Cognitive Functional Therapy For The
Cognitive Functional Therapy For The
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
L
ow back pain (LBP) is a common complaint among Adolescent rowers also appear to be
rowers.4,18,39,47,50,58 Research has suggested that there is a higher at particular risk, with up to 47.5% of
schoolgirl rowers reporting back pain
prevalence of LBP in elite male rowers, with 25% of total injuries
and higher level of disability compared
reported in the low back, compared to 15.2% in female rowers.18 to 15.5% of age-matched controls,39 sug-
gesting that rowing-related factors are as-
sociated with pain and disability.
TTSTUDY DESIGN: Case report. of pain while ergometer rowing and reduced
Previous research has found that row-
TTBACKGROUND: Contemporary low back pain functional disability were observed preintervention
ers with LBP report a gradual increase
models propose that the experience of and re- to 12 weeks postintervention by changes in Roland-
Morris Disability Questionnaire score (12/24 to of pain during ergometer rowing. 32 It
sponses to pain result from a complex interaction
of biopsychosocial factors. This supports the need 1/24) and the Patient-Specific Functional Scale has also been reported that rowers with
for a management approach that addresses the (4/30 to 26/30), and associated improvements LBP maintain their lumbar spine posture
biological, psychological, and social components in lower-limb and back muscle endurance and closer to end-range flexion and use less
that may be related to the pain disorder. This changes in hip and spinopelvic kinematics during of their available range across the drive
case report demonstrates the application of, and ergometer rowing. In particular, there was a greater
phase when compared to rowers without
outcomes associated with, a cognitive functional use of available range of movement in the lumbar
intervention that considers neurophysiological, spine postintervention. pain.32 It is proposed that these motor
control patterns could be maladaptive
TTDISCUSSION: The cognitive functional interven-
physical, psychosocial, cognitive, and lifestyle
dimensions for the management of a rower with and pain provocative, resulting in sus-
tion for this patient resulted in reduced pain and
nonspecific chronic low back pain. tained flexion loading (ie, strain) to the
functional disability related to ergometer rowing,
TTCASE DESCRIPTION: An adolescent male which was associated with a change in lumbar lumbar spine, which may, in turn, lead to
club-level rower with nonspecific chronic low back kinematics and improved lower-limb and back pain.35 Patients with LBP have been re-
pain was classified as having a motor control muscle endurance. The results suggest that provid- ported to present with altered movement
impairment with a lower lumbar compressive- ing the rower with greater use of his available patterns and body schema, which raises
loading pattern in flexion. Evaluation of this patient range of movement may enhance load distribution
included ergometer rowing analysis (clinical and the possibility that retraining movement
during the drive phase of rowing. Registered at
laboratory) before and after an 8-week inter- patterns through interventions that ad-
Australian New Zealand Clinical Trials Registry
vention, and outcome measures at a 12-week dress both cognitive and functional do-
(ACTRN12609000565246).
follow-up. The intervention consisted of a cognitive mains may assist with managing chronic
functional approach that targeted optimization of TTLEVEL OF EVIDENCE: Therapy, level 4.
J Orthop Sports Phys Ther 2013;43(8):542-554.
spinal pain.24,29,34,56 However, to date, it
movement behavior, providing the rower with alter-
native movement strategies to minimize sustained Epub 11 June 2013. doi:10.2519/jospt.2013.4699 is not known whether targeted interven-
TTKEY WORDS: low back pain in sports, motor
flexion loading. tions are able to influence these patterns.
TTOUTCOMES: Reduced temporal summation control impairment, spinopelvic kinematics It has been proposed that accurate
diagnosis and classification of an LBP
1
School 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 affiliations 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: [email protected] t Copyright ©2013 Journal of
Orthopaedic & Sports Physical Therapy ®
542 | august 2013 | volume 43 | number 8 | journal of orthopaedic & sports physical therapy
disorder (based on neurophysiological, study was to investigate whether a CFT ment. There was no peripheralization
physical behavioral, psychosocial, and intervention could alter the spinal kine- of the symptoms, and the pain did not
lifestyle factors) are required to allow matics and reduce the LBP of a male ado- affect his sleep. The aggravating factors
targeted interventions directed at the lescent rower during ergometer rowing. included postures (sitting, sustained
mechanisms that underlie such a disor- bending) and activities (rowing ergom-
der.12-14,34-36,55 O’Sullivan34-36 proposed a CASE DESCRIPTION eter, stationary cycling, bending, lifting,
management approach for chronic LBP loaded exercises in the gym). Avoidance
A
based on a multidimensional classifica- sports physiotherapist, who of provocative activities and stretching
tion system called cognitive functional had a postgraduate qualification hamstring and back muscles helped to
therapy (CFT). The CFT approach in- and 5 years of experience with the ease the pain. When asked, the patient
volves addressing cognitive, functional, Australian rowing team, performed an believed that (1) he would get better with
and lifestyle aspects of the disorder. The interview and a clinical examination. an appropriate exercise program, and (2)
key components of the cognitive compo- The physiotherapist was blinded to the rowing was likely to aggravate his back
nent involve addressing negative beliefs laboratory data. pain. He reported that his pain dur-
and fear regarding pain and magnetic A 17-year-old male rower (height, ing rowing was aggravated by trying to
resonance imaging findings; patient- 1.85 m; weight, 86 kg) in his fourth year achieve a more upright posture (sitting
centered education regarding the mech- of amateur club rowing competition was tall throughout the stroke, especially at
anisms that drive their vicious cycle of recruited for this study. Written informed the catch) and eased by adopting a more
pain and disability; and raising aware- consent was obtained from the rower and rounded thoracic posture. Ironically, even
ness of the body-mind responses to pain, his parent, and permission to conduct the though he reported that the rounded tho-
movement, and their perceived threat. laboratory testing and treatment proto- racic posture alleviated his symptoms, he
The functional component is behavior- col was granted by the Curtin University believed that this posture was not good
ally orientated and involves retraining Human Research Ethics Committee (HR for his back due to the postural advice he
body schema (awareness) with the use of 197/2008). At the time of recruitment, had been given. The patient’s past medi-
visual feedback, normalizing provocative the rower reported a 4-month history of cal history was unremarkable. The ath-
movement patterns and pain behaviors in LBP that initially occurred only at the lete’s goals were to return to exercise and
a graduated manner directed toward the end of rowing sessions. This progressed crew rowing.
patient’s functional goals, and strength- to pain provoked by gym sessions, sit-
ening and conditioning of the normalized ting at school, and light home duties. A Clinical Examination and Findings
movement pattern.14,34 A study51 involving magnetic resonance imaging scan of the Clinical observation of the athlete’s usual
82 adolescent female rowers with and lumbar spine was organized by the local sitting posture revealed a thoracic up-
without LBP demonstrated that a CFT physiotherapist and showed no radiologi- right sitting posture (flexed lumbar spine
approach was associated with a reduc- cal abnormalities. A previous rehabilita- and extended thoracic spine).38 Analysis
tion in the prevalence of LBP across the tion program designed by the patient’s of his movement patterns allowed the
season (from 48% to 24%) and reduced physiotherapist, which included rest therapist to identify the athlete’s full
pain intensity levels in subjects who from rowing, stretches of the hamstring available spinal range of movement. Ob-
complained of LBP at the commence- muscles, “core stability strategies,” and servation of forward bending revealed
ment of the rowing season. LBP was also low back muscle strengthening, did not full range of movement with self-report-
reduced in a group of adolescent female have a positive effect. Within 3 months, ed pain throughout (VAS, 6/10). Through
rowers whose static and dynamic row- the patient reported that his LBP had palpation of the trunk muscles, the phys-
ing postures were targeted with a similar worsened, which prevented him from iotherapist was able to identify that both
cognitive functional intervention.41 How- participating in any form of rowing train- the abdominal and paraspinal muscles
ever, to date, no studies have confirmed ing. Prior to his first episode of LBP, he were actively tense (firm resistance to
whether this intervention may success- had previously trained between 17 and 18 palpation) during bending, suggesting
fully alter spinal kinematics during row- hours a week and had been competing in that the patient was cocontracting these
ing or result in changes in pain response regular rowing regattas. muscles during the movement. The rower
during rowing. Furthermore, given that During the clinical interview, the initiated forward bending through the
spinal kinematics differ between genders rower reported feeling a localized deep lumbar region with delayed anterior pel-
and that males appear to be more suscep- ache, with an intensity of 6/10 on the vic rotation, and initiated return to an
tible to LBP, previously successful inter- visual analog scale (VAS) at the lower upright position via the thoracic spine,
ventions should be evaluated in the male lumbar region. This pain became sharp/ propping his hands on his thighs. The
population.18,27,33 The aim of this case catching pain (VAS, 8/10) with move- rower demonstrated full range of back-
journal of orthopaedic & sports physical therapy | volume 43 | number 8 | august 2013 | 543
[ 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
FIGURE 1. Comparison between (A) the athlete’s usual movement strategy (upright/rigid posture with cocontracted
the paraspinal and abdominal muscles trunk muscles) and (B) the new movement strategy (relaxed thoracolumbar region and relaxed trunk muscles)
was again detected by palpation dur- during ergometer rowing.
ing the execution of these tasks. Specific
movement tests undertaken by the rower Neurological screening was unre- passed several dimensions:
and observed by the physiotherapist markable,17 with absence of adverse neu- 1. Neurophysiological: dominant noci-
revealed poor thoracolumbar and lum- rological (reflexes, sensation, and power) ceptive with peripheral sensitization,
bopelvic dissociation, especially when or neural provocation findings. Passive as the pain was localized, had a clear
sitting on the rowing ergometer, sug- physiological motion segment testing mechanical behavior, and was ame
gesting the athlete’s inability to move the was normal.25 Palpation of the lumbar nable to change.
thorax, the lumbar spine, and the pelvis spine was able to reproduce the athlete’s 2. Physical behaviors: the key feature
independently.9,37 pain through central palpation of the that led to this classification was
Clinical observation during ergom- L4-5 and L5-S1 segments.25 Palpation LBP associated with flexion-loading
eter rowing revealed that the rower also revealed the presence of pain over activities. The patient presented
maintained a stiff thoracolumbar the lumbar erector spinae and quadratus with full active range of motion but
spine throughout the rowing stroke. lumborum. utilized cocontraction of trunk mus-
It was also observed that he initiated cles during bending tasks. Modifica-
the drive phase with thoracic spinal Clinical Reasoning tion of the functional tasks via
extension, followed by early elbow Based on the interview, physical ex- reduced trunk muscle cocontraction
flexion and late lower-limb exten- amination findings, and the absence of resulted in pain reduction.
sion. Palpation of the trunk muscles specific pathology (as assessed by mag- 3. Psychosocial and cognitive: the pa-
during ergometer rowing revealed co- netic resonance imaging), this patient tient presented with avoidant coping
contraction of the abdominal muscles was diagnosed with nonspecific chronic strategies, such as stopping
(FIGURE 1). He reported a pain intensity LBP, consistent with repetitive loading training and rest, as reported in his
of 6/10 during ergometer rowing. Modi- and bending strain of the lower lumbar clinical interview, and a belief that
fication of these movement patterns, spine. The disorder was chronic (greater holding the spine upright and brac
involving relaxed thoracolumbar flexion than 3 months in duration) and progres- ing his abdominal wall was positive
throughout the stroke (utilizing a great- sive, according to the classification sys- for his back, a lack of awareness of
er proportion of his full available range tem as described by O’Sullivan.12,14,34-37 his body schema and the mechan-
of movement), early extension of the The disorder was classified as a primary isms associated with his LBP, and so
lower limb, and delayed flexion of the maladaptive motor control impair- cial isolation from sport and friends.
upper limb during drive phase, resulted ment with a compressive-loading pat- 4. Lifestyle: physical deconditioning as
in reduced self-reported pain during er- tern (flexion bias) at the lower lumbar sociated with activity avoidance.
gometer rowing (VAS, 2/10). 35 spine.11,35,36 The classification encom- FIGURE 2 displays the clinical reasoning
544 | august 2013 | volume 43 | number 8 | journal of orthopaedic & sports physical therapy
Numeric Pain Rating Scale The NPRS is
Chronic back pain disorders an 11-point scale (0-10) of self-reported
pain intensity, with a minimal clinically
Red flags: significant difference of 2.7 The NPRS
• Cancer was administered verbally for each
• Infection minute during a 15-minute ergometer
• Inflammatory conditions trial, at preintervention and 8 weeks
• Fractures postintervention.
Roland-Morris Disability Questionnaire
The RMDQ is a disability measure that is
Specific chronic LBP (pathology) Nonspecific chronic LBP 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
Nonmechanical pain Mechanical pain (nociceptive pain)
scores is considered to be a minimal clini-
cally important difference.45
Patient-Specific Functional Scale To
Pelvic girdle pain L4-5, L5-S1 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
Decreased Increased Control Movement chosen by the participant.49 This outcome
“force closure” “force closure” impairment impairment measure has a minimal clinically signifi-
cant difference of 3 for 1 activity and 2 for
the average of more than 1 activity.49 This
Compressive Directional
loading (flexion subgroups rower chose rowing, lifting weights, and
loading) forward bending as the 3 activities most
affected by his LBP.
The secondary outcomes for this study
Psychosocial and cognitive dimensions: included hip, pelvic, and trunk kinemat-
• Passive coping strategies ics, which were collected by the research-
• Avoidant coping strategies for pain management er, who was blinded to the intervention.
• Incorrect belief regarding his back posture
Furthermore, isometric muscle testing of
• Poor body schema
• Lack of awareness of the mechanisms associated with his back pain the erector spinae, the quadriceps, and
• Social isolation the hip flexors was collected by the sports
physiotherapist as part of the physical
Lifestyle dimension: examination.
• Physical deconditioning Hip, Pelvic, and Trunk Kinematics Ki-
nematics during a 15-minute ergometer
FIGURE 2. Flow chart describing the different levels of the multidimensional classification system. Highlighted row were collected at preintervention and
areas display the classification assigned for the patient in this case report. Flow chart adapted from O’Sullivan,34-37 postintervention data collection using the
Fersum et al,14,15 Dankaerts et al,10,12 3SPACE FASTRAK system (Polhemus,
Colchester, VT). This has been shown to
used in this case report in a schematic the numeric pain rating scale (NPRS), be a valid tool to collect kinematics dur-
manner. and disability measured by the Roland- ing ergometer rowing, with an error of
Morris Disability Questionnaire (RMDQ) 0.4° when used on a modified ergometer,
Outcome Measures and the Patient-Specific Functional Scale and has been used in other rowing-relat-
Outcome measure data were collected at (PSFS). The primary outcome measures ed studies.30,33,48 A detailed description of
preintervention, 8 weeks postinterven- were collected by a researcher who was this process is described in the Labora-
tion, and a 12-week follow-up. The pri- blinded to the intervention as part of tory Analysis section of this paper.
mary outcomes for this study were the a larger randomized controlled trial Back Muscle Endurance To determine the
rower’s self-reported pain measured by (ACTRN12609000565246). rower’s level of back muscle endurance,
journal of orthopaedic & sports physical therapy | volume 43 | number 8 | august 2013 | 545
[ case report ]
hamstring flexibility has been reported tilt, and negative angles represented
as one of the individual risk factors for trunk extension and posterior pelvic tilt.
LBP in rowers.41,42 Only drive-phase data were analyzed, and
were normalized to time from the begin-
Laboratory Analysis ning of the drive phase (catch) to the
Motion analysis testing was performed end of the drive phase (finish). The drive
on a modified rowing ergometer30 in the phase is defined as the period during
preintervention and postintervention which the rower moves from the maxi-
laboratory analysis using the 3SPACE mum forward reach to the maximum
FASTRAK system (Polhemus) at 25 Hz.48 backward lean during ergometer rowing.
Four electromagnetic sensors were se-
cured onto the participant’s skin over- Laboratory Testing Protocol
lying the midfemur and the S2, L3, and The rower first performed a usual-sitting
T12 spinous processes, using double-sid- test, where he replicated his usual day-
ed tape and Fixomull Stretch (Smith & to-day sitting posture. He then completed
Nephew Pty Ltd, North Ryde, Australia). a warm-up of 5 minutes of submaximal
A rotary encoder was also connected to ergometer rowing. During the rowing
the flywheel of the rowing ergometer to trial, the rower was requested to row at a
determine the stroke length.33 The volt- very high intensity (17/20 on Borg rating
age generated by the rotary encoder was of perceived exertion) at a stroke rate of
calibrated with a ruler prior to the tri- 22 strokes per minute for a period of 15
als to determine stroke length and was minutes. This protocol has been used in
synchronized with the 3SPACE FAS- previous studies32,33 and was determined
TRAK (Polhemus) using a customized after consultations between the research
LabVIEW software program (Version team and coaches. During the ergome-
8.6.1; National Instruments Corporation, try trial, the rate of perceived exertion3
FIGURE 3. Hip, pelvic, and trunk kinematics. Austin, TX). The following angles were and the NPRS7 were verbally collected
Abbreviations: HA, hip angle; LA, lumbar angle; LLA,
calculated from the 3SPACE FASTRAK at the beginning of every minute of the
lower lumbar angle; SA, sacral angle; ULA, upper
lumbar angle. (Polhemus) data using customized Lab- ergometer trial and also at the end of
VIEW software (National Instruments the 15-minute ergometer trial. Rate of
the Biering-Sørensen test was used.2 This Corporation)5 and have been used in pre- perceived exertion was used only to stan-
test has been shown to be valid and reli- vious studies of rowing kinematics30,31,48 dardize output during ergometer rowing,
able in adolescents.1,46 Adolescent rowers (FIGURE 3): (1) hip angle, the angle of the and the result of the NPRS is presented
with LBP have been reported to perform S2 sensor relative to the femur sensor; in FIGURE 4.
significantly worse in this test compared (2) pelvis angle, the angle of the S2 sen-
to age-matched, pain-free rowers.40 sor relative to the vertical axis; (3) lower Intervention
Lower-Limb Muscle Endurance The lumbar angle, the angle of the L3 sen- Based on the clinical reasoning described
isometric squat and hip flexor muscle sor relative to the S2 sensor; (4) upper above, a CFT approach was employed to
test were described to be part of assess- lumbar angle, the angle of the T12 sen- address the disorder. A detailed descrip-
ment to classify patients with nonspecific sor relative to the L3 sensor; (5) lumbar tion of the rower’s intervention is pre-
chronic LBP.1,37 It has been postulated angle, the angle of the T12 sensor relative sented in the APPENDIX. This intervention
that poor muscle endurance in the lower to the S2 sensor. was conducted by the sports physiother-
limbs may be associated with compen- Only sagittal plane angles were re- apist, who was blinded to the outcome
satory spinal movement patterns.37 Evi- ported, as only movements in this plane measures data. The intervention was de-
dence has shown that adolescents with provoked pain and movements in the livered during 5 individual sessions over
LBP demonstrate poorer squat and hip frontal and transverse planes during a a duration of 8 weeks, between preinter-
flexor muscle test results compared to center-pulled ergometer rowing trial are vention and postintervention data collec-
adolescents without LBP in the general minimal.48 A hip angle of 0° reflected a tion.13,14,34-36,51 The program was tailored
population1 and in rowers.40 straight alignment between the S2 and to the patient’s goal of enhancing his
Sit-and-Reach Test This test has been the femur sensors. For trunk kinematics capacity to row without back pain. The
widely used to determine the flexibility and pelvic angles, positive values repre- intervention was composed of 2 major
of the hamstrings and back.23 Lack of sented trunk flexion and anterior pelvic components, a cognitive component and
546 | august 2013 | volume 43 | number 8 | journal of orthopaedic & sports physical therapy
a functional component (APPENDIX).
8
Cognitive Component The cognitive
component consisted of education re- 7
10
graduated manner (APPENDIX). 100
0
The rower was also asked to fill in a 80
60 –10
compliance sheet to indicate the level of 40 –20
20 –30
adherence to the program. From inspect-
0 –40
ing this sheet, he was deemed to have a 0 10 20 30 40 50 60 70 80 90 100 0 10 20 30 40 50 60 70 80 90 100
high level of compliance by the treating
physiotherapist. Drive Phase, % Drive Phase, %
T
30 30
Extension/Flexion, deg
25 20
ment in the primary outcome 20 10
15 0
measures following an 8-week phys- 10
–10
5
iotherapy intervention. The NPRS (FIGURE 0 –20
4) revealed a reduction in the intensity of –5 –30
–10 –40
the temporal summation of pain dem-
0 10 20 30 40 50 60 70 80 90 100 0 10 20 30 40 50 60 70 80 90 100
onstrated during ergometer rowing. The
results of the RMDQ and PSFS (TABLE) Drive Phase, % Drive Phase, %
also supported a reduction in disability.
The secondary outcomes for this study Follow-up Initial
journal of orthopaedic & sports physical therapy | volume 43 | number 8 | august 2013 | 547
[ case report ]
following the 8-week intervention. Al-
though kinematics data of 3 completed Outcome Measures and
rowing strokes were collected during the TABLE Kinematics Data at Preintervention,
last 15 seconds of every minute, only the Postintervention, and Follow-up
kinematics data of the first minute are
presented in FIGURE 5. The percentage Preintervention 8-wk Postintervention 12-wk Follow-up
of the stroke in the drive phase was also RMDQ (0-24) 12 1 1
increased following intervention (TABLE). PSFS (0-10)
Furthermore, there were improvements Rowing 1 9 9
in the physical assessments following the Lifting weights 0 8 8
intervention in the Biering-Sørensen test, Forward bending 3 9 9
the sit-and-reach test, the squat hold, and Physical assessments (Biering-Sørensen), s 30 65 80
the hip flexor hold (TABLE). Sit and reach, m –0.12 0.0 …
Squat hold, s 20 90 120
DISCUSSION Hip flexor hold, s 12 45 60
Usual sitting, deg
T
he results of this case study Sacral angle –0.5 8.9 …
support an association between a Lower lumbar angle 2.5 –3.8 …
cognitive functional approach to Upper lumbar angle 20.6 –12.5 …
managing and reducing pain and disabil- Lumbar angle 23.1 –14.6 …
the athlete demonstrated a clinically sig- Range between catch and finish
548 | august 2013 | volume 43 | number 8 | journal of orthopaedic & sports physical therapy
as the use of visual feedback through mir- be apparent in other rowers. Rather, the 2. B iering-Sørensen F. Physical measurements
rors and videos targeting visualization of purpose of this study was to support the as risk indicators for low-back trouble over
movement to retrain body schema57 and outlined systematic approach to individ- a one-year period. Spine (Phila Pa 1976).
1984;9:106-119.
to reduce sense of threat.8 Although spec- ually classify athletes with chronic LBP
3. Borg G. Perceived exertion as an indica-
ulative, a combination of factors, such as and to develop a targeted intervention tor of somatic stress. Scand J Rehabil Med.
postural changes, improvement in con- for this condition. Performance was not 1970;2:92-98.
ditioning and flexibility, improvement assessed in this study, as the goal of the 4. Budgett RG. The road to success in international
rowing. Br J Sports Med. 1989;23:49-50.
in confidence,16 improvement in body treatment, as defined by the rower, was
5. Burnett AF, Barrett CJ, Marshall RN, Elliott
awareness,29,56 reduced sense of threat,8 to return to rowing at any level. Although BC, Day RE. Three-dimensional measurement
and more relaxed movement patterns,35,53 palpation is widely used by physiothera- of lumbar spine kinematics for fast bowl-
might have enabled this athlete to resume pists during clinical examinations,26 the ers in cricket. Clin Biomech (Bristol, Avon).
1998;13:574-583.
rowing training with significantly lower validity and reliability of identifying ac-
6. Burnett AF, Cornelius MW, Dankaerts W,
levels of pain. tive muscle contraction (tension) during O’Sullivan PB. Spinal kinematics and trunk
Consistent with these findings, simi- static and dynamic postures have not muscle activity in cyclists: a comparison be-
lar cognitive functional approaches been reported, limiting the replication of tween healthy controls and non-specific chronic
low back pain subjects – a pilot investigation.
have been applied in populations of cy- this test. Quantitative kinetic informa-
Man Ther. 2004;9:211-219. http://dx.doi.
clists6,53,54 and female rowers.41,51 More tion and electromyography should also org/10.1016/j.math.2004.06.002
specifically, a similar cognitive functional be included in future studies. The test- 7. Cole B, Finch E, Gowland C, Mayo N. Physical
intervention was shown to reduce sum- retest reliability of the FASTRAK (Pol- Rehabilitation Outcome Measures. Baltimore,
MD: Williams & Wilkins; 1995.
mation of pain in a cyclist with nonspecif- hemus) motion analysis system utilized
8. Crombez G, Eccleston C, Van Damme S,
ic chronic LBP during a 2-hour outdoor during ergometer rowing was not tested Vlaeyen JW, Karoly P. Fear-avoidance model of
cycling task.53 This study also found a re- during this study and may be subject to chronic pain: the next generation. Clin J Pain.
lationship between clinical changes (re- soft tissue artifact errors. Future studies 2012;28:475-483. http://dx.doi.org/10.1097/
AJP.0b013e3182385392
duced pain and disability) and a change should include a randomized controlled
9. Dankaerts W, O’Sullivan P, Burnett A, Straker L.
in spinopelvic kinematics while rowing. trial with more participants of different Differences in sitting postures are associated
Similar to Van Hoof et al,53 we reported genders and levels of participation. with nonspecific chronic low back pain disor-
abolishment of the phenomenon of sum- ders when patients are subclassified. Spine
mation of pain in an athlete with non- Conclusion (Phila Pa 1976). 2006;31:698-704. http://dx.doi.
org/10.1097/01.brs.0000202532.76925.d2
specific chronic LBP while performing a 10. Dankaerts W, O’Sullivan P, Burnett A, Straker
T
functional task.54 he results of this study indi- L, Davey P, Gupta R. Discriminating healthy
This case report challenges the popu- cate that a cognitive functional in- controls and two clinical subgroups of nonspe-
cific chronic low back pain patients using trunk
lar belief that chronic LBP should be tervention appeared to be successful
muscle activation and lumbosacral kinemat-
managed by training neutral postures in reducing pain and disability associated ics of postures and movements: a statistical
and enhancing greater core stabil- with rowing in a male adolescent rower. classification model. Spine (Phila Pa 1976).
ity.20-22,43 The rower in this case study This was associated with greater range of 2009;34:1610-1618. http://dx.doi.org/10.1097/
BRS.0b013e3181aa6175
presented with a reduced use of his spinal movement during ergometer row-
11. Dankaerts W, O’Sullivan PB, Burnett AF, Straker
available spinal movement pattern dur- ing, increased back and hip muscle en- LM. The use of a mechanism-based classifica-
ing ergometer rowing prior to the inter- durance, and increased flexibility. t tion system to evaluate and direct management
vention. Whether this movement pattern of a patient with non-specific chronic low back
pain and motor control impairment – a case
had been reinforced by the prior stability AcknowledgementS: This study was sup-
report. Man Ther. 2007;12:181-191. http://dx.doi.
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Appendix
journal of orthopaedic & sports physical therapy | volume 43 | number 8 | august 2013 | 551
[ case report ]
Appendix
Functional Component
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Appendix
Bending. Minimal hip flexion. Bending. Anterior pelvic tilt and relaxed
paraspinal and abdominal muscles.
journal of orthopaedic & sports physical therapy | volume 43 | number 8 | august 2013 | 553
[ case report ]
Appendix
Middrive. Cocontracted paraspinal and abdominal Middrive. Relaxed paraspinal and abdominal
muscles. 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- Finish position. Extended thorax and cocontracted Finish position. Relaxed thorax and relaxed
leg squats, and rowing drills (postural paraspinal and abdominal muscles. paraspinal and abdominal muscles.
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.
Abbreviation: NSAID, nonsteroidal anti-inflammatory drug.
Return-to-Rowing Program
Weeks 1 to 2: ergometer rowing: 2 to 5 minutes (pain free) Weeks 5 to 6: on-water rowing: single scull, 4 km daily.
in new posture. Week 7: on-water rowing: pair/4, 12 km 3 times per week.
Weeks 3 to 4: ergometer rowing: 15 minutes, pain free. Week 8: on-water rowing: 8 sweep, return to crew rowing.
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