Clinical management of acute low back pain in elite and subelite rowers: a Delphi study of experienced and expert clinicians.

OBJECTIVES: Rowing-related low back pain (LBP) is common but published management research is lacking. This study aims to establish assessment and management behaviours and beliefs of experienced and expert clinicians when elite and subelite rowers present with an acute episode of LBP; second, to investigate how management differs for developing and masters rowers. This original research is intended to be used to develop rowing-related LBP management guidelines. METHODS: A three-round Delphi survey was used. Experienced clinicians participated in an internet-based survey (round 1), answering open-ended questions about assessment and management of rowing-related LBP. Statements were generated from the survey for expert clinicians to rate (round 2) and rerate (round 3). Consensus was gained when agreement reached a mean of 7 out of 10 and disagreement was 2 SD or less. RESULTS: Thirty-one experienced clinicians participated in round 1. Thirteen of 20 invited expert clinicians responded to round 2 (response rate 65%) and 12 of the 13 participated in round 3 (response rate 92%).One hundred and fifty-three of 215 statements (71%) relating to the management of LBP in elite and subelite rowers acquired consensus status. Four of six statements (67%) concerning developing rowers and two of four (50%) concerning masters rowers gained consensus. CONCLUSION: In the absence of established evidence, these consensus-derived statements are imperative to inform the development of guidelines for the assessment and management of rowing-related LBP. Findings broadly reflect adult LBP guidelines with specific differences. Future research is needed to strengthen specific recommendations and develop best practice guidelines in this athletic population.

Treating low back pain in athletes: a systematic review with meta-analysis.

OBJECTIVE: To summarise the evidence for non-pharmacological management of low back pain (LBP) in athletes, a common problem in sport that can negatively impact performance and contribute to early retirement. DATA SOURCES: Five databases (EMBASE, Medline, CINAHL, Web of Science, Scopus) were searched from inception to September 2020. The main outcomes of interest were pain, disability and return to sport (RTS). RESULTS: Among 1629 references, 14 randomised controlled trials (RCTs) involving 541 athletes were included. The trials had biases across multiple domains including performance, attrition and reporting. Treatments included exercise, biomechanical modifications and manual therapy. There were no trials evaluating the efficacy of surgery or injections. Exercise was the most frequently investigated treatment; no RTS data were reported for any exercise intervention. There was a reduction in pain and disability reported after all treatments. CONCLUSIONS: While several treatments for LBP in athletes improved pain and function, it was unclear what the most effective treatments were, and for whom. Exercise approaches generally reduced pain and improved function in athletes with LBP, but the effect on RTS is unknown. No conclusions regarding the value of manual therapy (massage, spinal manipulation) or biomechanical modifications alone could be drawn because of insufficient evidence. High-quality RCTs are urgently needed to determine the effect of commonly used interventions in treating LBP in athletes.

2021 consensus statement for preventing and managing low back pain in elite and subelite adult rowers.

PURPOSE: To synthesise evidence on low back pain (LBP) in adult rowers and to create a consensus statement to inform clinical practice. METHODS: There were four synthesis steps that informed the consensus statement. In step one, seven expert clinicians and researchers established the scope of the consensus statement and conducted a survey of experienced and expert clinicians to explore current practice. In step two, working groups examined current evidence relating to key scope questions and summarised key issues. In step three, we synthesised evidence for each group and used a modified Delphi process to aid in the creation of the overall consensus statements. Finally, in step four, we combined information from step three with the findings of the clinician survey (and with athlete and coach input) to produce recommendations for clinical practice. RESULTS: The scope of the consensus statement included epidemiology; biomechanics; management; the athlete's voice and clinical expertise. Prevention and management of LBP in rowers should include education on risk factors, rowing biomechanics and training load. If treatment is needed, non-invasive management, including early unloading from aggravating activities, effective pain control and exercise therapy should be considered. Fitness should be maintained with load management and progression to full training and competition. The role of surgery is unclear. Management should be athlete focused and a culture of openness within the team encouraged. CONCLUSION: Recommendations are based on current evidence and consensus and aligned with international LBP guidelines in non-athletic populations, but with advice aimed specifically at rowers. We recommend that research in relation to all aspects of prevention and management of LBP in rowers be intensified.

Prevalence and risk factors for back pain in sports: a systematic review with meta-analysis.

OBJECTIVES: We aimed to determine the prevalence of low back pain (LBP) in sport, and what risk factors were associated with LBP in athletes. DESIGN: Systematic review with meta-analysis. DATA SOURCES: Literature searches from database inception to June 2019 in Medline, Embase, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Web of Science and Scopus, supplemented by grey literature searching. ELIGIBILITY CRITERIA: Studies evaluating prevalence of LBP in adult athletes across all sports. RESULTS: Eighty-six studies were included (30 732, range 20-5958, participants), of which 45 were of 'high' quality. Definitions of LBP varied widely, and in 17 studies, no definition was provided. High-quality studies were pooled and the mean point prevalence across six studies was 42%; range 18%-80% (95% CI 27% to 58%, I2=97%). Lifetime prevalence across 13 studies was 63%; range 36%-88% (95% CI 51% to 74%, I2=99%). Twelve-month LBP prevalence from 22 studies was 51%; range 12%-94% (95% CI 41% to 61%, I2=98%). Comparison across sports was limited by participant numbers, study quality and methodologies, and varying LBP definitions. Risk factors for LBP included history of a previous episode with a pooled OR of 3.5; range 1.6-4.0 (95% CI 1.9 to 6.4). Statistically significant associations were reported for high training volume, periods of load increase and years of exposure to the sport. CONCLUSION: LBP in sport is common but estimates vary. Current evidence is insufficient to identify which sports are at highest risk. A previous episode of LBP, high training volume, periods of load increase and years of exposure are common risk factors.

Self-reported reproductive health of athletic and recreationally active males in Ireland: potential health effects interfering with performance.

Introduction: The syndrome of Relative Energy Deficiency in Sport (RED-S) consensus statements recognise that male athletes might have impaired fertility in terms of the Exercise Hypogonodal Male Condition (ExHMC). Thus, the aims of this study were to (1) identify risk of ExHMC in active males in various sports and (2) determine if associations between risk of ExHMC and health problems interfering with training and competition exist. Methods: A questionnaire was distributed online (November 2018-January 2019) using questions derived from the "Androgen Deficiency in the Aging Male Questionnaire" (ADAM-Q) to assess risk of ExHMC. Additional questions were included to collect information on participant demographics, injury and illness history and dietary habits. Logistic regression analyses explored differences between groups. Results: Risk of ExHMC was identified in 23.3% (n = 185) of 794 questionnaire participants. Following multivariate analyses, risk of ExHMC was independently associated with a lower than normal sex drive rating within the last month (OR 7.62, 95%CI 4.99-11.63) and less than three morning erections per week within the last month (OR: 4.67, 95%CI 3.23-6.76). Risk of ExHMC was associated with 15-21 days absence from training or competition during the previous 6 months due to overload injuries in the univariate analysis (OR = 2.69, 95% CI = 1.24-5.84). Conclusion: Risk of ExHMC and associated symptoms in this heterogeneous sample may be indicative of RED-S. Confounding factors such as over-training, medication use, fatigue and psychological stress need to be considered. Identification of male athletes exhibiting physiological symptoms associated with RED-S requires more research.

Rowers with a recent history of low back pain engage different regions of the lumbar erector spinae during rowing.

OBJECTIVES: Despite the high prevalence of low back pain (LBP) in rowers, there are few studies investigating changes in lumbar muscle activation in rowers with a recent history of LBP. Such knowledge is relevant to understand potential mechanisms contributing to the maintenance and recurrence of LBP in rowers. For the first time, we evaluate the spatial distribution of erector spinae (ES) activity in rowers with and without a recent history of LBP, using a novel application of high-density surface electromyography (HDEMG). DESIGN: Cross-sectional study. METHODS: Asymptomatic rowers (N=10) and rowers with a recent history of LBP (N=8) performed 7×4-min exercise bouts (rowing ergometer) until volitional exhaustion. HDEMG signals were acquired bilaterally over the lumbar ES and the root mean square (RMS) amplitude and entropy were analyzed. In addition, the y-axis coordinate of the barycentre (RMS-map) was used to assess changes in ES spatial activation. RESULTS: As the load increased, rowers with LBP showed higher amplitude (p<0.01) and less complexity (entropy) of the HDEMG signals (p<0.001). In addition, rowers with LBP showed opposite displacements of the barycentre, specifically showing a caudal shift of muscle activity at high intensities (p<0.001). CONCLUSIONS: Both the magnitude of activation and distribution of ES activity were altered in rowers with a recent history of LBP. The lower complexity of signals together with the caudal displacements of the barycentre suggest an inefficient recruitment of the ES as the load progressed. Modification of the rowing technique in conjunction with feedback from HDEMG might prove useful in future studies.

Screening for risk of low energy availability in athletic and recreationally active females in Ireland.

INTRODUCTION: Low energy availability (LEA) results in physiological adaptations, which can contribute to unfavourable health outcomes. Little information exists on risk of LEA in active individuals competing in different sports or levels of competition. The aims of this study were to (1) identify risk of LEA in females competing at different levels of competition and (2) investigate associations between risk of LEA, illness and dietary habits. METHODS: The validated questionnaire, 'Low Energy Availability in Females Questionnaire' was distributed online (November 2016-February 2017) to assess risk of LEA. Twenty-nine additional questions collected information on demographics, illness history and dietary habits. Participants were considered at risk of LEA if they attained a score of ≥ 8 and were grouped into: (i) international; (ii) provincial/inter-county; (iii) competitive; and (iv) recreationally active. Chi-square and logistic regression analyses were used to explore differences between those at risk or not at risk of LEA. RESULTS: Risk of LEA was identified in 40% (n = 331) of 833 participants and was 1.7 and 1.8 times more likely in international and provincial/inter-county athletes compared to those who were recreationally active (International: odds ratios (OR) 1.68, 95% confidence intervals (95%CI) 1.12-2.54; Provincial/inter-county: OR 1.83, 95%CI 1.20-2.77). In participants at risk of LEA, missing >22 days of training during the previous year due to illness occurred 3 times more frequently (OR 3.01, 95%CI 1.81-5.02). CONCLUSION: Risk of LEA was widespread in this heterogeneous sample. Awareness of LEA and the development of appropriate energy management strategies to ensure athlete health across levels of competition are required.