Development of a comprehensive clinical assessment protocol for low back and hip pain in powerlifters: a feasibility study

BACKGROUND

Low back and hip pain problems are frequent in powerlifting. There is a lack of information on the specific pain phenotypes and specific impairments in body function associated with these pain problems, as well as how to reach a clinical diagnosis relevant for powerlifters' pain problems. Therefore, the aim was to develop a comprehensive clinical assessment protocol for pain and function in powerlifters with low back and/or hip pain and evaluate its feasibility for use in further epidemiological or clinical studies of powerlifters.

METHODS

The study was conducted in two phases. In phase one, the protocol was developed according to literature regarding musculoskeletal assessment and sports injuries, and in phase two, feasibility was evaluated. Eight powerlifters with low back/hip pain were included in phase two. Four of them were examined independently by two physical therapists, and the other four were examined by one of the physical therapists. The time spent on the examination, whether the physical therapists could reach a clinical diagnosis without adding items to the protocol, and whether the two physical therapists were consistent in terms of the clinical diagnosis, were evaluated.

RESULTS

The protocol was developed including subjective examination, physical examination, and a clinical diagnosis based mainly on signs and symptoms of associated neurophysiological pain mechanisms and the specific impairments in body functions associated with the powerlifter's pain problem. The protocol met the feasibility criteria. The examination lasted approximately 1 h, no items needed to be added, and both physical therapists were able to make a consistent clinical diagnosis. Visual observation and alteration of movement strategy of the squat/deadlift were thought to be crucial for assessing the powerlifters' pain problem.

CONCLUSIONS

This is the first comprehensive clinical assessment protocol developed to describe powerlifters' pain problems/injuries with a clinical diagnosis based on the dominating neurophysiological pain mechanism and impairments in body functions. However, before use in larger studies, it is recommended that the protocol be further evaluated by a larger number of physical therapists and powerlifters to evaluate its reliability and whether the content of the protocol should be further expanded.

Are Anthropometric Measures, Range of Motion, or Movement Control Tests Associated with Lumbopelvic Flexion during Barbell Back Squats?

Background

Resistance training with the barbell back squat (BBS) exercise is practiced in sports, recreation, and rehabilitation. Although extensively debated, it is commonly believed and recommended that maintaining a neutral lumbopelvic alignment during BBS is an important technical aspect that might reduce the risk of injury. There is limited knowledge of how objectively measurable factors affect the extent to which the lumbopelvic region moves into flexion during a BBS.

Purpose

The aim of the study was to investigate the association among anthropometric measurements, range of motion in the hips and ankle joints, lumbopelvic movement control tests, and flexion of the lumbopelvic region during execution of the BBS.

Study design

Observational, cross sectional.

Methods

Eighteen experienced powerlifters and Olympic weightlifters were included and measurements of lumbopelvic movements were collected with inertial measurement units during BBS performed at 70 % of 1RM. Examination of anthropometric properties, range of motion in the hip and ankle joints, and lumbopelvic movement control tests were collected as independent variables. Linear regression analysis was used to investigate which independent variables were associated with lumbopelvic flexion during a BBS.

Results

The linear regression showed that a higher range of motion in ankle dorsiflexion could statistically significantly explain an increased amplitude of lumbopelvic flexion during the BBS. Anthropometrics, range of motion of the hips, and performance in lumbopelvic movement control tests did not show any statistically significant associations.

Conclusions

The results suggest that strength and conditioning professionals and clinicians who instruct and assess lifting technique in the BBS and/or use the BBS to assess performance or as an intervention should recognize that a higher range of motion in the ankle joints might affect lumbopelvic flexion during the BBS. In practice, the value of an individual assessment of lifting technique focusing on the goal of the movement should be emphasized.

Level of Evidence

3.

Role of the Flexion Relaxation Phenomenon in the Analysis of Low Back Pain Risk in the Powerlifter: A Proof-of-Principle Study

INTRODUCTION

Unlike the most common training approaches for bodybuilding, powerlifting programs are generally based on maximum and submaximal loads, putting enormous stresses on the lumbar spine. The flexion relaxation phenomenon evaluation is a clinical tool used for low back pain (LBP) assessment. This study aimed to evaluate the role of the flexion relaxation phenomenon in the analysis of LBP in the powerlifters.

METHODS

Healthy professional powerlifters participated in the study. In fact, we divided the participants into a LBP-low-risk group and a LBP-high-risk group, based on a prior history of LBP. Outcome measures included flexion relaxation ratio (FRR) and trough surface electromyography collected during trunk maximum voluntary flexion; furthermore, during a bench press lifting, we measured the height of the arched back (ARCH), using a camera and the Kinovea video editing software, to consider a potential correlation with the risk of LBP.

RESULTS

We included a group of 18 male (aged 24-39 y) powerlifters of 93 kg category. We measured a nonsignificant mean difference of ARCH between low-risk LBP group and high-risk LBP subjects. Curiously, maximum voluntary flexions were both above the threshold of 3.2 μV; therefore, with an absence of appropriate myoelectric silence, on the contrary, the FRR ratios were higher than 9.5, considering the presence of the phenomenon, exclusively for the low-risk group. The lumbar arched back measurement data did not report any association with the LBP risk, regarding the maximum voluntary flexion value, and even more than the FRR there is a relationship with the presence or the absence of LBP risk.

CONCLUSIONS

FRR could be considered as a useful parameter for studying the risk of LBP in powerlifting. The FRR index not only refers to the possible myoelectric silence of the lumbar muscles in trunk maximum forward flexion but also takes into account the energy value delivered by the lumbar muscles during the flexion. Furthermore, we can indicate that the size of the powerlifter ARCH may not be a determining factor in the occurrence of LBP.

The Effect of Cautionary Versus Resiliency Spine Education on Maximum Deadlift Performance and Back Beliefs: A Randomized Control Trial

ABSTRACT

Scott, KM, Kreisel, BR, Florkiewicz, EM, Crowell, MS, Morris, JB, McHenry, PA, and Benedict, TM. The effect of cautionary versus resiliency spine education on maximum deadlift performance and back beliefs: A randomized control trial. J Strength Cond Res 38(7): e341-e348, 2024-The purpose of this study was to determine the effect of cautionary information about the spine vs. a message of spine resiliency on maximum deadlift (MDL) performance and beliefs regarding the vulnerability of the spine. This cluster randomized control trial involved 903 military new cadets (n = 903) during their mandatory fitness test in cadet basic training (mean age 18.3 years, body mass index 23.8 kg·m-2, 22% female). Subjects were cluster randomized to 3 groups. The cautionary group received a message warning them to protect their backs while deadlifting, the resiliency group received a message encouraging confidence while deadlifting, and the control group received the standardized Army deadlift education only. The outcome measures were MDL weight lifted and perceived spine vulnerability. Significance was set at alpha ≤0.05. There were no between-group differences in weight lifted (p=0.40). Most subjects believed that the spine is vulnerable to injury. Three times as many subjects who received the resiliency education improved their beliefs about the vulnerability of their spines compared with those receiving the cautionary education (p<0.001). This study demonstrated the potential for brief resiliency education to positively influence beliefs about spine vulnerability, whereas cautionary education did not impair performance.

Lumbopelvic movement control in powerlifters with and without low back pain

OBJECTIVES

To measure lumbopelvic movement control in powerlifters with and without low back pain (LBP).

DESIGN

Quantitative Cross-sectional.

PARTICIPANTS

Twelve powerlifters with LBP and 28 powerlifters without LBP.

SETTING

Powerlifters were recruited in nine different cities and filmed while performing a movement control test battery.

MAIN OUTCOME MEASURES

Lumbopelvic movement control test battery consisting of seven tests, with a possible score between 0 and 13. The tests were rated by a physical therapist blinded to the group allocation and comparisons of the frequency of current/incorrect tests between groups were calculated.

RESULTS

There was no statistically significant difference in the movement control test battery between the powerlifters with LBP (Median = 7.0, (2-11)) and powerlifters without LBP (Median = 6.0, (1-10)) (P = 0.59). There were no statistically significant differences between groups when the individual movement control tests were analyzed separately.

CONCLUSIONS

The lack of significant differences between groups indicates that performance in lumbopelvic movement control test might not be associated with LBP in powerlifters. More studies on associations between LBP and movement control and other body functions are needed to guide assessment and treatment of powerlifters with LBP and for investigation of possible risk factors for LBP in powerlifters.

Thoracolumbar and Lumbopelvic Spinal Alignment During the Barbell Back Squat: A Comparison Between Men and Women

Background

Maintaining neutral spinal alignment is considered important when performing the barbell back squat exercise. Since male and female lifters may differ in injury location it is important to examine whether they differ in spinal alignment during the back squat.

Objectives

The study aimed to quantify the spinal alignment in the upper and lower lumbar spine during the barbell back squat exercise in male and female lifters. Secondary aims were to compare alignment during the back squat to standing habitual lumbar spine alignment and determine whether male and female lifters differ in these aspects.

Study Design

Observational, Cross-sectional.

Methods

Competitive power- and weightlifters were recruited and performed three repetitions of the barbell back squat exercise using a load equivalent to 70% of their one-repetition maximum. Spinal alignment and range of motion were measured using inertial measurement units placed on the thoracic, lumbar and sacral spine. Data was presented descriptively and comparisons between men and women as well as spinal alignment in four different positions were done with a factorial repeated measures analysis of variance.

Results

Twenty-three (14 males, 9 females) were included. During execution of the squat, spinal alignment adjustments in the lumbar spine were made in all three planes of movement, compared to the start position, in both male and female lifters. Compared to their standing habitual posture, all lifters adjusted their upper lumbar spine to a less lordotic position when in the start position of the back squat (standing upright with the barbell on their back). Only male lifters assumed a less lordotic alignment in their lower lumbar spine in the start position compared their habitual posture.

Conclusions

Adjustments of spinal alignment, predominantly in the sagittal plane, are made during execution of the back squat in both male and female lifters. Further, lifters adopt a less lordotic alignment with a heavy barbell on their upper back, more so in male than female lifters. In conclusion, it seems that spinal alignment changes noticeably during the barbell back squat.

Level of Evidence

3©The Author(s).

Chronic Lower Back Pain in Weight Lifters: Epidemiology, Evaluation, and Management

» Chronic lower back pain (LBP) is common in both nonathletes and weight lifters, but the diagnosis and treatment should be approached differently in these 2 populations based on the unique movement patterns causing the pain.» Injury rates of weight lifters are far less than those of contact sports, ranging from 1.0 to 4.4 injuries per 1,000 workout hours. However, the lower back was consistently one of the top 2 injury sites for weight lifters, accounting for anywhere from 23% to 59% of all injuries. LBP was most often associated with the squat or deadlift.» Guidelines for evaluating general LBP are applicable to weight lifters, including a thorough history and physical examination. However, the differential diagnosis will change based on the patient's lifting history. Of the many etiologies of back pain, weight lifters are most likely to be diagnosed with muscle strain or ligamentous sprain, degenerative disk disease, disk herniation, spondylolysis, spondylolisthesis, or lumbar facet syndrome.» Traditional recommended therapies include nonsteroidal anti-inflammatory drugs, physical therapy, and activity modification, which are often insufficient to resolve pain and prevent injury recurrence. Because most athletes will want to continue to lift weights, lifting-specific behavior modifications focused on improved technique and correcting mobility and muscular imbalances are important aspects of management in this patient population.

Thoracolumbar And Lumbopelvic Spinal Alignment During The Deadlift Exercise: A Comparison Between Men And Women

Background

A neutral spinal alignment is considered important during the execution of the deadlift exercise to decrease the risk of injury. Since male and female powerlifters experience pain in different parts of their backs, it is important to examine whether men and women differ in spinal alignment during the deadlift.

Objectives

The purpose of this study was to quantify the spinal alignment in the upper (thoracolumbar, T11-L2) and lower (lumbopelvic, L2-S2) lumbar spine during the deadlift exercise in male and female lifters. Secondary aims were to compare lumbar spine alignment during the deadlift to standing habitual posture, and determine whether male and female lifters differ in these aspects.

Study Design

Observational, Cross-sectional.

Methods

Twenty-four (14 men, 10 women) lifters performed three repetitions of the deadlift exercise using 70% of their respective one-repetition maximum. Spinal alignment and spinal range of motion were measured using three inertial measurement units placed on the thoracic, lumbar and sacral spine. Data from three different positions were analyzed; habitual posture in standing, and start and stop positions of the deadlift, i.e. bottom and finish position respectively.

Results

During the deadlift, spinal adjustments were evident in all three planes of movement. From standing habitual posture to the start position the lumbar lordosis decreased 13° in the upper and 20° in the lower lumbar spine. From start position to stop position the total range of motion in the sagittal plane was 11° in the upper and 22° in the lower lumbar spine. The decreased lumbar lordosis from standing habitual posture to the start position was significantly greater among men.

Conclusions

Men and women adjust their spinal alignment in all three planes of movement when performing a deadlift and men seem to make greater adjustments from their standing habitual posture to start position in the sagittal plane.

Level of Evidence

3.

Influences of limited flexibility of the lower extremities and occurrence of low back pain in adolescent baseball players: A prospective cohort study

BACKGROUND

Limited flexibility of the lower extremities, such as hamstring tightness, has long been suggested as a physical risk factor for low back pain among adolescent athletes. However, few prospective cohort studies have examined the direction of causality for this relationship. This prospective cohort study investigated the relationship between limited flexibility of the lower extremities and the occurrence of low back pain among high school baseball players.

METHODS

Participants comprised 335 high school baseball players from 43 high school baseball teams who had undergone baseline medical evaluations (a self-completed questionnaire and physical examination). Occurrence of low back pain during a 1-year follow up, and associations with measurements of flexibility of the lower extremities such as straight-leg-raising angle (hamstring tightness), Thomas test (iliopsoas tightness), heel-buttock-distance (quadriceps tightness), and passive range of motion of the hip were investigated.

RESULTS

In total, 296 players (88.4%) participated in the 1-year follow-up survey, with 147 of the 296 players (49.7%) reporting the occurrence of low back pain during follow-up. The number of players with low back pain during follow-up peaked in November, then decreased and was lowest in June. After adjusting for factors associated with low back pain using logistic regression modeling, a significant association between hamstring tightness on the non-throwing arm side and low back pain (odds ratio 2.86, 95% confidence interval 1.17-6.94; P = 0.018) was found.

CONCLUSIONS

Hamstring tightness on the non-throwing arm side was identified as a potential risk factor for low back pain in high school baseball players. These results may provide guidance in the development of future prevention programs.

Regulating Movement Frequency and Speed: Implications for Lumbar Spine Load Management Strategies Demonstrated Using an In Vitro Porcine Model

The relationship between internal loading dose and low-back injury risk during lifting is well known. However, the implications of movement parameters that influence joint loading rates-movement frequency and speed-on time-dependent spine loading responses remain less documented. This study quantified the effect of loading rate and frequency on the tolerated cumulative loading dose and its relation to joint lifespan. Thirty-two porcine spinal units were exposed to biofidelic compression loading paradigms that differed by joint compression rate (4.2 and 8.3 kN/s) and frequency (30 and 60 cycles per minute). Cyclic compression testing was applied until failure was detected or 10,800 continuous cycles were tolerated. Instantaneous weighting factors were calculated to evaluate the cumulative load and Kaplan-Meier survival probability functions were examined following nonlinear dose normalization of the cyclic lifespan. Significant reductions in cumulative compression were tolerated when spinal units were compressed at 8.3 kN/s (P < .001, 67%) and when loaded at 30 cycles per minute (P = .008, 45%). There was a positive moderate relationship between cumulative load tolerance and normalized cyclic lifespan (R2 = .52), which was supported by joint survivorship functions. The frequency and speed of movement execution should be evaluated in parallel to loading dose for the management of low-back training exposures.

Variability of lumbar spinal alignment among power- and weightlifters during the deadlift and barbell back squat

The aims of the study were to evaluate the relative and absolute variability of upper (T11-L2) and lower (L2-S2) lumbar spinal alignment in power- and weightlifters during the deadlift and back squat exercises, and to compare this alignment between the two lifting groups. Twenty-four competitive powerlifters (n = 14) and weightlifters (n = 10) performed three repetitions of the deadlift and the back squat exercises using a load equivalent to 70% of their respective one-repetition maximum. The main outcome measures were the three-dimensional lumbar spinal alignment for start position, minimum and maximum angle of their spinal alignment, and range of motion measured using inertial measurement units. Relative intra-trial reliability was calculated using the two-way random model intraclass correlation coefficient (ICC) and absolute reliability with minimal detectable change (MDC). The ICC ranged between 0.69 and 0.99 and the MDC between 1°-8° for the deadlift. Corresponding figures for the squat were 0.78-0.99 and 1°-6°. In all participants during both exercises, spinal adjustments were made in both thoracolumbar and lumbopelvic areas in all three dimensions. In conclusion, when performing three repetitions of the deadlift and the squat, lumbar spinal alignment of the lifters did not change much between repetitions and did not differ significantly between power- and weightlifters.