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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
(ACTRN12609000565246).
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 aliations 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: Leo.Ng@curtin.edu.au Copyright ©2013 Journal of
Orthopaedic & Sports Physical Therapy®
J.P. CAÑEIRO, PT, MSc, MSports1,2 • LEO NG, PT, MMT1 • ANGUS BURNETT, PhD3
AMITY CAMPBELL, PhD1 • PETER O’SULLIVAN, PT, Grad Dip Manip, PhD1,2
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 dier 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.
CASE DESCRIPTION
A
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 eect. 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
aect 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
independently.9,37
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
lumborum.
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
manner.
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
(ACTRN12609000565246).
Numeric Pain Rating Scale The NPRS is
an 11-point scale (0-10) of self-reported
pain intensity, with a minimal clinically
significant dierence of 2.7 The NPRS
was administered verbally for each
minute during a 15-minute ergometer
trial, at preintervention and 8 weeks
postintervention.
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 dierence.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 dierence 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
aected 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
examination.
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)
Decreased
“force closure”
Increased
“force closure”
Pelvic girdle pain
Control
impairment
Movement
impairment
Compressive
loading (flexion
loading)
Directional
subgroups
L4-5, L5-S1
Red flags:
• Cancer
• Infection
• Inflammatory conditions
• Fractures
FIGURE 2. Flow chart describing the dierent 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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[
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]
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.
Intervention
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
pain.
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
physiotherapist.
OUTCOMES
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
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
1
2
3
4
5
6
7
8
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
0 10 20 30 40 50 60 70 80 90 100
20
40
60
80
100
120
140
160
Hip Angle, deg
Drive Phase, %
Hip Angle
–40
0 10 20 30 40 50 60 70 80 90 100
–30
–20
–10
0
10
20
30
Posterior/Anterior Tilt, deg
Drive Phase, %
Pelvic Angle
–10
0 10 20 30 40 50 60 70 80 90 100
–5
0
5
10
15
20
25
30
Extension/Flexion, deg
Drive Phase, %
Lower Lumbar Angle
–40
0 10 20 30 40 50 60 70 80 90 100
–30
–20
–10
0
10
20
30
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).
DISCUSSION
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
stiness.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
TABLE
Outcome Measures and
Kinematics Data at Preintervention,
Postintervention, and Follow-up
Abbreviations: PSFS, Patient-Specific Functional Scale; RMDQ, Roland-Morris Disability
Questionnaire.
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 …
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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 dierent genders and levels
of participation.
CONCLUSION
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 FUNCTIONAL THERAPY FOR SINGLE CASE ROWER
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
rowing.
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
posture.
• The rower followed these instructions dili-
gently, despite an increase in pain levels,
reduced rowing ability, and an increase in
disability.
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
pain.
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).
APPENDIX
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case report
]
Clinical Findings Cognitive Functional Therapy
Body awareness and specific movement
training:
• 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
dissociation).
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.
APPENDIX
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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.
APPENDIX
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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
muscles.
Catch position. Promote thoracic flexion at catch.
Middrive. Relaxed paraspinal and abdominal
muscles.
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
APPENDIX
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.
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