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Journal of Back and Musculoskeletal Rehabilitation 28 (2015) 365–376 DOI 10.3233/BMR-140529 IOS Press
Low back pain among Italian rowers: A cross-sectional survey F. Masellia,∗ , A. Ciuroa , R. Mastrosimonea, M. Cannoneb, P. Nicolic , A. Signorid and M. Testaa a
Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genova, Campus of Savona, Italy b “Fondazione Padre Pio” Rehabilitation Centre, Foggia, Italy c Nursing Home “Domus Salutis”, Brescia, Italy d Department of Health Sciences, Section of Biostatistics, University of Genova, Italy
Abstract. BACKGROUND: Low Back Pain is commonly reported to be a very frequent disorder in rowing, but it is still unclear if its prevalence is higher than in other sports or even in a non-athletes group. OBJECTIVES: To determine prevalence of low back pain (LBP) with and without irradiated pain and possibly related risk factors in a group of elite Italian rowers. METHODS: The study was conducted during the 2010 Italian Indoor Rowing Championship held in Bari from 30th to 31st January. All the 415 rowers who qualified for the national championship were asked to complete a three-page questionnaire on LBP, assisted by a physiotherapist. RESULTS: One hundred and thirty-three athletes (32%) completed the assessment. LBP was very common, with a lifetime and 1 year prevalence of 64.7% and 40.6% respectively. During the last episode, the LBP intensity, measured by a numeric rating scale (NRS), presented a median value of 6/10, and 40% of rowers reported some limitation in daily living activities (ADL). Odds ratio (OR) to suffer from LBP was 2.62 in males compared to females; athletes who row both in sculling and sweep or only sweep showed an OR of 4.43 and 3.32 respectively. CONCLUSIONS: The prevalence of low back pain among rowers seems to be comparable to the one of the general population, even if the recovery appears to be faster. The risk of developing LBP is associated with the rowing typology and the gender, but a prospective study with an adequate sample size is necessary to clearly identify risk factors for LBP in rowers and to implement effective prevention strategies. Keywords: Low back pain, rowing, prevalence, athletes
1. Introduction Low Back Pain is commonly reported to be a very frequent disorder in rowing, but it is still unclear if its prevalence is higher than in other sports or even in a non-athletes group [13]. Stallard first published a study on LBP in 29 rowers [24] pointing out that low back pain episodes in rowers are primarily of mechanical ∗ Corresponding author: Filippo Maselli, Lecturer Master of Rehabilitation of Muscoloskeletal Disorder, University of Genova, Campus of Savona, Italy. E-mail: [email protected].
origin (change of rowing technique, intensity in training load). According to literature, rowing presents a high risk of LBP, in relation to multiple causes such as the characteristics of technical gesture, the morphology of the athlete and also the type of training and the materials used [4,11,13,23,25]. In a recent retrospective study performed at the Australian Institute of Sports, Hickey et al. [11] analysed injuries over a 10-year period and found that Low Back Pain (LBP) accounts for 25% and 15.2% of the total injuries among elite male and female rowers, respectively [11]. Some authors have suggested that the high frequency of injuries in rowing could be due to the high
c 2015 – IOS Press and the authors. All rights reserved ISSN 1053-8127/15/$35.00
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impact compressive forces acting on the spine [6,17]. These, combined with the repetitive nature of the technical gesture, may create an excessive degree of mobility as a result of changes in spinal viscoelastic tissues [7,20], and favour back injuries [22]. Other authors in functional and electrophysiological study assert that the increase in lumbar flexion can lead to fatigue of back muscles, increasing the risk of spine accidents [10]. Nevertheless, the relationship between the muscle strength of the trunk and the presence or incidence of Low Back Pain remains a controversial hypothesis. McGregor et al. [18] assessed the strength of the trunk in 22 elite rowers and the incidence of Low Back Pain, and they evaluated the presence of asymmetries in terms of cross-sectional area in the considered muscle groups. No asymmetries in size were related to the presence of low back pain, neither to the side used to row. Beside the spinal factors, some external factors, such as sport skills, design and materials of rigs, rowing workouts in the weight room and the use of rowing simulators, were also considered as risk factors for the presence or incidence of LBP [3,26,29]. Many authors hypothesized an increased risk for LBP after excessive use of indoor rowing, especially after the use of a row ergometer (rowing machine) [3, 29], being common for rowers to train for more than 90 consecutive minutes with these simulators [3]. It has been speculated that another risk factor could be the moment of the day, especially the morning, in which the race or workout [22] is attempted [1]. Being studies on Italian rowers population absent, we decided to analyze, by means of a questionnaire, the prevalence of low back pain with and without irradiated pain in a group of elite Italian rowers in order to identify any statistically significant association between some aspects of rowing and LBP. The analysis took place during the 10th edition of the Italian Indoor Rowing Championship.
2. Materials and methods 2.1. Study design, setting and participants The study was designed as a cross-sectional survey among athletes competing at the national elite level rowing discipline and it was conducted during the 2010 Italian Indoor Rowing Championship held in Bari from 30th to 31st January. All the athletes qualified for the national championship were asked to complete a threepage questionnaire on LBP (Appendix 1). The ex-
clusion criteria were essentially based on the possible presence of specific spinal diseases; the “adaptive” class (athletes with a physical disability) was also excluded as not object of the survey. Both coaches and athletes were informed about the survey through the official event website and the related social network pages, such as the Facebook event page. Furthermore, the components of the research group were present during the opening ceremony of the competition to encourage the athletes to take part in the survey. A letter and a consent form, describing purposes and procedures of the study, were distributed to the athletes. Each was invited to fill in the questionnaire with the assistance of a trained physiotherapist in order to avoid any misunderstanding, errors or missing data. 2.2. Questionnaire The questionnaire was based on the standardized Nordic questionnaires that have been developed and validated in order to study the prevalence of occupational musculoskeletal symptoms [2]. The LBP prevalence was defined according to the recommendations for standardized definitions of low back pain in prevalence studies [9]. The questionnaire was designed according to the following criteria: 1) the time frame of prevalence of LBP (in life, the last year, the last 6 months, the last month), 2) the site of low back pain, 3) the observed symptoms, 4) the duration of symptoms, 5) the frequency of symptoms, 6) the severity of low back pain, 7) secondary disabilities and/or limitation in participation (limitation of daily living activities (ADL), absence from work and suspension from training), 8) consultation with Health Care Professionals (physician, physical therapist, chiropractor, etc.). A two-sided anatomical drawing was included in the form to identify the back pain localization. Moreover, additional questions were asked in order to evaluate: 1) the correlation between LBP and sporting activities during the racing season and during the training period, 2) the correlation with the typology of rowing used. The form included also questions about age, gender, height, weight, career duration (number of years of competition in the relevant sport), weekly training volume (hours) and presence of known musculoskeletal disorders (scoliosis, kyphosis, vertebral-hip-tibial tuberosity osteochondrosis, valgus/varus knees).
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Table 1 Characteristics of athletes Characteristics
Age Gender Female Male Body Mass Index Years of experience 5 (3–9) Weekly hours Musculoskeletal disorders Typology of row Only sculling Sculling/Sweep Sweep Change of typology of row Category Cadet Junior Master Youngsters Senior Other Other sports No Yes
Mean (SD)/Median (25th–75th percentile) or N(%) 19 (16–33) 26 (20) 107 (80) 24.1 (2.3) 14 (6–20) 41 (30.8) 59 (44.4) 50 (37.6) 24 (18) 65 (48.9) 7 (5.3) 23 (17.3) 28 (21) 25 (18.8) 46 (34.6) 4 (3) 86 (65) 47 (35)
2.3. Questionnaire pre-testing and training of the research group In order to verify the presence of ambiguous or unclear questions, the questionnaire was preliminarily tested in a group of volunteers. Furthermore, the authors have trained seven physical therapists for the proper administration of the questionnaire. 2.4. Statistical analysis Continuous variables were tested for their skewness and only the Body Mass Index resulted symmetrical. The mean and standard deviation (SD) was used, while median and 25th–75th percentile were used for other continuous variables. Count and percentages were reported for categorical factors. The univariate impact of baseline characteristics of rowers on low back pain was assessed by means of a univariate logistic model. A multivariate logistic model with a stepwise selection procedure was used to adjust for baseline covariates which showed a p-value < 0.10 at univariate analysis. Odds ratio (OR) and 95% CI were estimated with respect to the reference category for each covariate. A p-value of 0.05 was considered statistically significant. All statistical analyses were carried out with SPSS v18.
Fig. 1. Prevalence of low back pain.
3. Results Four hundred and fifteen athletes were identified as participants in the championship; of those, a total of 133 (32%) completed the questionnaire. The characteristics of the athletes are reported in Table 1. The median age of the athletes who completed the questionnaire was 19 years (range 16–33). The 50% of subjects have been practicing rowing for less than 5 years while the median weekly hours of training was 14 hours (range 6–20). The 35% of athletes practiced other sports in addition to rowing. The prevalence of low back pain is reported in Fig. 1. Eightysix athletes (64.7%) declared at least one episode of low back pain, while only 26 athletes (19.5%) suffered from LBP over the previous month. Figure 2 shows the number and the duration of events of LBP. During all life, a median number of 4 events was reported with a median duration of 3 days per episode. The median intensity of pain during the last event was 6 on 10 (measured by a Numeric Rating Scale – NRS) with 75% of athletes who declared intensity lower or equal to 7 on 10. The lower back was the most involved region in 65 athletes (75%). Table 2 shows disorders and remedies among patients with low back pain. Particularly, 42 athletes (48.8%) did not suffer physical disability during the last event of low back pain, while 26.8% of athletes were disabled in less than 50% of their activities. 31 athletes (36%) presented pain irradiated to the lower limb and, among them, 21 athletes (67.7%) referred pain radiation down to knee and 6 athletes (19.4%) down to ankle. Burning or tingling sensations were associated to pain irradiation in about
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Fig. 2. Number and length of episodes of LBP.
60% of subjects, while 38.7% of athletes with pain radiated to lower limb did not show any other associated symptoms. About 85% of subjects reported low back pain during training, mostly related to the “endurance 75%” (> 10.000 m) (49.3%) and the use of a rowing ergometer (40.7%). Among the athletes (64%) who sought care or treatment, 60% consulted a physical therapist, 18.2% an osteopath and 27.3% a medical doctor (16.4% an orthopaedic specialist). Several athletes recurred to more than one specialist. Regarding athletes who took drugs (54.7%), 30% took diclofenac and 19.2% took tiocolchicoside. Table 3 shows results of univariate logistic regression. Higher probability to be affected by low back pain was associated with the typology of rowing and the gender. Athletes who use both sculling and sweep (OR = 4.43; P < 0.001; 95% CI: 1.87–10.48) and athletes who use only sweep (OR = 3.32; P = 0.03; 95% CI: 1.16–9.55) had a higher probability to suffer low back pain, compared with athletes who use only sculling. Males had a higher probability to be affected by low back pain compared to females (OR = 2.62; P = 0.03; 95% CI: 1.09–6.27). A trend towards a higher probability to suffer low back pain, even if not fully significant, was demonstrated also for athletes with others musculoskeletal disorders (OR =
2.09; P = 0.08), for athletes who changed typology of rowing (OR = 1.94; P = 0.07) and for athletes who practiced additional sports (OR = 2.00; P = 0.08). After the stepwise analysis, the typology of rowing resulted as the only factor significantly associated to low back pain.
4. Discussion After our investigation LBP appears to be very common among Italian rowers, with a lifetime and 1-year prevalence of 64.7% and 40.6% respectively. As this was an indoor rowing competition, one could argue that the population may have been skewed towards those who engage in more ergometer training or in a higher volume of ergometer training than usual, in preparation for the National championships. Nowadays higher volume of ergometer training during winter is a usual training method for elite rowers, who mainly composed our population sample. Moreover, our results are comparable to the results of Bahr et al. [2] who found a lifetime and 1-year prevalence of 63.3% and 55.3% among 199 rowers after the administration of a questionnaire during the outdoor Norwegian Championships in 2000. While these lifetime
F. Maselli et al. / Low back pain among Italian rowers: A cross-sectional survey Table 2 Disorders for athletes with low back pain Disorders and remedies Pain Intensity (measured by NRS) Disability in ADL No All activity Less than 50% More than 50% Break of practice No Yes Length of break (days) Recourse to cures No Yes Drugs No Yes Suggested (friends) Self – medication Doctor Pain radiated at lower limb No Yes During training No Yes Training cycle most involved∗ Endurance 75% (>10.000 meters) Endurance 65% (2.000–10.000 m.) Chrono 110% (< 2.000 meters) All cycles Work most involved∗ Sculling Sweep Boat Rowing ergometer Weightlifting Report correlation with stress No Yes ∗ More
Median (25th–75th percentile) or N(%) 6 (5–7) 42 (48.8) 2 (2.3) 23 (26.8) 9 (10.4) 43 (50) 43 (50) 3 (2–7) 31 (36) 55 (64) 39 (45.3) 47 (54.7) 3 (6.4) 5 (10.6) 39 (83) 55 (64) 31 (36) 13 (15.1) 73 (84.9) 36 (49.3) 16 (21.9) 22 (30.1) 5 (6.8) 16 (18.6) 23 (26.7) 20 (23.3) 35 (40.7) 13 (15.1) 56 (65.1) 30 (34.9)
than one answer was possible.
and 1-year prevalence rates appear to be enclosed in the 11–84% and 22–65% rates found in general population [30], nevertheless, the data available on general population come from studies which adopted different definitions of LBP and investigated population samples of different age. For these reasons, these data should be compared with care. It is well known that the prevalence of LBP increases from childhood to adulthood [12], therefore, considering the median age of our sample (19 years), one might suppose that the prevalence of LBP in rowers is higher than the one in an age and gender comparable sample of general population. This remark is consistent with the results of Bahr et al. [2] who, in an age and gender control group comprising 157 non-athletes, found a lifetime and 1
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year prevalence of 51% and 47% respectively with a statistically significant difference (+12% in rowers – p < 0.018) of lifetime prevalence value. To clarify this matter, it would be appropriate, as recommended by Dionne et al. [9], that future studies use the same definitions of prevalence and compare the results of age matched samples of the general population. Following the recommendations from Dionne et al. [9], our questionnaire included questions about frequency, duration and intensity of LBP. The results showed that frequency/recurrence of LBP within our sample are quite high with an average of 4 episodes during life and 2 episodes during the last year. To the best of our knowledge, there is no other available data about the frequency of LBP in rowers and in general population, so our results may be considered useful data for future studies. The period of mandatory suspension from training associated to the LBP episode in Italian rowers was 3 days on average, while in general population, 80% of LBP patients reported 1 week sick leave [29]. We are aware that interruption of training is not strictly comparable to sick leave, but nonetheless our results could suggest that recovery among Italian rowers is faster than in general population, despite higher frequency/recurrence of their LBP episodes. It is a matter of fact that athletes conduct a more active lifestyle, compared to general population, and this positive behavior could explain the faster recovery that we assessed in our samples of rowers. In fact all guidelines on the management of LBP recommend to stay active because it improves the prognosis in terms of pain reduction and return to normal activities [16,21]. Analysing the LBP intensity during the last episode, which was measured by means of a NRS, we found that it was in median 6/10. Teitz et al. [29] reported a mean severity of back pain of “6.4 + 2.2” on a scale of 1 to 10. We widened the field of our research by investigating the presence of disability related to LBP and we found that about 40% of rowers with LBP reported disability in ADL during the last episode and 12.7% reported disability in over 50% of ADL. To our knowledge, there is no data about severity of disability in rowers or in general population. In our sample, 64% of rowers affected by LBP sought treatment (41,2% of the whole sample) recurring to one health professional at least. These data significantly differ from the ones related to general population ,where only 15–20% of LBP patients ask for a health professional intervention [19], and to the rowers’ population investigated by Bahr et al. [2], where only 24.1% of 199 Norwegian rowers received outpa-
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F. Maselli et al. / Low back pain among Italian rowers: A cross-sectional survey Table 3 Results of univariate logistic regression Low back pain
OR
P
Gender (Male vs Female) Age (1-year increment) Body mass index Years of experience (1-year increment) Weekly hours (1-hour increment) Musculoskeletal disorders (Yes vs No) Typology of rowing Only sculling (Reference category) Sculling/Sweep Sweep Change of typology of row (Yes vs No) Category Junior (Reference category) Cadet Youngsters Master Senior Other sports (Yes vs No)
2.62 0.99 0.98 1.05 1.01 2.09
0.03 0.96 0.84 0.08 0.63 0.08 0.001
tient medical assistance because of LBP. The greater propensity to ask for a health consultation may be a further explanation of the shorter duration of back pain in rowers than the general population. The 54.7% of the athletes with LBP assumed drugs; of them, 30% took diclofenac and 19.2% took tiocolchicoside. In 83% of cases, a medical doctor prescribed drugs. To the best of our knowledge there are no data on medication assumption among rowers with LBP but our findings are quite similar to the result of Ivanova et al who found that, in general population, 69.4% of LBP patients recurs to drugs assumption [14]. This behaviour seems to be conflicting with the recommendations of the international guidelines that suggest avoiding excessive use of NSAIDs and the use of paracetamol as first choice [16,21]. A better understanding of the impact of LBP in terms of missed training session and of the correlation between type of training and LBP can give important indication for prevention and training management. We found that 50% of rowers with LBP (32.3% of the sample) missed training activities for 3 days. Teitz et al. [29] reported that 37% of 515 former intercollegiate rowers missed 1 or more week of practice because of LBP, while Bahr et al. [2] reported 25.6 % of 199 rowers missed training at least for 1 day. As for the correlation between LBP and training, we found that 84.9% of rowers reporting LBP (55% of the sample) reported pain during training. The training period dedicated to the “endurance 75%” was the most concerned (49.3%), while rowing by ergometer was the most involved type of training (40.7%). Our results confirm the previous
1.00 4.43 3.32 1.94 1.00 0.18 0.66 0.92 0.85 2.00
0.07 0.42
0.08
95% CI for OR Lower Upper 1.09 6.27 0.97 1.03 0.84 1.15 0.99 1.12 0.97 1.06 0.91 4.76 – 1.87 1.16 0.94
– 10.48 9.55 4.01
– 0.03 0.20 0.28 0.29 0.91
– 1.13 2.17 3.04 2.50 4.39
findings published by Teitz et al. [28], which indicate a relationship between LBP and ergometer training (p < 0.001). The result of the univariate logistic regression showed that the risk of developing LBP is associated with rowing typology and gender. Males had an OR 2.62 compared to females, but the relatively low number of women who completed the questionnaire (only 20% of the sample) could bias these data. Considering the type of rowing, rowers who mainly row both in sculling and sweep or only sweep showed an OR of 4.43 and 3.32 respectively. Our data confirm findings of previous study that found an association between sweep rowing and LBP [5,27,31]. However, our results must be interpreted with caution because this is a cross-sectional study, not able to identify a cause-effect correlation between rowing and LBP but only to estimate an association between them. Moreover, the large IC of OR values indicate that larger samples are necessary in order to obtain more accurate results. For these reasons a prospective study with an adequate sample size is necessary to clearly identify risk factors for LBP in rowers and to implement effective prevention strategies. Our questionnaire aimed also at investigating the prevalence of sciatica, defined as “Pain radiating down the leg below the knee in the distribution of the sciatic nerve” [8]. Results showed that 4.5% of Italian rowers reported pain radiating down to the ankle, with burning sensation or tingling. To the best of our knowledge, there is no data on the prevalence of sciatica among rowers, but these results are in line with the prevalence occurring in general population [15]. In any case, due
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to the very low number of rowers with sciatica (only six), is not possible to draw any conclusions from these data. An additional limitation in our study is the low rate of completed questionnaires (32%). This result is analogous to that achieved by Teitz et al. [29] (34.8%) but is very far from 99% registered by Bahr et al. [2] with self-administered questionnaires. The relatively low rate of completed questionnaires of our survey was due to two main factors: limited time available for athletes during the competition and the way we administered the questionnaire. In our survey athletes completed the questionnaire assisted by a research group member in order to avoid any misunderstanding, errors or missing data. If it is true that this time consuming strategy caused the low rate of completed questionnaires, on the other hand, it enabled us to obtain more accurate data.
5. Conclusion The value of prevalence of low back pain in rowers seems to be at least comparable to the one in general population but the recovery seems to be faster in rowers. We found that LBP has a significant impact in terms of disability and missed training among Italian rowers. Additionally, Italian rowers showed a greater propensity to consult a health professional. Gender (male), training cycle (“endurance 75%”), type of training (ergometer) and rowing typology (sweep) showed to be significantly associated to LBP. In order to demonstrate a cause-effect correlation, identifying them as actual risk factors and consequently implementing effective prevention strategies in rowers, a prospective study with an adequate sample size is advisable.
Conflict of interest None.
Patient consent Obtained.
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The authors thank Clarissa Bruno Pt, Buongiorno Nicola Pt, Lorenzo Laviola Pt, Alessandro Lipari Pt, Maria Grazia Massaro Pt, Maria Pina Matera Pt, Antonella Papapietro Pt, the FIC (Federazione Italiana Canottaggio) for their involvement to collect the data of this project and Alessandro Ciuro, Andrew Code, Vanessa Lista (British Consulate, Naples) for language assistance.
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Appendix
SURVEY ROWING PART A – PERSONAL INFO 1. NAME
2.PROVINCE
SURNAME
REGION
3..BIRTHDAY
WEIGHT
HEIGHT
4.OCCUPATION
6. How many hours a week do you train?
5.For how many years do you pracce rowing at compeve level 7.What kind of row do you use?
sculling sweep: even odd
8.Did you change your rowing style? If yes how?
yes no from sculling to sweep from sweep to sculling from odd to even from even to odd
9.If yes, for how long?
______________________________________
10.Other sport pracced 11.Known musculoskeletal desease: Scoliosis Kyphosis Osteochondrosis (spinal - hip - bial tuberosity) tuberosity)teocondrosi (vertebrale – anca biale) - tuberosità Knees (Vare - valgus) Feet (flat – cave)
12.Which of these compeve category you belong to:
Lower limb dismetria
Other__________________________________
Youngster Senior Master
Cadet
Junior
Other________________
PART B – MUSCULOSKELETAL DESEASE: LOW BACK PAIN 13.
Did you ever have episodes of low back pain? yes no If you answered YES, marks on the body chart the area or areas concerned and answer the following quesons:
N° episodes Duraon in days
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14.
In the last year did you have episodes of low back pain?
YES NO If you answered YES, marks on the body chart the area or areas concerned and answer the following quesons:
N° episodes Duraon in days
15.
The past six months did you have episodes of low back pain?
yes no If you answered YES, marks on the body chart the area or areas concerned and answer the following quesons:
N° episodes Duration in days
16. During the last month did you have episodes of low back pain? YES NO
If you answered YES, marks on the body chart the area or areas concerned and answer the following quesons:
N° episodes Duraon in days
17.
Were you limited in daily acvies by symptoms of the last episode? (dressing, washing, walking, driving ....)
Yes, always Yes, less than 50% Yes, more than 50% No
Did you stop training?
Yes No
If yes, for how long?
F. Maselli et al. / Low back pain among Italian rowers: A cross-sectional survey
18.
Did you ever seek for any kind of health praconer cure/ advice (physician, physical therapist or other) If yes please specify which figure
Yes
No
19.
Did you ever use drugs to reduce the symptoms?
Yes
No
If yes please specify wich drug Specify who prescribed you drugs
20.
Medical prescripon
Friends/Family advices
Self medicaon
Yes
If yes specify level of irradiaon?
Knee
Ankle
Did you ever have radiang pain to the lower limb?
21.
Specifies the presence of other discomforts in addion to pain at lower limb (eg ngling, burning,weakness, etc.)
22.
Which was your maximal pain intensity perceived in your last episode (Mark with a cross based on your experience)
1
2
3
4
5
6
7
8
9
10 Maximum pain
Minimum pain 23.
24.
No
Did you noce if the low back pain episodes coincide with periods of...
Training
Pre-compeon
Preparaon Compeon
If episodes of low back pain coincide with periods of intense training
With wich training cycle *the percentage is relave to the maximal exercise performed during a standard compeon that is 2000 meters which represent 100%
wich type of work? . . *>10000 meters **from 2000 meters to 10000 meters ***
Journal of Back and Musculoskeletal Rehabilitation 28 (2015) 365–376 DOI 10.3233/BMR-140529 IOS Press
Low back pain among Italian rowers: A cross-sectional survey F. Masellia,∗ , A. Ciuroa , R. Mastrosimonea, M. Cannoneb, P. Nicolic , A. Signorid and M. Testaa a
Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genova, Campus of Savona, Italy b “Fondazione Padre Pio” Rehabilitation Centre, Foggia, Italy c Nursing Home “Domus Salutis”, Brescia, Italy d Department of Health Sciences, Section of Biostatistics, University of Genova, Italy
Abstract. BACKGROUND: Low Back Pain is commonly reported to be a very frequent disorder in rowing, but it is still unclear if its prevalence is higher than in other sports or even in a non-athletes group. OBJECTIVES: To determine prevalence of low back pain (LBP) with and without irradiated pain and possibly related risk factors in a group of elite Italian rowers. METHODS: The study was conducted during the 2010 Italian Indoor Rowing Championship held in Bari from 30th to 31st January. All the 415 rowers who qualified for the national championship were asked to complete a three-page questionnaire on LBP, assisted by a physiotherapist. RESULTS: One hundred and thirty-three athletes (32%) completed the assessment. LBP was very common, with a lifetime and 1 year prevalence of 64.7% and 40.6% respectively. During the last episode, the LBP intensity, measured by a numeric rating scale (NRS), presented a median value of 6/10, and 40% of rowers reported some limitation in daily living activities (ADL). Odds ratio (OR) to suffer from LBP was 2.62 in males compared to females; athletes who row both in sculling and sweep or only sweep showed an OR of 4.43 and 3.32 respectively. CONCLUSIONS: The prevalence of low back pain among rowers seems to be comparable to the one of the general population, even if the recovery appears to be faster. The risk of developing LBP is associated with the rowing typology and the gender, but a prospective study with an adequate sample size is necessary to clearly identify risk factors for LBP in rowers and to implement effective prevention strategies. Keywords: Low back pain, rowing, prevalence, athletes
1. Introduction Low Back Pain is commonly reported to be a very frequent disorder in rowing, but it is still unclear if its prevalence is higher than in other sports or even in a non-athletes group [13]. Stallard first published a study on LBP in 29 rowers [24] pointing out that low back pain episodes in rowers are primarily of mechanical ∗ Corresponding author: Filippo Maselli, Lecturer Master of Rehabilitation of Muscoloskeletal Disorder, University of Genova, Campus of Savona, Italy. E-mail: [email protected].
origin (change of rowing technique, intensity in training load). According to literature, rowing presents a high risk of LBP, in relation to multiple causes such as the characteristics of technical gesture, the morphology of the athlete and also the type of training and the materials used [4,11,13,23,25]. In a recent retrospective study performed at the Australian Institute of Sports, Hickey et al. [11] analysed injuries over a 10-year period and found that Low Back Pain (LBP) accounts for 25% and 15.2% of the total injuries among elite male and female rowers, respectively [11]. Some authors have suggested that the high frequency of injuries in rowing could be due to the high
c 2015 – IOS Press and the authors. All rights reserved ISSN 1053-8127/15/$35.00
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impact compressive forces acting on the spine [6,17]. These, combined with the repetitive nature of the technical gesture, may create an excessive degree of mobility as a result of changes in spinal viscoelastic tissues [7,20], and favour back injuries [22]. Other authors in functional and electrophysiological study assert that the increase in lumbar flexion can lead to fatigue of back muscles, increasing the risk of spine accidents [10]. Nevertheless, the relationship between the muscle strength of the trunk and the presence or incidence of Low Back Pain remains a controversial hypothesis. McGregor et al. [18] assessed the strength of the trunk in 22 elite rowers and the incidence of Low Back Pain, and they evaluated the presence of asymmetries in terms of cross-sectional area in the considered muscle groups. No asymmetries in size were related to the presence of low back pain, neither to the side used to row. Beside the spinal factors, some external factors, such as sport skills, design and materials of rigs, rowing workouts in the weight room and the use of rowing simulators, were also considered as risk factors for the presence or incidence of LBP [3,26,29]. Many authors hypothesized an increased risk for LBP after excessive use of indoor rowing, especially after the use of a row ergometer (rowing machine) [3, 29], being common for rowers to train for more than 90 consecutive minutes with these simulators [3]. It has been speculated that another risk factor could be the moment of the day, especially the morning, in which the race or workout [22] is attempted [1]. Being studies on Italian rowers population absent, we decided to analyze, by means of a questionnaire, the prevalence of low back pain with and without irradiated pain in a group of elite Italian rowers in order to identify any statistically significant association between some aspects of rowing and LBP. The analysis took place during the 10th edition of the Italian Indoor Rowing Championship.
2. Materials and methods 2.1. Study design, setting and participants The study was designed as a cross-sectional survey among athletes competing at the national elite level rowing discipline and it was conducted during the 2010 Italian Indoor Rowing Championship held in Bari from 30th to 31st January. All the athletes qualified for the national championship were asked to complete a threepage questionnaire on LBP (Appendix 1). The ex-
clusion criteria were essentially based on the possible presence of specific spinal diseases; the “adaptive” class (athletes with a physical disability) was also excluded as not object of the survey. Both coaches and athletes were informed about the survey through the official event website and the related social network pages, such as the Facebook event page. Furthermore, the components of the research group were present during the opening ceremony of the competition to encourage the athletes to take part in the survey. A letter and a consent form, describing purposes and procedures of the study, were distributed to the athletes. Each was invited to fill in the questionnaire with the assistance of a trained physiotherapist in order to avoid any misunderstanding, errors or missing data. 2.2. Questionnaire The questionnaire was based on the standardized Nordic questionnaires that have been developed and validated in order to study the prevalence of occupational musculoskeletal symptoms [2]. The LBP prevalence was defined according to the recommendations for standardized definitions of low back pain in prevalence studies [9]. The questionnaire was designed according to the following criteria: 1) the time frame of prevalence of LBP (in life, the last year, the last 6 months, the last month), 2) the site of low back pain, 3) the observed symptoms, 4) the duration of symptoms, 5) the frequency of symptoms, 6) the severity of low back pain, 7) secondary disabilities and/or limitation in participation (limitation of daily living activities (ADL), absence from work and suspension from training), 8) consultation with Health Care Professionals (physician, physical therapist, chiropractor, etc.). A two-sided anatomical drawing was included in the form to identify the back pain localization. Moreover, additional questions were asked in order to evaluate: 1) the correlation between LBP and sporting activities during the racing season and during the training period, 2) the correlation with the typology of rowing used. The form included also questions about age, gender, height, weight, career duration (number of years of competition in the relevant sport), weekly training volume (hours) and presence of known musculoskeletal disorders (scoliosis, kyphosis, vertebral-hip-tibial tuberosity osteochondrosis, valgus/varus knees).
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Table 1 Characteristics of athletes Characteristics
Age Gender Female Male Body Mass Index Years of experience 5 (3–9) Weekly hours Musculoskeletal disorders Typology of row Only sculling Sculling/Sweep Sweep Change of typology of row Category Cadet Junior Master Youngsters Senior Other Other sports No Yes
Mean (SD)/Median (25th–75th percentile) or N(%) 19 (16–33) 26 (20) 107 (80) 24.1 (2.3) 14 (6–20) 41 (30.8) 59 (44.4) 50 (37.6) 24 (18) 65 (48.9) 7 (5.3) 23 (17.3) 28 (21) 25 (18.8) 46 (34.6) 4 (3) 86 (65) 47 (35)
2.3. Questionnaire pre-testing and training of the research group In order to verify the presence of ambiguous or unclear questions, the questionnaire was preliminarily tested in a group of volunteers. Furthermore, the authors have trained seven physical therapists for the proper administration of the questionnaire. 2.4. Statistical analysis Continuous variables were tested for their skewness and only the Body Mass Index resulted symmetrical. The mean and standard deviation (SD) was used, while median and 25th–75th percentile were used for other continuous variables. Count and percentages were reported for categorical factors. The univariate impact of baseline characteristics of rowers on low back pain was assessed by means of a univariate logistic model. A multivariate logistic model with a stepwise selection procedure was used to adjust for baseline covariates which showed a p-value < 0.10 at univariate analysis. Odds ratio (OR) and 95% CI were estimated with respect to the reference category for each covariate. A p-value of 0.05 was considered statistically significant. All statistical analyses were carried out with SPSS v18.
Fig. 1. Prevalence of low back pain.
3. Results Four hundred and fifteen athletes were identified as participants in the championship; of those, a total of 133 (32%) completed the questionnaire. The characteristics of the athletes are reported in Table 1. The median age of the athletes who completed the questionnaire was 19 years (range 16–33). The 50% of subjects have been practicing rowing for less than 5 years while the median weekly hours of training was 14 hours (range 6–20). The 35% of athletes practiced other sports in addition to rowing. The prevalence of low back pain is reported in Fig. 1. Eightysix athletes (64.7%) declared at least one episode of low back pain, while only 26 athletes (19.5%) suffered from LBP over the previous month. Figure 2 shows the number and the duration of events of LBP. During all life, a median number of 4 events was reported with a median duration of 3 days per episode. The median intensity of pain during the last event was 6 on 10 (measured by a Numeric Rating Scale – NRS) with 75% of athletes who declared intensity lower or equal to 7 on 10. The lower back was the most involved region in 65 athletes (75%). Table 2 shows disorders and remedies among patients with low back pain. Particularly, 42 athletes (48.8%) did not suffer physical disability during the last event of low back pain, while 26.8% of athletes were disabled in less than 50% of their activities. 31 athletes (36%) presented pain irradiated to the lower limb and, among them, 21 athletes (67.7%) referred pain radiation down to knee and 6 athletes (19.4%) down to ankle. Burning or tingling sensations were associated to pain irradiation in about
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Fig. 2. Number and length of episodes of LBP.
60% of subjects, while 38.7% of athletes with pain radiated to lower limb did not show any other associated symptoms. About 85% of subjects reported low back pain during training, mostly related to the “endurance 75%” (> 10.000 m) (49.3%) and the use of a rowing ergometer (40.7%). Among the athletes (64%) who sought care or treatment, 60% consulted a physical therapist, 18.2% an osteopath and 27.3% a medical doctor (16.4% an orthopaedic specialist). Several athletes recurred to more than one specialist. Regarding athletes who took drugs (54.7%), 30% took diclofenac and 19.2% took tiocolchicoside. Table 3 shows results of univariate logistic regression. Higher probability to be affected by low back pain was associated with the typology of rowing and the gender. Athletes who use both sculling and sweep (OR = 4.43; P < 0.001; 95% CI: 1.87–10.48) and athletes who use only sweep (OR = 3.32; P = 0.03; 95% CI: 1.16–9.55) had a higher probability to suffer low back pain, compared with athletes who use only sculling. Males had a higher probability to be affected by low back pain compared to females (OR = 2.62; P = 0.03; 95% CI: 1.09–6.27). A trend towards a higher probability to suffer low back pain, even if not fully significant, was demonstrated also for athletes with others musculoskeletal disorders (OR =
2.09; P = 0.08), for athletes who changed typology of rowing (OR = 1.94; P = 0.07) and for athletes who practiced additional sports (OR = 2.00; P = 0.08). After the stepwise analysis, the typology of rowing resulted as the only factor significantly associated to low back pain.
4. Discussion After our investigation LBP appears to be very common among Italian rowers, with a lifetime and 1-year prevalence of 64.7% and 40.6% respectively. As this was an indoor rowing competition, one could argue that the population may have been skewed towards those who engage in more ergometer training or in a higher volume of ergometer training than usual, in preparation for the National championships. Nowadays higher volume of ergometer training during winter is a usual training method for elite rowers, who mainly composed our population sample. Moreover, our results are comparable to the results of Bahr et al. [2] who found a lifetime and 1-year prevalence of 63.3% and 55.3% among 199 rowers after the administration of a questionnaire during the outdoor Norwegian Championships in 2000. While these lifetime
F. Maselli et al. / Low back pain among Italian rowers: A cross-sectional survey Table 2 Disorders for athletes with low back pain Disorders and remedies Pain Intensity (measured by NRS) Disability in ADL No All activity Less than 50% More than 50% Break of practice No Yes Length of break (days) Recourse to cures No Yes Drugs No Yes Suggested (friends) Self – medication Doctor Pain radiated at lower limb No Yes During training No Yes Training cycle most involved∗ Endurance 75% (>10.000 meters) Endurance 65% (2.000–10.000 m.) Chrono 110% (< 2.000 meters) All cycles Work most involved∗ Sculling Sweep Boat Rowing ergometer Weightlifting Report correlation with stress No Yes ∗ More
Median (25th–75th percentile) or N(%) 6 (5–7) 42 (48.8) 2 (2.3) 23 (26.8) 9 (10.4) 43 (50) 43 (50) 3 (2–7) 31 (36) 55 (64) 39 (45.3) 47 (54.7) 3 (6.4) 5 (10.6) 39 (83) 55 (64) 31 (36) 13 (15.1) 73 (84.9) 36 (49.3) 16 (21.9) 22 (30.1) 5 (6.8) 16 (18.6) 23 (26.7) 20 (23.3) 35 (40.7) 13 (15.1) 56 (65.1) 30 (34.9)
than one answer was possible.
and 1-year prevalence rates appear to be enclosed in the 11–84% and 22–65% rates found in general population [30], nevertheless, the data available on general population come from studies which adopted different definitions of LBP and investigated population samples of different age. For these reasons, these data should be compared with care. It is well known that the prevalence of LBP increases from childhood to adulthood [12], therefore, considering the median age of our sample (19 years), one might suppose that the prevalence of LBP in rowers is higher than the one in an age and gender comparable sample of general population. This remark is consistent with the results of Bahr et al. [2] who, in an age and gender control group comprising 157 non-athletes, found a lifetime and 1
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year prevalence of 51% and 47% respectively with a statistically significant difference (+12% in rowers – p < 0.018) of lifetime prevalence value. To clarify this matter, it would be appropriate, as recommended by Dionne et al. [9], that future studies use the same definitions of prevalence and compare the results of age matched samples of the general population. Following the recommendations from Dionne et al. [9], our questionnaire included questions about frequency, duration and intensity of LBP. The results showed that frequency/recurrence of LBP within our sample are quite high with an average of 4 episodes during life and 2 episodes during the last year. To the best of our knowledge, there is no other available data about the frequency of LBP in rowers and in general population, so our results may be considered useful data for future studies. The period of mandatory suspension from training associated to the LBP episode in Italian rowers was 3 days on average, while in general population, 80% of LBP patients reported 1 week sick leave [29]. We are aware that interruption of training is not strictly comparable to sick leave, but nonetheless our results could suggest that recovery among Italian rowers is faster than in general population, despite higher frequency/recurrence of their LBP episodes. It is a matter of fact that athletes conduct a more active lifestyle, compared to general population, and this positive behavior could explain the faster recovery that we assessed in our samples of rowers. In fact all guidelines on the management of LBP recommend to stay active because it improves the prognosis in terms of pain reduction and return to normal activities [16,21]. Analysing the LBP intensity during the last episode, which was measured by means of a NRS, we found that it was in median 6/10. Teitz et al. [29] reported a mean severity of back pain of “6.4 + 2.2” on a scale of 1 to 10. We widened the field of our research by investigating the presence of disability related to LBP and we found that about 40% of rowers with LBP reported disability in ADL during the last episode and 12.7% reported disability in over 50% of ADL. To our knowledge, there is no data about severity of disability in rowers or in general population. In our sample, 64% of rowers affected by LBP sought treatment (41,2% of the whole sample) recurring to one health professional at least. These data significantly differ from the ones related to general population ,where only 15–20% of LBP patients ask for a health professional intervention [19], and to the rowers’ population investigated by Bahr et al. [2], where only 24.1% of 199 Norwegian rowers received outpa-
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F. Maselli et al. / Low back pain among Italian rowers: A cross-sectional survey Table 3 Results of univariate logistic regression Low back pain
OR
P
Gender (Male vs Female) Age (1-year increment) Body mass index Years of experience (1-year increment) Weekly hours (1-hour increment) Musculoskeletal disorders (Yes vs No) Typology of rowing Only sculling (Reference category) Sculling/Sweep Sweep Change of typology of row (Yes vs No) Category Junior (Reference category) Cadet Youngsters Master Senior Other sports (Yes vs No)
2.62 0.99 0.98 1.05 1.01 2.09
0.03 0.96 0.84 0.08 0.63 0.08 0.001
tient medical assistance because of LBP. The greater propensity to ask for a health consultation may be a further explanation of the shorter duration of back pain in rowers than the general population. The 54.7% of the athletes with LBP assumed drugs; of them, 30% took diclofenac and 19.2% took tiocolchicoside. In 83% of cases, a medical doctor prescribed drugs. To the best of our knowledge there are no data on medication assumption among rowers with LBP but our findings are quite similar to the result of Ivanova et al who found that, in general population, 69.4% of LBP patients recurs to drugs assumption [14]. This behaviour seems to be conflicting with the recommendations of the international guidelines that suggest avoiding excessive use of NSAIDs and the use of paracetamol as first choice [16,21]. A better understanding of the impact of LBP in terms of missed training session and of the correlation between type of training and LBP can give important indication for prevention and training management. We found that 50% of rowers with LBP (32.3% of the sample) missed training activities for 3 days. Teitz et al. [29] reported that 37% of 515 former intercollegiate rowers missed 1 or more week of practice because of LBP, while Bahr et al. [2] reported 25.6 % of 199 rowers missed training at least for 1 day. As for the correlation between LBP and training, we found that 84.9% of rowers reporting LBP (55% of the sample) reported pain during training. The training period dedicated to the “endurance 75%” was the most concerned (49.3%), while rowing by ergometer was the most involved type of training (40.7%). Our results confirm the previous
1.00 4.43 3.32 1.94 1.00 0.18 0.66 0.92 0.85 2.00
0.07 0.42
0.08
95% CI for OR Lower Upper 1.09 6.27 0.97 1.03 0.84 1.15 0.99 1.12 0.97 1.06 0.91 4.76 – 1.87 1.16 0.94
– 10.48 9.55 4.01
– 0.03 0.20 0.28 0.29 0.91
– 1.13 2.17 3.04 2.50 4.39
findings published by Teitz et al. [28], which indicate a relationship between LBP and ergometer training (p < 0.001). The result of the univariate logistic regression showed that the risk of developing LBP is associated with rowing typology and gender. Males had an OR 2.62 compared to females, but the relatively low number of women who completed the questionnaire (only 20% of the sample) could bias these data. Considering the type of rowing, rowers who mainly row both in sculling and sweep or only sweep showed an OR of 4.43 and 3.32 respectively. Our data confirm findings of previous study that found an association between sweep rowing and LBP [5,27,31]. However, our results must be interpreted with caution because this is a cross-sectional study, not able to identify a cause-effect correlation between rowing and LBP but only to estimate an association between them. Moreover, the large IC of OR values indicate that larger samples are necessary in order to obtain more accurate results. For these reasons a prospective study with an adequate sample size is necessary to clearly identify risk factors for LBP in rowers and to implement effective prevention strategies. Our questionnaire aimed also at investigating the prevalence of sciatica, defined as “Pain radiating down the leg below the knee in the distribution of the sciatic nerve” [8]. Results showed that 4.5% of Italian rowers reported pain radiating down to the ankle, with burning sensation or tingling. To the best of our knowledge, there is no data on the prevalence of sciatica among rowers, but these results are in line with the prevalence occurring in general population [15]. In any case, due
F. Maselli et al. / Low back pain among Italian rowers: A cross-sectional survey
to the very low number of rowers with sciatica (only six), is not possible to draw any conclusions from these data. An additional limitation in our study is the low rate of completed questionnaires (32%). This result is analogous to that achieved by Teitz et al. [29] (34.8%) but is very far from 99% registered by Bahr et al. [2] with self-administered questionnaires. The relatively low rate of completed questionnaires of our survey was due to two main factors: limited time available for athletes during the competition and the way we administered the questionnaire. In our survey athletes completed the questionnaire assisted by a research group member in order to avoid any misunderstanding, errors or missing data. If it is true that this time consuming strategy caused the low rate of completed questionnaires, on the other hand, it enabled us to obtain more accurate data.
5. Conclusion The value of prevalence of low back pain in rowers seems to be at least comparable to the one in general population but the recovery seems to be faster in rowers. We found that LBP has a significant impact in terms of disability and missed training among Italian rowers. Additionally, Italian rowers showed a greater propensity to consult a health professional. Gender (male), training cycle (“endurance 75%”), type of training (ergometer) and rowing typology (sweep) showed to be significantly associated to LBP. In order to demonstrate a cause-effect correlation, identifying them as actual risk factors and consequently implementing effective prevention strategies in rowers, a prospective study with an adequate sample size is advisable.
Conflict of interest None.
Patient consent Obtained.
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The authors thank Clarissa Bruno Pt, Buongiorno Nicola Pt, Lorenzo Laviola Pt, Alessandro Lipari Pt, Maria Grazia Massaro Pt, Maria Pina Matera Pt, Antonella Papapietro Pt, the FIC (Federazione Italiana Canottaggio) for their involvement to collect the data of this project and Alessandro Ciuro, Andrew Code, Vanessa Lista (British Consulate, Naples) for language assistance.
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F. Maselli et al. / Low back pain among Italian rowers: A cross-sectional survey
Appendix
SURVEY ROWING PART A – PERSONAL INFO 1. NAME
2.PROVINCE
SURNAME
REGION
3..BIRTHDAY
WEIGHT
HEIGHT
4.OCCUPATION
6. How many hours a week do you train?
5.For how many years do you pracce rowing at compeve level 7.What kind of row do you use?
sculling sweep: even odd
8.Did you change your rowing style? If yes how?
yes no from sculling to sweep from sweep to sculling from odd to even from even to odd
9.If yes, for how long?
______________________________________
10.Other sport pracced 11.Known musculoskeletal desease: Scoliosis Kyphosis Osteochondrosis (spinal - hip - bial tuberosity) tuberosity)teocondrosi (vertebrale – anca biale) - tuberosità Knees (Vare - valgus) Feet (flat – cave)
12.Which of these compeve category you belong to:
Lower limb dismetria
Other__________________________________
Youngster Senior Master
Cadet
Junior
Other________________
PART B – MUSCULOSKELETAL DESEASE: LOW BACK PAIN 13.
Did you ever have episodes of low back pain? yes no If you answered YES, marks on the body chart the area or areas concerned and answer the following quesons:
N° episodes Duraon in days
373
374
F. Maselli et al. / Low back pain among Italian rowers: A cross-sectional survey
14.
In the last year did you have episodes of low back pain?
YES NO If you answered YES, marks on the body chart the area or areas concerned and answer the following quesons:
N° episodes Duraon in days
15.
The past six months did you have episodes of low back pain?
yes no If you answered YES, marks on the body chart the area or areas concerned and answer the following quesons:
N° episodes Duration in days
16. During the last month did you have episodes of low back pain? YES NO
If you answered YES, marks on the body chart the area or areas concerned and answer the following quesons:
N° episodes Duraon in days
17.
Were you limited in daily acvies by symptoms of the last episode? (dressing, washing, walking, driving ....)
Yes, always Yes, less than 50% Yes, more than 50% No
Did you stop training?
Yes No
If yes, for how long?
F. Maselli et al. / Low back pain among Italian rowers: A cross-sectional survey
18.
Did you ever seek for any kind of health praconer cure/ advice (physician, physical therapist or other) If yes please specify which figure
Yes
No
19.
Did you ever use drugs to reduce the symptoms?
Yes
No
If yes please specify wich drug Specify who prescribed you drugs
20.
Medical prescripon
Friends/Family advices
Self medicaon
Yes
If yes specify level of irradiaon?
Knee
Ankle
Did you ever have radiang pain to the lower limb?
21.
Specifies the presence of other discomforts in addion to pain at lower limb (eg ngling, burning,weakness, etc.)
22.
Which was your maximal pain intensity perceived in your last episode (Mark with a cross based on your experience)
1
2
3
4
5
6
7
8
9
10 Maximum pain
Minimum pain 23.
24.
No
Did you noce if the low back pain episodes coincide with periods of...
Training
Pre-compeon
Preparaon Compeon
If episodes of low back pain coincide with periods of intense training
With wich training cycle *the percentage is relave to the maximal exercise performed during a standard compeon that is 2000 meters which represent 100%
wich type of work? . . *>10000 meters **from 2000 meters to 10000 meters ***
