 8-week inter-
vention, and outcome measures at a 12-week
follow-up. The intervention consisted of a cognitive
functional approach that targeted optimization of
movement behavior, providing the rower with alter-
native movement strategies to minimize sustained
flexion loading.
OUTCOMES: Reduced temporal summation
of pain while ergometer rowing and reduced
functional disability were observed preintervention
to 12 weeks postintervention by changes in Roland-
Morris Disability Questionnaire score (12/24 to
1/24) and the Patient-Specific Functional Scale
(4/30 to 26/30), and associated improvements
in lower-limb and back muscle endurance and
changes in hip and spinopelvic kinematics during
ergometer rowing. In particular, there was a greater
use of available range of movement in the lumbar
spine postintervention.
DISCUSSION: The cognitive functional interven-
tion for this patient resulted in reduced pain and
functional disability related to ergometer rowing,
which was associated with a change in lumbar
kinematics and improved lower-limb and back
muscle endurance. The results suggest that provid-
ing the rower with greater use of his available
range of movement may enhance load distribution
during the drive phase of rowing. Registered at
Australian New Zealand Clinical Trials Registry
LEVEL OF EVIDENCE: Therapy, level 4.
J Orthop Sports Phys Ther 2013;43(8):542-554.
Epub 11 June 2013. doi:10.2519/jospt.2013.4699
KEY WORDS: low back pain in sports, motor
control impairment, spinopelvic kinematics
1School of Physiotherapy, Physiotherapy Research Centre, Curtin Health Innovation Research Institute, Curtin University, Perth, Australia. 2Body Logic Physiotherapy, Perth,
Australia. 3Department of Sports Science and Physical Education, The Chinese University of Hong Kong, Hong Kong, China. Permission to conduct the study protocol was
granted by the Curtin University Human Research Ethics Committee. This study was supported by research grants from the Physiotherapy Research Foundation tagged Sports
Physiotherapy Australia grant as part of a randomized controlled clinical trial (T09-THE/SPA001). The authors certify that they have no aliations with or financial involvement
in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Leo Ng, Physiotherapy Research
Centre, Curtin Health Innovation Research Institute, Curtin University, GPO Box U1987, Perth, WA 6845 Australia. E-mail: Copyright ©2013 Journal of
Orthopaedic & Sports Physical Therapy®
Cognitive Functional Therapy for the
Management of Low Back Pain in an
Adolescent Male Rower: A Case Report
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journal of orthopaedic & sports physical therapy | volume 43 | number 8 | august 2013 | 543
disorder (based on neurophysiological,
physical behavioral, psychosocial, and
lifestyle factors) are required to allow
targeted interventions directed at the
mechanisms that underlie such a disor-
der.12-14,34-36,55 O’Sullivan34-36 proposed a
management approach for chronic LBP
based on a multidimensional classifica-
tion system called cognitive functional
therapy (CFT). The CFT approach in-
volves addressing cognitive, functional,
and lifestyle aspects of the disorder. The
key components of the cognitive compo-
nent involve addressing negative beliefs
and fear regarding pain and magnetic
resonance imaging findings; patient-
centered education regarding the mech-
anisms that drive their vicious cycle of
pain and disability; and raising aware-
ness of the body-mind responses to pain,
movement, and their perceived threat.
The functional component is behavior-
ally orientated and involves retraining
body schema (awareness) with the use of
visual feedback, normalizing provocative
movement patterns and pain behaviors in
a graduated manner directed toward the
patient’s functional goals, and strength-
ening and conditioning of the normalized
movement pattern.14,34 A study51 involving
82 adolescent female rowers with and
without LBP demonstrated that a CFT
approach was associated with a reduc-
tion in the prevalence of LBP across the
season (from 48% to 24%) and reduced
pain intensity levels in subjects who
complained of LBP at the commence-
ment of the rowing season. LBP was also
reduced in a group of adolescent female
rowers whose static and dynamic row-
ing postures were targeted with a similar
cognitive functional intervention.41 How-
ever, to date, no studies have confirmed
whether this intervention may success-
fully alter spinal kinematics during row-
ing or result in changes in pain response
during rowing. Furthermore, given that
spinal kinematics dier between genders
and that males appear to be more suscep-
tible to LBP, previously successful inter-
ventions should be evaluated in the male
population.18,27,33 The aim of this case
study was to investigate whether a CFT
intervention could alter the spinal kine-
matics and reduce the LBP of a male ado-
lescent rower during ergometer rowing.
sports physiotherapist, who
had a postgraduate qualification
and 5 years of experience with the
Australian rowing team, performed an
interview and a clinical examination.
The physiotherapist was blinded to the
laboratory data.
A 17-year-old male rower (height,
1.85 m; weight, 86 kg) in his fourth year
of amateur club rowing competition was
recruited for this study. Written informed
consent was obtained from the rower and
his parent, and permission to conduct the
laboratory testing and treatment proto-
col was granted by the Curtin University
Human Research Ethics Committee (HR
197/2008). At the time of recruitment,
the rower reported a 4-month history of
LBP that initially occurred only at the
end of rowing sessions. This progressed
to pain provoked by gym sessions, sit-
ting at school, and light home duties. A
magnetic resonance imaging scan of the
lumbar spine was organized by the local
physiotherapist and showed no radiologi-
cal abnormalities. A previous rehabilita-
tion program designed by the patient’s
physiotherapist, which included rest
from rowing, stretches of the hamstring
muscles, “core stability strategies,” and
low back muscle strengthening, did not
have a positive eect. Within 3 months,
the patient reported that his LBP had
worsened, which prevented him from
participating in any form of rowing train-
ing. Prior to his first episode of LBP, he
had previously trained between 17 and 18
hours a week and had been competing in
regular rowing regattas.
During the clinical interview, the
rower reported feeling a localized deep
ache, with an intensity of 6/10 on the
visual analog scale (VAS) at the lower
lumbar region. This pain became sharp/
catching pain (VAS, 8/10) with move-
ment. There was no peripheralization
of the symptoms, and the pain did not
aect his sleep. The aggravating factors
included postures (sitting, sustained
bending) and activities (rowing ergom-
eter, stationary cycling, bending, lifting,
loaded exercises in the gym). Avoidance
of provocative activities and stretching
hamstring and back muscles helped to
ease the pain. When asked, the patient
believed that (1) he would get better with
an appropriate exercise program, and (2)
rowing was likely to aggravate his back
pain. He reported that his pain dur-
ing rowing was aggravated by trying to
achieve a more upright posture (sitting
tall throughout the stroke, especially at
the catch) and eased by adopting a more
rounded thoracic posture. Ironically, even
though he reported that the rounded tho-
racic posture alleviated his symptoms, he
believed that this posture was not good
for his back due to the postural advice he
had been given. The patient’s past medi-
cal history was unremarkable. The ath-
lete’s goals were to return to exercise and
crew rowing.
Clinical Examination and Findings
Clinical observation of the athlete’s usual
sitting posture revealed a thoracic up-
right sitting posture (flexed lumbar spine
and extended thoracic spine).38 Analysis
of his movement patterns allowed the
therapist to identify the athlete’s full
available spinal range of movement. Ob-
servation of forward bending revealed
full range of movement with self-report-
ed pain throughout (VAS, 6/10). Through
palpation of the trunk muscles, the phys-
iotherapist was able to identify that both
the abdominal and paraspinal muscles
were actively tense (firm resistance to
palpation) during bending, suggesting
that the patient was cocontracting these
muscles during the movement. The rower
initiated forward bending through the
lumbar region with delayed anterior pel-
vic rotation, and initiated return to an
upright position via the thoracic spine,
propping his hands on his thighs. The
rower demonstrated full range of back-
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case report
ward and bilateral sidebending with no
pain. Modification of forward bending
was instigated by instructing the rower to
relax the trunk muscles during bending
by facilitation of thoracic flexion, with a
relaxed abdominal wall (no breath hold-
ing), bending with more anterior pelvic
rotation, slight knee flexion, and return-
ing to upright via the hips while relaxing
the thoracolumbar spine.12,35 The rower
reported a significant reduction of back
pain (VAS, 2/10). Analysis of functional
tests demonstrated that the athlete as-
sumed an extended thoracolumbar spine
posture (observable reduction of lum-
bar lordosis and increase in lordosis in
the upper lumbar and lower thoracic
spine) when squatting or performing
a sit-to-stand task.9,37 Cocontraction of
the paraspinal and abdominal muscles
was again detected by palpation dur-
ing the execution of these tasks. Specific
movement tests undertaken by the rower
and observed by the physiotherapist
revealed poor thoracolumbar and lum-
bopelvic dissociation, especially when
sitting on the rowing ergometer, sug-
gesting the athlete’s inability to move the
thorax, the lumbar spine, and the pelvis
Clinical observation during ergom-
eter rowing revealed that the rower
maintained a stiff thoracolumbar
spine throughout the rowing stroke.
It was also observed that he initiated
the drive phase with thoracic spinal
extension, followed by early elbow
flexion and late lower-limb exten-
sion. Palpation of the trunk muscles
during ergometer rowing revealed co-
contraction of the abdominal muscles
(FIGURE 1). He reported a pain intensity
of 6/10 during ergometer rowing. Modi-
fication of these movement patterns,
involving relaxed thoracolumbar flexion
throughout the stroke (utilizing a great-
er proportion of his full available range
of movement), early extension of the
lower limb, and delayed flexion of the
upper limb during drive phase, resulted
in reduced self-reported pain during er-
gometer rowing (VAS, 2/10).35
Neurological screening was unre-
markable,17 with absence of adverse neu-
rological (reflexes, sensation, and power)
or neural provocation findings. Passive
physiological motion segment testing
was normal.25 Palpation of the lumbar
spine was able to reproduce the athlete’s
pain through central palpation of the
L4-5 and L5-S1 segments.25 Palpation
also revealed the presence of pain over
the lumbar erector spinae and quadratus
Clinical Reasoning
Based on the interview, physical ex-
amination findings, and the absence of
specific pathology (as assessed by mag-
netic resonance imaging), this patient
was diagnosed with nonspecific chronic
LBP, consistent with repetitive loading
and bending strain of the lower lumbar
spine. The disorder was chronic (greater
than 3 months in duration) and progres-
sive, according to the classification sys-
tem as described by O’Sullivan.12,14,34-37
The disorder was classified as a primary
maladaptive motor control impair-
ment with a compressive-loading pat-
tern (flexion bias) at the lower lumbar
spine.11,35,36 The classification encom-
passed several dimensions:
1. Neurophysiological: dominant noci-
ceptive with peripheral sensitization,
as the pain was localized, had a clear
mechanical behavior, and was ame-
nable to change.
2. Physical behaviors: the key feature
that led to this classification was
LBP associated with flexion-loading
activities. The patient presented with
full active range of motion but uti-
lized cocontraction of trunk muscles
during bending tasks. Modification
of the functional tasks via reduced
trunk muscle cocontraction resulted
in pain reduction.
3. Psychosocial and cognitive: the pa-
tient presented with avoidant coping
strategies, such as stopping training
and rest, as reported in his clinical
interview, and a belief that holding
the spine upright and bracing his
abdominal wall was positive for his
back, a lack of awareness of his body
schema and the mechanisms associ-
ated with his LBP, and social isola-
tion from sport and friends.
4. Lifestyle: physical deconditioning as
sociated with activity avoidance.
FIGURE 2 displays the clinical reasoning
FIGURE 1. Comparison between (A) the athlete’s usual movement strategy (upright/rigid posture with cocontracted
trunk muscles) and (B) the new movement strategy (relaxed thoracolumbar region and relaxed trunk muscles)
during ergometer rowing.
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journal of orthopaedic & sports physical therapy | volume 43 | number 8 | august 2013 | 545
used in this case report in a schematic
Outcome Measures
Outcome measure data were collected at
preintervention, 8 weeks postinterven-
tion, and a 12-week follow-up. The pri-
mary outcomes for this study were the
rower’s self-reported pain measured by
the numeric pain rating scale (NPRS),
and disability measured by the Roland-
Morris Disability Questionnaire (RMDQ)
and the Patient-Specific Functional Scale
(PSFS). The primary outcome measures
were collected by a researcher who was
blinded to the intervention as part of
a larger randomized controlled trial
Numeric Pain Rating Scale The NPRS is
an 11-point scale (0-10) of self-reported
pain intensity, with a minimal clinically
significant dierence of 2.7 The NPRS
was administered verbally for each
minute during a 15-minute ergometer
trial, at preintervention and 8 weeks
Roland-Morris Disability Questionnaire
The RMDQ is a disability measure that is
widely used in LBP studies, with a score
of zero representing no disability and a
score of 24 maximal disability.44 A dif-
ference of 2.5 points in RMDQ change
scores is considered to be a minimal clini-
cally important dierence.45
Patient-Specific Functional Scale To
quantify self-reported functional disabil-
ity, the PSFS was selected. In this scale,
zero represents maximal disability and 10
represents no disability for each activity
chosen by the participant.49 This outcome
measure has a minimal clinically signifi-
cant dierence of 3 for 1 activity and 2 for
the average of more than 1 activity.49 This
rower chose rowing, lifting weights, and
forward bending as the 3 activities most
aected by his LBP.
The secondary outcomes for this study
included hip, pelvic, and trunk kinemat-
ics, which were collected by the research-
er, who was blinded to the intervention.
Furthermore, isometric muscle testing of
the erector spinae, the quadriceps, and
the hip flexors was collected by the sports
physiotherapist as part of the physical
Hip, Pelvic, and Trunk Kinematics Ki-
nematics during a 15-minute ergometer
row were collected at preintervention and
postintervention data collection using the
3SPACE FASTRAK system (Polhemus,
Colchester, VT). This has been shown to
be a valid tool to collect kinematics dur-
ing ergometer rowing, with an error of
0.4° when used on a modified ergometer,
and has been used in other rowing-relat-
ed studies.30,33,48 A detailed description of
this process is described in the Labora-
tory Analysis section of this paper.
Back Muscle Endurance To determine the
rower’s level of back muscle endurance,
Chronic back pain disorders
Psychosocial and cognitive dimensions:
• Passive coping strategies
• Avoidant coping strategies for pain management
• Incorrect belief regarding his back posture
• Poor body schema
• Lack of awareness of the mechanisms associated with his back pain
• Social isolation
Lifestyle dimension:
• Physical deconditioning
Specific chronic LBP (pathology) Nonspecific chronic LBP
Nonmechanical pain Mechanical pain (nociceptive pain)
“force closure”
“force closure”
Pelvic girdle pain
loading (flexion
L4-5, L5-S1
Red flags:
• Cancer
• Infection
• Inflammatory conditions
• Fractures
FIGURE 2. Flow chart describing the dierent levels of the multidimensional classification system. Highlighted
areas display the classification assigned for the patient in this case report. Flow chart adapted from O’Sullivan,34-37
Fersum et al,14,15 Dankaerts et al,10,12
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case report
the Biering-Sørensen test was used.2 This
test has been shown to be valid and reli-
able in adolescents.1,46 Adolescent rowers
with LBP have been reported to perform
significantly worse in this test compared
to age-matched, pain-free rowers.40
Lower-Limb Muscle Endurance The
isometric squat and hip flexor muscle
test were described to be part of assess-
ment to classify patients with nonspecific
chronic LBP.1,37 It has been postulated
that poor muscle endurance in the lower
limbs may be associated with compen-
satory spinal movement patterns.37 Evi-
dence has shown that adolescents with
LBP demonstrate poorer squat and hip
flexor muscle test results compared to
adolescents without LBP in the general
population1 and in rowers.40
Sit-and-Reach Test This test has been
widely used to determine the flexibility
of the hamstrings and back.23 Lack of
hamstring flexibility has been reported
as one of the individual risk factors for
LBP in rowers.41,42
Laboratory Analysis
Motion analysis testing was performed
on a modified rowing ergometer30 in the
preintervention and postintervention
laboratory analysis using the 3SPACE
FASTRAK system (Polhemus) at 25 Hz.48
Four electromagnetic sensors were se-
cured onto the participant’s skin over-
lying the midfemur and the S2, L3, and
T12 spinous processes, using double-sid-
ed tape and Fixomull Stretch (Smith &
Nephew Pty Ltd, North Ryde, Australia).
A rotary encoder was also connected to
the flywheel of the rowing ergometer to
determine the stroke length.33 The volt-
age generated by the rotary encoder was
calibrated with a ruler prior to the tri-
als to determine stroke length and was
synchronized with the 3SPACE FAS-
TRAK (Polhemus) using a customized
LabVIEW software program (Version
8.6.1; National Instruments Corporation,
Austin, TX). The following angles were
calculated from the 3SPACE FASTRAK
(Polhemus) data using customized Lab-
VIEW software (National Instruments
Corporation)5 and have been used in pre-
vious studies of rowing kinematics30,31,48
(FIGURE 3): (1) hip angle, the angle of the
S2 sensor relative to the femur sensor;
(2) pelvis angle, the angle of the S2 sen-
sor relative to the vertical axis; (3) lower
lumbar angle, the angle of the L3 sen-
sor relative to the S2 sensor; (4) upper
lumbar angle, the angle of the T12 sen-
sor relative to the L3 sensor; (5) lumbar
angle, the angle of the T12 sensor relative
to the S2 sensor.
Only sagittal plane angles were re-
ported, as only movements in this plane
provoked pain and movements in the
frontal and transverse planes during a
center-pulled ergometer rowing trial are
minimal.48 A hip angle of 0° reflected a
straight alignment between the S2 and
the femur sensors. For trunk kinematics
and pelvic angles, positive values repre-
sented trunk flexion and anterior pelvic
tilt, and negative angles represented
trunk extension and posterior pelvic tilt.
Only drive-phase data were analyzed, and
were normalized to time from the begin-
ning of the drive phase (catch) to the
end of the drive phase (finish). The drive
phase is defined as the period during
which the rower moves from the maxi-
mum forward reach to the maximum
backward lean during ergometer rowing.
Laboratory Testing Protocol
The rower first performed a usual-sitting
test, where he replicated his usual day-
to-day sitting posture. He then completed
a warm-up of 5 minutes of submaximal
ergometer rowing. During the rowing
trial, the rower was requested to row at a
very high intensity (17/20 on Borg rating
of perceived exertion) at a stroke rate of
22 strokes per minute for a period of 15
minutes. This protocol has been used in
previous studies32,33 and was determined
after consultations between the research
team and coaches. During the ergome-
try trial, the rate of perceived exertion3
and the NPRS7 were verbally collected
at the beginning of every minute of the
ergometer trial and also at the end of
the 15-minute ergometer trial. Rate of
perceived exertion was used only to stan-
dardize output during ergometer rowing,
and the result of the NPRS is presented
in FIGURE 4.
Based on the clinical reasoning described
above, a CFT approach was employed to
address the disorder. A detailed descrip-
tion of the rower’s intervention is pre-
sented in the APPENDIX. This intervention
was conducted by the sports physiother-
apist, who was blinded to the outcome
measures data. The intervention was de-
livered during 5 individual sessions over
a duration of 8 weeks, between preinter-
vention and postintervention data collec-
tion.13,14,34-36,51 The program was tailored
to the patient’s goal of enhancing his
capacity to row without back pain. The
intervention was composed of 2 major
components, a cognitive component and
FIGURE 3. Hip, pelvic, and trunk kinematics.
Abbreviations: HA, hip angle; LA, lumbar angle; LLA,
lower lumbar angle; SA, sacral angle; ULA, upper
lumbar angle.
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journal of orthopaedic & sports physical therapy | volume 43 | number 8 | august 2013 | 547
a functional component (APPENDIX).
Cognitive Component The cognitive
component consisted of education re-
garding the pain mechanism (a cycle of
pain, as outlined in a diagram based on
the findings from the examinations, the
RMDQ, and the PSFS), using the patient
interview and physical findings to chal-
lenge the patient’s beliefs regarding his
Functional Component The functional
component was behaviorally and cogni-
tively orientated to train body awareness
(with the use of mirrors and videos) and to
provide alternative strategies to normalize
the rower’s postural and movement pat-
terns, allowing him to confront activity
avoidance by moving in a pain-free man-
ner. This component included posture and
movement retraining and lower-limb and
back muscle endurance training in rowing-
specific postures. Exercises and movement
modification were integrated into a row-
ing-specific routine to return the athlete to
his sport in a graduated manner (APPENDIX).
The rower was also asked to fill in a
compliance sheet to indicate the level of
adherence to the program. From inspect-
ing this sheet, he was deemed to have a
high level of compliance by the treating
This rower showed an improve-
ment in the primary outcome
measures following an 8-week phys-
iotherapy intervention. The NPRS (FIGURE
4) revealed a reduction in the intensity of
the temporal summation of pain demon-
strated during ergometer rowing. The re-
sults of the RMDQ and PSFS (TABLE) also
supported a reduction in disability.
The secondary outcomes for this study
demonstrated a change in trunk, pelvic,
and lumbar kinematics during rowing
following the intervention (FIGURE 5). The
kinematics data indicated that the athlete
rowed with greater hip flexion throughout,
placed the pelvis in a more posterior pelvic
tilt, and had a greater range of movement
throughout the drive phase (demonstrated
by greater range of lower lumbar angle
and greater angle and less flexion in the
upper lumbar angle) following the 8-week
intervention. Although kinematics data of
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Pain Intensity (0-10)
Time, min
Initial Follow-up
FIGURE 4. Numeric pain rating scale during ergometer rowing at preintervention laboratory analysis (initial) and
postintervention laboratory analysis (follow-up).
0 10 20 30 40 50 60 70 80 90 100
Hip Angle, deg
Drive Phase, %
Hip Angle
0 10 20 30 40 50 60 70 80 90 100
Posterior/Anterior Tilt, deg
Drive Phase, %
Pelvic Angle
0 10 20 30 40 50 60 70 80 90 100
Extension/Flexion, deg
Drive Phase, %
Lower Lumbar Angle
0 10 20 30 40 50 60 70 80 90 100
Extension/Flexion, deg
Drive Phase, %
Upper Lumbar Angle
Follow-up Initial
FIGURE 5. Hip, pelvic, and trunk kinematics of the drive phase during the first minute of the rowing ergometer
trial. Positive angles indicate flexion angles (anterior pelvic tilt of the sacral angle) and negative angles indicate
extension angles (posterior pelvic tilt). Dotted lines represent the preintervention kinematics (initial) and solid lines
represent the postintervention kinematics (follow-up).
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case report
3 completed rowing strokes were collected
during the last 15 seconds of every minute,
only the kinematics data of the first minute
are presented in FIGURE 5. The percentage
of the stroke in the drive phase was also
increased following intervention (TABLE).
Furthermore, there were improvements
in the physical assessments following the
intervention in the Biering-Sørensen test,
the sit-and-reach test, the squat hold, and
the hip flexor hold (TABLE).
The results of this case study sup-
port an association between a cogni-
tive functional approach to managing
and reducing pain and disability in an
adolescent male rower during ergometer
rowing. After the intervention, the athlete
demonstrated a clinically significant im-
provement in pain and, more importantly,
a reduction in the intensity of pain ramp-
ing (temporal summation) during ergom-
eter rowing.
The reduction in pain and disability in
this rower was associated with observed
changes in spinopelvic kinematics, in-
creased back and hip muscle endurance,
and increased sit-and-reach flexibility. Pos-
tintervention, the kinematics data revealed
that the rower utilized a greater proportion
of his available range of movement in the
lower lumbar spine (FIGURE 5). It is possible
that the intervention provided this athlete
with an alternative movement strategy and
enhanced load distribution across the lum-
bar spine, thereby reducing focal strain and
loading of the lower lumbar region (area of
pain).9,15,35,53,54 Another possible interpre-
tation is that the rower developed greater
load tolerance due to the rowing-specific
conditioning. It is also possible that the
intervention reduced his fear of back load-
ing by reframing his beliefs about pain and
teaching adaptive movement strategies re-
lated to rowing.
Although trunk muscle activation was
not assessed using electromyography, it
is postulated that this athlete presented
with a compressive-loading disorder, with
a bias toward flexion loading,35 that was
driven by increased trunk muscle cocon-
traction (detected on clinical examination)
and resulted in a reduced use of lumbar
range of motion during ergometer rowing.
O’Sullivan35 proposed that adopting mal-
adaptive movement patterns associated
with trunk muscle cocontraction may lead
to nonphysiological loading of the lumbar
spine (not end range) during loading tasks
(eg, rowing). This observation is consistent
with suggestions that some individuals
with nonspecific chronic LBP may have
greater trunk muscle coactivity compared
to asymptomatic individuals during trunk
movements in the frontal, sagittal,10 and
transverse20,52 planes of movement. Fur-
thermore, increases in trunk muscle activ-
ity have been associated with greater trunk
stiness.28 Future studies employing elec-
tromyography will be able to determine the
veracity of these hypotheses.
This case report assessed an interven-
tion aimed at optimizing cognitive and
movement behaviors to provide an ado-
lescent male rower with alternative cop-
ing and movement strategies, allowing
him to gain strength and conditioning in
a nonprovocative and relaxed manner.
This approach included a strong cognitive
component, such as changing his beliefs
regarding the need to hold his thorax erect
and brace his spine, as well as the use of
visual feedback through mirrors and vid-
eos targeting visualization of movement to
Outcome Measures and  
Kinematics Data at Preintervention,
Postintervention, and Follow-up
Abbreviations: PSFS, Patient-Specific Functional Scale; RMDQ, Roland-Morris Disability
Preintervention 8-wk Postintervention 12-wk Follow-up
RMDQ (0-24) 12 1 1
PSFS (0-10)
Rowing 1 9 9
Lifting weights 0 8 8
Forward bending 3 9 9
Physical assessments
Biering-Sørensen, s 30 65 80
Sit and reach, m –0.12 0.0 0
Squat hold, s 20 90 120
Hip flexor hold, s 12 45 60
Usual sitting, deg
Sacral angle –0.5 8.9
Lower lumbar angle 2.5 3.8
Upper lumbar angle 20.6 –12.5
Lumbar angle 23.1 –14.6
Stroke length, m
First min 1.45 1.44
Range between catch and finish
First min, deg
Sacral angle 36.4 26.3
Lower lumbar angle 5.5 23.5
Upper lumbar angle 4.0 11.3
Lumbar angle 9.5 13.9
Hip angle 71.4 73.9
Stroke in drive phase, %
First min 33.7 38.3
43-08 Caneiro.indd 548 7/19/2013 3:45:37 PM
journal of orthopaedic & sports physical therapy | volume 43 | number 8 | august 2013 | 549
retrain body schema57 and to reduce sense
of threat.8 Although speculative, a combi-
nation of factors, such as postural changes,
improvement in conditioning and flexibil-
ity, improvement in confidence,16 improve-
ment in body awareness,29,56 reduced sense
of threat,8 and more relaxed movement
patterns,35,53 might have enabled this ath-
lete to resume rowing training with signifi-
cantly lower levels of pain.
Consistent with these findings, similar
cognitive functional approaches have been
applied in populations of cyclists6,53,54 and
female rowers.41,51 More specifically, a simi-
lar cognitive functional intervention was
shown to reduce summation of pain in a
cyclist with nonspecific chronic LBP during
a 2-hour outdoor cycling task.53 This study
also found a relationship between clinical
changes (reduced pain and disability) and
a change in spinopelvic kinematics while
rowing. Similar to Van Hoof et al,53 we re-
ported abolishment of the phenomenon of
summation of pain in an athlete with non-
specific chronic LBP while performing a
functional task.54
This case report challenges the popular
belief that chronic LBP should be managed
by training neutral postures and enhanc-
ing greater core stability.20-22,43 The rower
in this case study presented with a reduced
use of his available spinal movement pat-
tern during ergometer rowing prior to
the intervention. Whether this movement
pattern had been reinforced by the prior
stability training program is not known,
although he reported that this approach
led to an increase in his levels of pain and
disability. In contrast, following the cogni-
tive functional approach, he demonstrated
more lumbar flexion and greater flexibility
during the drive phase.
The authors acknowledge potential
limitations of this study. The study design
is that of a single case study, and therefore
it cannot be concluded that the success of
the current intervention would be appar-
ent in other rowers. Rather, the purpose of
this study was to support the outlined sys-
tematic approach to individually classify
athletes with chronic LBP and to develop
a targeted intervention for this condition.
Performance was not assessed in this study,
as the goal of the treatment, as defined by
the rower, was to return to rowing at any
level. Although palpation is widely used by
physiotherapists during clinical examina-
tions,26 the validity and reliability of iden-
tifying active muscle contraction (tension)
during static and dynamic postures have
not been reported, limiting the replication
of this test. Quantitative kinetic informa-
tion and electromyography should also be
included in future studies. The test-retest
reliability of the FASTRAK (Polhemus)
motion analysis system utilized during er-
gometer rowing was not tested during this
study and may be subject to soft tissue ar-
tifact errors. Future studies should include
a randomized controlled trial with more
participants of dierent genders and levels
of participation.
The results of this study indicate
that a cognitive functional interven-
tion appeared to be successful in re-
ducing pain and disability associated with
rowing in a male adolescent rower. This
was associated with greater range of spi-
nal movement during ergometer rowing,
increased back and hip muscle endurance,
and increased flexibility. t
ACKNOWLEDGEMENTS: This study was sup-
ported by research grants from the Phys-
iotherapy Research Foundation tagged
Sports Physiotherapy Australia grant as
part of a randomized controlled clinical tri-
al (T09-THE/SPA001). The authors would
also like to acknowledge the help of Paul
Davey for his assistance. There was equal
contribution to the manuscript between the
first and the second author.
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Cognitive Component
Clinical Findings Cognitive Functional Therapy
Education regarding the vicious cycle of pain
specific to this rower:
The findings from his examination were
outlined in a diagram in order to demon-
strate all factors involved with develop-
ment and persistence of his pain disorder.
These included negative beliefs about
pain, a lack of awareness of his body sche-
ma, abdominal bracing associated with
provocative movement patterns, avoidant
behaviors, physical deconditioning, and
social isolation from sport and friends.
Negative beliefs about pain:
“Bending is not good for me.”
“Round thoracic is a bad posture.
Avoidance behaviors:
Told to avoid bending in sitting, squatting, and
Passive coping strategies:
Prolonged rest, NSAIDs, social isolation from
rowing team.
Core stability:
Performed core stability exercises and kept
trunk upright in sitting and rowing.
Challenge beliefs:
Review of the radiology highlighted that no
structural abnormalities were reported.
Education regarding movement behaviors:
He had adopted protective movement patterns
associated with cocontraction of the trunk
muscles, leading to increased loading and pain
provocation. The importance of using the hips
and legs during bending, lifting, and squatting
tasks to reduce focal stress was explained.
The rower was able to experience that when
performing his pain-provocative activities in
the new, relaxed way, there was an immediate
reduction in pain. This was reinforced using
feedback through use of video and mirrors.
Development of this rower’s pain cycle:
Despite a normal radiological report, the
rower was told that he needed to protect
his back from “further damage.” The
instructions were to avoid bending during
sitting, lifting, and rowing. However, no
alternative strategies were proposed. In
addition, he was advised to perform core
stability exercises to enhance the stability
of his spine and further protect it.
The rower reported that adopting a more
rounded thoracic posture would alleviate
his pain; however, he was advised that
this was not a good posture, and therefore
he persisted with rowing in an upright
The rower followed these instructions dili-
gently, despite an increase in pain levels,
reduced rowing ability, and an increase in
Adopting a more relaxed, rounded posture in fact
relieved his symptoms. Movement (bending,
squatting, and ergometer rowing) with a relaxed
trunk (without abdominal bracing) reduced his
Active coping strategies:
Prescribed daily activities such as walking and
stationary cycling.
The physical activities were progressed to
rowing-specific tasks (ie, ergometer rowing and
on-water rowing, as described below).
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case report
Clinical Findings Cognitive Functional Therapy
Body awareness and specific movement
As a sweep rower, he needed to be able to
reach forward and across (rotating his up-
per body toward the side he was rowing).
Therefore, the ability to dissociate (move
independently) between the thoracic
region and the lumbopelvic region was
considered important.
Lumbopelvic and thoracolumbar dissocia-
tion exercises were used to improve his
body schema and awareness in space
through the use of manual feedback in
crook-lying and sitting. This was soon pro-
gressed from manual feedback to the use
of mirrors, so the athlete could actively
correct himself.
The same process was repeated with the
rower on the ergometer. Mirrors and digital
photographs were used to compare his
usual posture (thoracic upright sitting:
flexed lumbar spine and extended thoracic
spine) to a more relaxed posture (lumbo-
pelvic upright sitting: extended lumbar
spine and flexed thoracic spine).
Poor body schema. Poor lumbopelvic and thora-
columbar dissociation. Cocontraction between
abdominals and back extensors.
Rower’s catch position. Lack of anterior pelvic tilt
and thoracic flexion with cocontraction of
paraspinal and abdominal muscles.
Pelvic, lumbar, thoracic dissociation exercises:
lumbopelvic and thoracolumbar dissociation
exercises. Crook-lying (focused on lumbosacral
Ergometer. Encouraged anterior pelvic tilt and
thoracic flexion.
Functional Component
Clinical Findings Cognitive Functional Therapy
This component aimed to provide alterna-
tive strategies to normalize the rower’s
postural and movement behaviors, allow-
ing him to move in a pain-free manner.
Using the aggravating factors on the
Patient-Specific Functional Scale, the
physical therapist trained the rower to per-
form the previously pain-provocative tasks
in a relaxed and controlled manner, reduc-
ing his pain. For example, during bending,
sit-to-stand, and squatting, the rower had
reduced pain when he maintained a more
relaxed thorax and more bending through
the knees and hips (see photos). These
exercises aimed to initiate the drive to
perform the task via the legs, as opposed
to via the trunk.
Sitting. Cocontraction of paraspinal and
abdominal muscles.
Sitting. Relaxed paraspinal and abdominal
muscles, anterior pelvic tilt.
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journal of orthopaedic & sports physical therapy | volume 43 | number 8 | august 2013 | 553
Clinical Findings Cognitive Functional Therapy
Bending. Minimal hip flexion.
Sit-to-stand. Thorax extended.
Squat. Thorax extended.
Bending. Anterior pelvic tilt and relaxed
paraspinal and abdominal muscles.
Sit-to-stand. Relaxed thorax.
Squat. Relaxed thorax.
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[ case report ]
Clinical Findings Cognitive Functional Therapy
Posture retraining during ergometer rowing:
Based on the principles of normalization
of his movement in previous functional
tasks, the rower was asked to adopt a
more relaxed thoracic posture, allowing
him to reach farther with his upper body.
In addition, he was encouraged to engage
his legs earlier during the drive phase. To
facilitate the training of the new rowing
technique, the rower was given exercises
such as displayed. In the clinic, the prac-
tice of the “new” posture during ergom-
eter rowing was performed next to a long
mirror, where the rower could check and
correct his technique. The execution and
visualization of pain-free movement be-
havior reinforce the adoption of a new, al-
ternative movement strategy. The “usual”
and “new” rowing postures were filmed
with the rower’s phone device so he could
use it as a form of virtual training.
Catch position. Lack of hip flexion, anterior pelvic
tilt, and thoracic flexion.
Middrive. Cocontracted paraspinal and abdominal
Catch position. Promote thoracic flexion at catch.
Middrive. Relaxed paraspinal and abdominal
Exercise dosage:
The rower was encouraged to perform
these exercises to the point of loss of form
(as perceived by the rower or as seen
in the mirror) or muscle fatigue. These
exercises form part of a circuit that was
repeated 3 to 4 times in each session
every second day. The setup of this circuit
also aimed to increase lower-limb and
back muscle endurance, including sit and
forward reach, sit-to-stand, squats, single-
leg squats, and rowing drills (postural
retraining). On average, to accomplish a
race, a rower has to perform 240 strokes.
Based on this information, the exercises
were progressed such that the rower’s ulti-
mate goal was to perform 240 repetitions
of the exercises within the circuit session.
The rower was able to achieve that goal in
week 6. The circuit was then performed 3
times a week for maintenance.
Finish position. Extended thorax and cocontracted
paraspinal and abdominal muscles.
Finish position. Relaxed thorax and relaxed
paraspinal and abdominal muscles.
Abbreviation: NSAID, nonsteroidal anti-inflammatory drug.
Return-to-Rowing Program
Weeks 1 to 2: ergometer rowing: 2 to 5 minutes (pain free)
in new posture.
Weeks 3 to 4: ergometer rowing: 15 minutes, pain free.
Weeks 5 to 6: on-water rowing: single scull, 4 km daily.
Week 7: on-water rowing: pair/4, 12 km 3 times per week.
Week 8: on-water rowing: 8 sweep, return to crew rowing.
43-08 Caneiro.indd 554 7/19/2013 3:46:07 PM
... Although the majority of articles also used psychological outcomes in combination with biological, the psychological outcomes received less attention. For example, disability, pain intensity and pain location were the most frequent primary outcomes used to assess and evaluate patients [39][40][41][42][43][44], and active range of motion, posture and spinal movement were also frequently used [43,[45][46][47][48][49][50]. In their perspective paper about a movement control schema, Alrwaily et al. [45] suggest that this type of approach exists within a BPS perspective. ...
... Although other elements, such as patient rapport and emotions were mentioned or alluded to in these and other examples, it is the biological aspects of emotions (the nervous system processes) that are foregrounded. Thus, many of the texts that engaged with pain neurophysiology education [40,48,[52][53][54][55][56], although stating this approach to be part of the BPS model, often largely reduced it from its trifecta to the "bio." ...
... This approach was believed to result in changes in patient behaviour (such as movement patterns or levels of activity), and consequently a reduction in their pain. For example, nine studies [46][47][48][49][50][57][58][59][60] referred to an intervention known as cognitive functional therapy, which was discussed in the texts as being BPS-oriented. For example, in their overview of this treatment, Cowell et al. [57, p.80] state that "Cognitive functional therapy is a biopsychosocially oriented behavioural intervention for low back pain". ...
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Purpose: Low back pain (LBP) is the leading cause of disability worldwide. Clinical research advocates using the biopsychosocial model (BPS) to manage LBP, however there is still no clear consensus regarding the meaning of this model in physiotherapy and how best to apply it. The aim of this study was to investigate how physiotherapy LBP literature enacts the BPS model. Material and methods: We conducted a critical review using discourse analysis of 66 articles retrieved from the PubMed and Web of Science databases. Results: Analysis suggest that many texts conflated the BPS with the biomedical model [Discourse 1: Conflating the BPS with the biomedical model]. Psychological aspects were almost exclusively conceptualised as cognitive and behavioural [Discourse 2: Cognition, behaviour, yellow flags and rapport]. Social context was rarely mentioned [Discourse 3: Brief and occasional social underpinnings]; and other broader aspects of care such as culture and power dynamics received little attention within the texts [Discourse 4: Expanded aspects of care]. Conclusion: Results imply that multiple important factors such as interpersonal or institutional power relations, cultural considerations, ethical, and social aspects of health may not be incorporated into physiotherapy research and practice when working with people with LBP.
... These might have been temporally related to improvements in muscle activity during the extension phase and might have further led to a temporal association between improvements in muscle The present study suggested that each pain-related factor results in muscle activity adaptations during each movement phase. Concerning treatment, the effectiveness of cognitive functional therapy 23,42 and graded sensorimotor re-education 22 as interventions for psychological factors and body perception disturbance in patients with CLBP has been reported. Considering the temporal influence of pain-related factors on muscle activity, the abovementioned interventions should be combined with a motor control approach for specific muscle activity in patients with CLBP. ...
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Purpose: The cross-sectional and longitudinal associations between pain-related factors and muscle activity in patients with chronic low back pain (CLBP) are unclear. This study aimed to examine the temporal associations between them in a CLBP patient using a single-case analysis to account for an individual course. Patient and methods: A patient with a history of lower back pain lasting more than 3 months was studied from March 16, 2020 to May 30, 2020. Surface electromyographic signals were recorded from over the bilateral lumbar erector spinae in the patient while performing a standing trunk flexion and re-extension task. The average value for muscle activity during each movement phase was estimated, and the flexion relaxation ratio (FRR) of all channels was subsequently calculated. Pain-related factors and disability were assessed using questionnaires. All assessments were performed nine times, along with 2-3 months of intervention. Once or twice per week, the patient received physical therapy that consisted of soft tissue mobilization, joint mobilization, nerve mobilization, and patient education. A cross-lag correlation analysis of this single case was conducted. Results: Pain-related factors showed a trend toward improvements in all variables when compared to those in the first assessment; however, there was no general change (increase) in FRR over time. The cross-lag correlation analysis revealed that improvements in FRR were associated with improvements in body perception disturbance (ρ = -0.78, p < 0.01), and that improvements in muscle activity during the extension phase were associated with improvements in pain (ρ = 0.75), psychological factors (ρ = 0.57), and disability (ρ = 0.67) (p < 0.05). Conclusion: Our findings suggest that improvements in body perception were temporally associated with improvements in FRR, and improvements in pain, psychological factors, and disability were temporally associated with a reduction in muscle activity during the trunk extension phase in this patient with CLBP.
... 36 Moreover, 8 weeks of CBT improved spine kinematics and increased lower limb and trunk muscle endurance in a rower with CLBP. 53 Similar to our results, Khan et al 54 demonstrated that patients with CLBP showed greater improvement in pain and disability after a program containing CBT associated with general exercise compared with general exercise alone; however, muscle thickness was not evaluated in their study. Vasseljen et al 2 indicated that the value of changes observed in TrA contraction thickness ratio was associated with the mean pain value being reduced after a stabilization program. ...
Objective: Nonspecific chronic low back pain (NCLBP) is a major public health and global socioeconomic burden with a variety of symptoms, such as fear-avoidance behaviors. This study aimed to evaluate the effect of cognitive behavioral therapy (CBT) associated with stabilization exercise (SE) on thickness of transverse abdominis (TrA) muscle in patients with NCLBP. Methods: Forty patients with NCLBP were randomly assigned into experimental CBT associated with SE (n = 20) and control groups without SE (n = 20). Transverse abdominis muscle thickness was assessed during abdominal drawing in maneuver (ADIM) and active straight leg raise (ASLR) of the right lower limb using ultrasound imaging. Fear-avoidance belief and disability were evaluated using a fear-avoidance belief questionnaire (FABQ) and a Roland-Morris disability questionnaire (RMDQ) before and after intervention. Results: Mixed-model analysis of variance indicated that the effect of time was significant for the right and left TrA contraction thickness during ADIM and left TrA contraction thickness during ASLR (P < .05). However, the experimental group exhibited higher right and left TrA muscle thickness compared with the control group during ADIM (P = .001). Moreover, there were no significant differences between groups in the thickness of TrA muscle during ASLR (P > .05). The effect of time was significant for FABQ (P = .02) and RMDQ (P = .01); however, the effect of group was significant for the FABQ after intervention (P = .04). Conclusions: Stabilization exercise associated with CBT is more effective than SE alone in improving fear avoidance belief and in increasing the thickness of the TrA muscle during ADIM task.
... 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. Therefore, a combination of factors, such as postural changes, awareness of positive and negative posture situations, improvement in confidence, reduced sense of threat and more relaxed movement patterns, might have reduced the pain and kinesiophobia in patients with neck pain. ...
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.
... However, in persistent LBP, they are usually unhelpful and provocative and disproportionate to the degree of tissue pathology and persisting beyond tissue healing times. These pain-related functional behaviors may vary from subtle movement and postural changes to overt safety behaviors (e.g., propping with hands, avoidance of loading the spine or a limb, repetitive "checking" of the pain, grimacing, and wincing) among highly distressed people with LBP [87]. In adolescents with persistent LBP, their individual LBP experience and movement pattern should be evaluated because the specific movements and activities that are provocative can vary [33,92]. ...
Adolescent low back pain has received limited research attention despite its potentially considerable impact on quality of life. The role of diagnostic triage to identify serious or specific pathology and/or order relevant investigations is considered. An overview of contemporary pain mechanisms is provided, with specific reference to the wide range of risk factors for persistent low back pain. Education and exercise framed within a biopsychosocial framework are the cornerstones of treatment. There is a lack of data on more comprehensive personalized treatment approaches among adolescents. One such approach – Cognitive Functional Therapy – which has shown promise in adults and active adolescents with low back pain, is described and illustrated using a case study. The most promising avenues, in practice and research, may be those that view adolescent low back pain as less of a local structural spinal issue and more of an indication of the general health of the adolescent.
... Clinical trials have shown that standard tasks such as sitting posture and lumbar ROM during forward bending did not change after CFT (O' Sullivan et al., 2015;Vibe Fersum et al., 2013). In contrast, several case studies that evaluated patient-specific activities showed that an improvement in pain and disability was associated with a less protective movement behaviour after CFT (Caneiro, Ng, Burnett, Campbell, & O'Sullivan, 2013;Caneiro, Smith, Smith, Rabey, Moseley, & O'Sullivan, 2017;Meziat Filho, 2016). Therefore, it might be more appropriate to evaluate the specific movements that were targeted during treatment instead of using standardized tasks. ...
Background Most studies fail to show an association between higher levels of pain‐related fear and protective movement behavior in patients with chronic low back pain (CLBP). This may be explained by the fact that only general measures of pain‐related fear have been used to examine the association with movement patterns. This study explored whether task‐specific, instead of general measures of pain‐related fear can predict movement behavior. Methods Fifty‐five patients with CLBP and 54 healthy persons performed a lifting task while kinematic measurements were obtained to assess lumbar range of motion (ROM). Scores on the Photograph Daily Activities Series‐Short Electronic Version (PHODA‐SeV), Tampa Scale for Kinesiophobia and its Activity Avoidance and Somatic Focus subscales were used as general measures of pain‐related fear. The score on a picture of the PHODA‐SeV, showing a person lifting a heavy object with a bent back, was used as task‐specific measure of pain‐related fear. Results Lumbar ROM was predicted by task‐specific, but not by general measures of pain‐related fear. Only the scores on one other picture of the PHODA‐SeV, similar to the task‐specific picture regarding threat value and movement characteristics, predicted the lumbar ROM. Compared to healthy persons, patients with CLBP used significantly less ROM, except the subgroup with a low score on the task‐specific measure of pain‐related fear, who used a similar ROM. Conclusions Our results suggest to use task‐specific measures of pain‐related fear when assessing the relationship with movement. It would be of interest to investigate whether reducing task‐specific fear changes protective movement behavior. This article is protected by copyright. All rights reserved.
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Background Low back pain (LBP) is highly prevalent in the rowing population. The body of existing research variously investigates risk factors, prevention, and treatment methods. Purpose The purpose of this scoping review was to explore the breadth and depth of the LBP literature in rowing and to identify areas for future research. Study Design Scoping review Methods PubMed, Ebsco and ScienceDirect were searched from inception to November 1, 2020. Only published, peer-reviewed, primary, and secondary data pertaining to LBP in rowing were included for this study. Arksey and O’Malley’s framework for guided data synthesis was used. Reporting quality of a subsection of the data was assessed using the STROBE tool. Results Following the removal of duplicates and abstract screening, a set of 78 studies were included and divided into the following categories: epidemiology, biomechanics, biopsychosocial, and miscellaneous. The incidence and prevalence of LBP in rowers were well mapped. The biomechanical literature covered a wide range of investigations with limited cohesion. Significant risk factors for LBP in rowers included back pain history and prolonged ergometer use. Conclusion A lack of consistent definitions within the studies caused fragmentation of the literature. There was good evidence for prolonged ergometer use and history of LBP to constitute risk factors and this may assist future LBP preventative action. Methodological issues such as small sample size and barriers to injury reporting increased heterogeneity and decreased data quality. Further exploration is required to determine the mechanism of LBP in rowers through research with larger samples.
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Pain is often presumed to be part of the sport injury experience. The time-loss definition of injury leads to under-reported athletic pain impacting performance and quality of life. Whilst research regarding the assessment and classification of back pain in athletes is emerging, little has been reported regarding how peripheral pain is assessed and classified in research and practice. Six databases will be searched for relevant articles. Title and abstract screening followed by full-text screening will be completed by two independent reviewers. Data charting will be carried out using a modified standardised form. Descriptive results and frequencies will be reported. Pain measures identified in the studies will be mapped against the IOC Athlete Pain Framework alongside a narrative summary. Published peer-reviewed primary research studies alongside systematic reviews and clinical practice guidelines reporting the assessment or classification of pain in athletes of any age with chronic or acute peripheral pain across all study contexts in the English language on human participants from inception of the databases will be included. The results of this study are part of a body of research which will be used to inform the development of a pain assessment framework. The scoping review will be submitted for peer-reviewed journal publication and presented at sports medicine conferences. This review will inform researchers and clinicians working with athletes in pain how pain assessment and classification is currently conducted and positioned against the IOC Athlete Pain Framework.
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[(Persian)]. AbSTrACT Aims and background: Neck pain is one of the most common problems in human societies. There are many factors involved in the etiology of neck pain, and cognitive problems related to pain are among the most important factors involved for non-specific neck pain. The aim of this study was to investigate the effect of six weeks of functional cognitive training on the pain intensity, disability and Kinesiophobia in people with non-specific chronic neck pain. Material and Methods: The present study was a clinical trial study with one intervention group and one control group. In this clinical trial study, 24 patients with chronic neck pain were randomly divided into two groups of Cognitive Functional Exercise (n=12) and Control (n=12). The variables of pain intensity, disability, and Kinesiophobia were evaluated before and immediately after six weeks of cognitive exercises by the Visual Analog Scale, neck disability questionnaire, and Tampa Scale of Kinesiophobia, respectively. Data were analyzed using Repeated Measures ANOVA and paired t-test. results: Comparing the two groups after treatment, there was a significant difference in pain intensity (P =0.001), disability index (P = 0.001), and Tampa Scale of Kinesiophobia (P = 0.001) was observed, so that in the intervention group in all factors a significant decrease was observed. Also, the results of the T-pair test showed that there is a significant difference in the group of intervention before and after the test in all variables (P = 0.001). But there was no significant difference for the control group. Conclusion: The findings showed that the intervention of functional cognitive exercises improves pain, disability, and Kinesiophobia in people with chronic neck pain, so it is suggested that functional cognitive exercises can be used as a complementary method in improving individuals with non-specific chronic neck pain.
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The biomedical model is still used to diagnose chronic lower back pain by the majority of Japanese physicians. A new approach to chronic lower back pain called cognitive functional therapy (CFT) was developed by Peter O'Sullivan based on the biopsychosocial model. This is a physiotherapist-led approach and differs from other foundational cognitive interventions. There is much evidence of the use of CFT. For example, CFT has shown promising results in the reduction of fear, pain and disability in the long term. For chronic lower back pain, the biopsychosocial model is essential to manage patient conditions. Therefore, we should understand the biopsychosocial model and put it to practice. CFT is helpful to understand the model and can improve patient outcomes.
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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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The trunk and pelvis kinematics of 20 healthy male and female adolescent rowers were recorded during an ergometer trial using an electromagnetic tracking system (Fastrak). The kinematics of each drive phase were collected during the 1st and 20th minute, respectively. The mean and range of the kinematics, stroke rate and stroke length were compared between genders and over time. Male rowers postured their pelvis with more posterior tilt and their thoracic spine in more flexion than female rowers (P < .05). Both genders postured their pelvis in more posterior pelvic rotation and upper trunk in more flexion over time. Male rowers were found to have a significantly shorter drive phase than female rowers (P = .001). Differences in trunk and pelvic kinematics between adolescent male and female rowers suggest potentially various mechanisms for biomechanical stress. Assessment and training of rowers should take gender differences into consideration.
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Background: Non-specific chronic low back pain disorders have been proven resistant to change, and there is still a lack of clear evidence for one specific treatment intervention being superior to another. Methods: This randomized controlled trial aimed to investigate the efficacy of a behavioural approach to management, classification-based cognitive functional therapy, compared with traditional manual therapy and exercise. Linear mixed models were used to estimate the group differences in treatment effects. Primary outcomes at 12-month follow-up were Oswestry Disability Index and pain intensity, measured with numeric rating scale. Inclusion criteria were as follows: age between 18 and 65 years, diagnosed with non-specific chronic low back pain for >3 months, localized pain from T12 to gluteal folds, provoked with postures, movement and activities. Oswestry Disability Index had to be >14% and pain intensity last 14 days >2/10. A total of 121 patients were randomized to either classification-based cognitive functional therapy group n = 62) or manual therapy and exercise group (n > = 59). Results: The classification-based cognitive functional therapy group displayed significantly superior outcomes to the manual therapy and exercise group, both statistically (p < 0.001) and clinically. For Oswestry Disability Index, the classification-based cognitive functional therapy group improved by 13.7 points, and the manual therapy and exercise group by 5.5 points. For pain intensity, the classification-based cognitive functional therapy improved by 3.2 points, and the manual therapy and exercise group by 1.5 points. Conclusions: The classification-based cognitive functional therapy produced superior outcomes for non-specific chronic low back pain compared with traditional manual therapy and exercise.
Spinal stability is related to the recruitment and control of active muscle stiffness. Stochastic system identification techniques were used to calculate the effective stiffness and dynamics of the trunk during active trunk extension exertions. Twenty-one healthy adult subjects (10 males, I I females) wore a harness with a cable attached to a servomotor such that isotonic flexion preloads of 100, 135, and 170N were applied at the T10 level of the trunk. A pseudorandom stochastic force sequence (bandwidth 0-10Hz, amplitude +/- 30 N) was superimposed on the preload causing small amplitude trunk movements. Nonparametric impulse response functions of trunk dynamics were computed and revealed that the system exhibited underdamped second-order behavior. Second-order trunk dynamics were determined by calculating the best least-squares fit to the IRF. The quality of the model was quantified by comparing estimated and observed displacement variance accounted for (VAF), and quality of the second-order fits was calculated as a percentage and referred to as fit accuracy. Mean VAF and fit accuracy were 87.8 +/- 4.0% and 96.0 +/- 14.3%, respectively, indicating that the model accurately represented active trunk kinematic response. The accuracy of the kinematic representation was not influenced by preload or gender. Mean effective stiffness was 2.78 +/- 0.96 N/mm and increased significantly with preload (p < 0.00 1), but did not vary with gender (p = 0.425). Mean effective damping was 314 +/- 72 N s/m and effective trunk mass was 37.0 +/- 9.3 kg. We conclude that stochastic system identification techniques should be used to calculate effective trunk stiffness and dynamics. (c) 2004 Elsevier Ltd. All rights reserved.
Performance differences have been noted between male and female rowers; the aim of this study was to determine if these are due to differences in rowing technique. An electromagnetic motion measurement device in conjunction with a load cell was used to compare the ergometer rowing kinematics of female and male elite national rowers. Male rowers generated significantly greater peak force during the stroke, ( p < 0.0001) and greater power. Although there was no difference in stroke length, females demonstrated a more optimal lumbopelvic rhythm due to a greater anterior pelvic rotation during the stroke ( p < 0.05). This is likely to account for the lack of difference in stroke length. In conclusion, gender differences do exist in kinematic parameters of rowing technique. With a greater mass and height, the male athletes are more powerful than the females; however, females appear to optimize their kinematics in an attempt to enhance performance.
The purpose of the present investigation was to determine the relationships of the sit and reach test, a component of the American Alliance for Health, Physical Education, Recreation and Dance Health Related Fitness Test, 1980, with criterion measures of back and hamstring flexibility. Young females (N = 100) with a mean age of 14.08 years ± .825 were administered two trials of three tests. The measurements included the sit and reach test, passive hamstring flexibility using a Leighton Flexometer, and a test of back flexibility using a protocol suggested by Macrae and Wright in 1969. Test-retest reliability estimates exceeded .90 for all measurements. Results indicated that the sit and reach test had a moderate relationship (r = .64) with passive hamstring flexibility. The correlations between the sit and reach test and total back flexibility (r = .07), upper back flexibility (r = −.16), and lower back flexibility (r = .28) were low. These findings indicate the sit and reach test has moderate criterion-related validity when used as an assessment of hamstring flexibility, but appears not to provide a valid assessment of back and, in particular, low back flexibility which is one of the reasons it was included in the Health Related Fitness Test.