Eur Spine J DOI 10.1007/s00586-015-4034-7
ORIGINAL ARTICLE
Low back pain status of female university students in relation to different sport activities Pardis Noormohammadpour1,2,3 • Mohsen Rostami1,3 • Mohammad Ali Mansournia4 • Farzin Farahbakhsh1,3 • Mohammad Hosein Pourgharib Shahi1,2 • Ramin Kordi1,3
Received: 18 December 2014 / Revised: 13 May 2015 / Accepted: 14 May 2015 Ó Springer-Verlag Berlin Heidelberg 2015
Abstract Purpose To investigate the prevalence of low back pain (LBP) and its absence rate among female university student athletes in different types of sports. Methods A cross-sectional study based on a standard selfreporting questionnaire was performed among 1335 athletes. Participants were female athletes who attended the National Sports Olympiad of Female University Students in basketball, volleyball, futsal, tennis, badminton, swimming, track and field, shooting, and karate. Results One thousand and fifty-nine athletes with the mean (SD) age of 23.1 (3.8) years responded to the questionnaire (response rate 79 %). The 12-month prevalence of LBP was 39.0 %; in addition, lifetime and point prevalence of LBP were 59.7 and 17.8 %, respectively. Basketball (47.9 %) and karate (44.0 %) players had
reported the highest 12-month prevalence of LBP. Also, LBP prevalences in shooting (29.7 %) and badminton (42.4 %) players were not negligible. Results show that, LBP led to relatively high absence rate from training sessions (27.9 %) and matches (13.0 %). Conclusion While most of the existing literatures regarding female athletes’ LBP have focused on particular sports with specific low back demands (such as skiing and rowing), many other sports have not been studied very well in this regard. Investigating LBP prevalence and related factors in other types of sports, such as combat sports, badminton and shooting, can help us better understand the prevalence of low back pain and provide us with necessary insight to take effective steps towards its prevention in athletes. Keywords Competitive sports Lumbar pain Prevalence
Electronic supplementary material The online version of this article (doi:10.1007/s00586-015-4034-7) contains supplementary material, which is available to authorized users. & Ramin Kordi [email protected] 1
Sports Medicine Research Center, Neuroscience Institute, Tehran University of Medical Sciences, No 7, Al-e Ahmad St., Tehran, Iran
2
Department of Sports and Exercise Medicine, School of Medicine, Tehran University of Medical Sciences, Imam Khomeini Hospital, Bagher Khan St., Chamran Highway, Tehran, Iran
3
Spine Division, Noorafshar Rehabilitation and Sports Medicine Hospital, 17th St., Khodaverdi St., Niavaran, Tehran, Iran
4
Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Poursina St., Shanzdah-e Azar St., Tehran, Iran
Introduction Low back pain (LBP) is a common musculoskeletal problem throughout the world [1]. The prevalence of LBP in the general population has been investigated in several studies and systematic reviews [1, 2]. Although comprehensive studies exist regarding LBP in the non-athletic population, few studies have discussed LBP prevalence, correlates and epidemiology in athletes. Several studies have assessed the LBP prevalence and risk factors in particular fields of sports regarding the awkward spine posturing and putting significant load on lumbar spine. Cyclic flexion and rotation loading of the lumbar spine during the rowing strokes [3–5], static flexed position of the back in skiing [6, 7], gymnast’s frequent landing [8], twisting and
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high load movements in football and handball players [9], and pressing load in the lifting phase with possible lordotic posture while holding heavy weights in weightlifters [10], have all been suggested as predisposing LBP factors in athletes. Interestingly, Greene et al. showed that there was no significant difference among LBP incidence rates between contact and non-contact sports [11]. While a previous study showed LBP frequency is less among general population who participated in sport activities [12], improper movements involving end range of motions in spine, repetitive compressive loading, high volume of training, and lack of time for full recovery could be the causes of spinal overuse injuries and consequently persistent, chronic or recurrent LBP in athletes [13]. To the best of our knowledge, none of previous studies investigates the prevalence of low back pain in sports without significant spinal demands such as shooting and futsal. In addition, only few studies [14, 15] assessed the LBP prevalence in female athletes participated in the combat sports, while high mechanical loading (due to repetitive rotations and hyper extensions) on lumbar spine and the role this area plays as a source of dynamic power and static control of trunk could be a possible cause of low back pain in such sports [16]. Several potential consequences of LBP, such as recurrent episodes or chronic LBP [17] have been mentioned in previous studies compromising athlete’s performance [18] and causing vulnerability to other injuries via changes in neuromuscular control and stabilization of lumbar-pelvic complex [19]. Investigating the prevalence of LBP and its risk factors among different types of sports, particularly in special groups such as females, adolescents, and professionals could be beneficial regarding development of prevention strategies for LBP and its adverse consequences [9]. Unfortunately, many of earlier studies which addressed the prevalence of low back pain in athletes have a small sample size (fewer than 100 subjects) [15, 20–22]. Also, in other studies with larger sample size, the response rate was not high enough [5, 23]. In addition, several previous studies in this field have not used the standard [24] definition of LBP [6, 7, 22] or have not stated their study’s definition of LBP clearly (or at all) [21, 23, 25]. Finally, almost all former studies have evaluated the prevalence of low back pain in developed countries [20, 26, 27] whose conclusions may not hold for underdeveloped or developing countries. Therefore, more epidemiologic studies with a large sample size and an internationally acceptable low back pain definition [24] can help us better understand the prevalence of low back pain and correlates, and provide us with necessary insight to take effective steps towards its prevention and management in athletes. Present study aims to investigate the prevalence of LBP among female athletes who attended the National Sports
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Olympiad of Female University Students in nine different fields of sports, and assess their care seeking behaviors and sick leaves due to LBP.
Materials and methods This study was designed as a cross-sectional survey of female university athletes competing at the National Sports Olympiad of Female University Students in Shahrekord, Iran. All female athletes who attended the Olympiad were asked to participate in the study. This Olympiad holds in 9 fields of sports among selected students of all medical universities all around the country. In total, 1335 female students from 30 universities were competing in the 9 following sports: Volleyball, Basketball, Futsal, Tennis, Badminton, Swimming, Tracking, shooting, and Karate. The study’s questionnaire (which is available in the supplementary materials) was designed based on previous studies [3, 8, 24, 26] and expert panel consultation. Initially, information gathered about general characteristics such as age, height, weight, field of sport, training hours per week, age of starting to compete, and years of experience in sport training. In the questionnaire, a human figure (mannequin) was used to define LBP for the subjects [28]. In this regard, LBP was defined as ‘‘The low back pain is a pain between the last rib and lower gluteal fold as you can see in the following mannequin (gray area), which is bad enough to limit or change athletes’ daily routine or sports activities for more than 1 day and is not due to menstruation’’ [24]. After defining LBP, there were questions regarding LBP prevalence such as having LBP during the last 48 h, during last 12 months, during any time after beginning sports participation, and during any time throughout the life. Finally, questions about visiting a LBP specialist, medication intake, para-clinical tests (plain radiography or MRI), and absenteeism from training sessions, competitions and classes as a result of LBP, were asked. Prior to the study, the questionnaire’s reliability was examined by a test retest pilot study. Fifty female athletes answered the questionnaire twice within 10 days apart. All questions were answered with high temporal reliability (ICC [ 0.9). Statistical analysis of data was performed via SPSS software version 16 (SPSS Inc, Illinois, US). Descriptive data are expressed by mean (SD) and p \ 0.05 is considered as statistically significant. Point prevalence was calculated by number of athletes who reported LBP during last 48 h based on questionnaire. Furthermore, 12-month, life-time and sport-life prevalence of LBP were calculated in the same way. Using logistic regression analysis, the relationship
7.1 (4.9) 7.9 (3.9) 5.4 (4.3) 6.4 (5.0) 7.8 (6.2) 6.7 (5.3) 7.5 (4.8) 6.8 (4.7)
SD standard deviation
Values are represented as mean (SD)
23.2 (3.3) 7.2 (4.0) Experience in sport training (years)
5.2 (3.7)
16.0 (4.2) 14.8 (4.0) 18.4 (3.7) 16.8 (3.9) 15.3 (5.0) 16.2 (4.9) 15.6 (3.8) 16.4 (3.7) 7.8 (4.5) 15.5 (3.5) Age of starting to compete (years)
22.1 (2.5) 21.8 (2.1)
5.5 (3.7) 5.5 (4.5)
22.7 (2.4) 21.3 (2.3)
5.8 (3.5) 4.1 (2.5)
22.6 (2.1) 22.3 (3.5)
5.8 (5.0) 4.3 (2.8)
22.3 (2.2) 22.5 (2.4)
5.0 (3.7) 15.4 (3.9)
5.2 (3.1) 21.7 (2.2)
5.2 (3.4)
23.1 (3.8)
BMI (kg/m2)
Training/week (hours)
162.2 (8.0) 58.4 (12.6)
22.8 (4.0) 23.8 (4.0)
163.0 (8.8) 60.5 (9.6) 169.4 (8.8) 58.1 (8.9)
23.2 (3.6) 23.1 (4.0)
165.0 (9.3) 62.0 (10.7) 162.0 (9.9) 58.3 (8.7)
22.9 (4.9) 23.1 (3.7)
164.2 (8.5) 60.3 (10.2) 164.9 (9.5) 61.5 (9.9)
23.2 (3.6) 23.2 (3.3)
169.9 (11.4) 63.8 (15.3)
22.7 (2.7)
170.8 (9.2) 64.5 (12.9) Height (cm) Weight (kg)
Badminton (n = 125) Tennis (n = 85) Futsal (n = 136) Volleyball (n = 114) Basketball (n = 140)
In this study, we found that the point prevalence of LBP among female student athletes with the mean (SD) age of 23.1 (3.1) was 17.8 %. Also, the 1-year prevalence, sports-
Variables
Discussion
Table 1 The basic characteristics of the participants in the study
In total, 1059 athletes completed the questionnaire (response rate = 79.3 %). Subjects had a mean (SD) age of 23.1 (3.8) and a mean (SD) BMI of 22.1 (2.5) (Table 1). Table 2 presents the responses to the study’s questionnaire. More than half of the athletes in each field had experienced LBP during their life time. More than 30 % of the subjects had experienced LBP during the previous 12-months and 10–25 % reported LBP during the past 48 h. Female basketball and karate players reported the highest prevalence of LBP in different time periods and they had highest consumption of medication and sick leaves due to LBP (Table 3). On the other hand, swimmers and shooters experienced less LBP (Table 2). Training hours per week and years of experience in sports fields is showed in Table 1. Badminton and track and field players had the maximum training hours per week, whereas, karate players had the largest amount of experience in sport. Karate players reported the highest care seeking behaviors, including visiting an LBP specialist, use of medication and taking a lumbar radiology or MRI test, and largest number of absences from training sessions, matches or university classes among all different sports (Table 3). Comparison of LBP odds ratios in various time periods and among different sports have been shown in Figs. 1, 2, 3 and 4. As seen in figures, the odds ratio of LBP among shooters was lower than other players over all time periods. Also, there were no differences in occurrence of LBP between the karate (combat sport), track and field (non-contact sport), volleyball (limited-contact sport), and basketball (contact sport) players over all time periods.
Swimming (n = 138)
Results
Age (years)
Track and field (n = 121)
Shooting (n = 91)
Karate (n = 109)
All (n = 1059)
between the type of sport and different characteristics of LBP was investigated. The odds ratios (ORs) and 95 % confidence intervals (CIs) were calculated for each of the variables, while models were adjusted for factors including age, BMI, training hours per week, and years of experience in sports training. Since, the largest portion of participants in our study sample were basketball players, this group was considered as the reference group in the logistic regression analysis. All subjects received written and oral information about the study procedures before participation. The study protocol was approved by the Ethical Committee of Tehran University of Medical Sciences.
165.4 (9.8) 60.9 (11.4)
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Eur Spine J Table 2 LBP prevalence in different time periods in sports groups Variables
Basketball (n = 140)
Volleyball (n = 114)
Futsal (n = 136)
Tennis (n = 85)
Badminton (n = 125)
Swimming (n = 138)
Track and field (n = 121)
Shooting (n = 91)
Karate (n = 109)
All (n = 1059)
Point prevalence
22.9 (32)
20.2 (23)
16.9 (23)
18.8 (16)
12.8 (16)
18.1 (25)
14.9 (18)
9.9 (9)
24.8 (27)
17.8 (189)
1 year prevalence
47.9 (67)
40.4 (46)
36.0 (49)
30.6 (26)
42.4 (53)
34.1 (47)
41.3 (50)
29.7 (27)
44.0 (48)
39.0 (413)
Sports-life prevalence
48.6 (68)
47.4 (54)
37.5 (51)
32.9 (28)
46.4 (58)
32.6 (45)
46.3 (56)
31.9 (29)
47.7 (52)
41.6 (441)
Life-time prevalence
68.6 (96)
63.2 (72)
54.4 (74)
52.9 (45)
62.34 (78)
47.8 (66)
66.9 (81)
50.5 (46)
67.9 (74)
59.7 (632)
Values are represented as percentage (number) LBP low back pain
life prevalence and life-time prevalence of the subjects were 29, 41.6 and 59.7 %, respectively. Hangai et al. [29] reported that the life-time prevalence of LBP among female students with the mean age of 18.3 years was 63 %. In the study by Schmidt et al. [26], which investigated the prevalence of LBP among adolescent athletes, the point prevalence, 1-year prevalence and life-time prevalence of LBP among female athletes with the mean age of 15.4 were reported to be 9.7, 58.4 and 66.4 %, respectively. While it has been previously shown that the prevalence of LBP increases with age [1], the lower prevalence of LBP among our subjects (who are older than female athletes of other studies) could be explained by the differences in the definition of LBP and also the fields of sports which have been investigated in this study. Recent study shows that shooting players have a significantly lower prevalence of LBP. This can explain by the lower mean of LBP prevalence in present study in comparison with prior studies, since our results also account for shooting players among other sports. In addition, earlier studies have shown that some demographic factors such as age [30], body weight [31], and BMI [32, 33] can increase the probability of LBP in athletes. While previous studies in non-athlete populations confirm the role of social and environmental risk factors (such as smoking) in LBP prevalence [1, 2], studies in this regard are little in athletes and further studies seems to be required in this field. Finally, several sports related [29] factors such as active years [32], types of sport [29], and duration of training (hours per week) [31, 34], have been investigated in former studies. Due to diverse list of related factors, subjects in different studies are heterogeneous and this may be considered as another reason for divergent findings among different studies. Comparing different sports, we found that basketball players had the highest life-time (68.6 %), 1-year (47.9 %), and sports-life (48.6 %) prevalence of LBP. The
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high prevalence of LBP among adolescent basketball players has been shown before [14]. It has been previously reported that some movements such as sudden and repetitive lumber flexion, hyperextension, rotation, and axial load are associated with the higher incidence of LBP among young athletes [35]. Considering the nature of basketball, it could be suggested that the higher prevalence of LBP among basketball players might be due to the special movements of the players during competitions and training sessions. Also, karate players had the highest point prevalence of LBP (24.8 %). Our data showed a high prevalence of LBP during the life-time (67.9 %), 1-year (44 %) and sports-life (47.7 %) of karate players. This might be due to the nature of combat sports and high risk of direct trauma of the athletes in course of competitions [29]. These findings are consistent with the previous report which reported an odds ratio of 1.57 for the risk of experiencing LBP among adolescent karate players [14]. To the best of our knowledge, this is the first study showing that shooting players have the lowest point prevalence (9.9 %), 1-year prevalence (29.7 %) and sports-life prevalence (31.9 %) of LBP, despite the higher mean age of shooting players. This could be explained by low-loading movements of this non-contact sport. Considering the relatively high life-time prevalence of LBP (50 %) in comparison with non-athletes [1], it could be suggested that LBP prevention programs should not be ignored in shooting players. Also, the lowest life-time prevalence (47.8 %) of LBP was found among swimmers who had the least training hours per week. This finding is in agreement with the study by Skoffer et al. [34] which reported an odds ratio of 0.6 for the LBP among schoolchildren swimmers and suggested swimming as a preventing sport for LBP. However, Sato et al. [14] reported an odds ratio of 1.4 for the LBP among adolescent swimmers.
Basketball (n = 140)
19.2 (24)
17.6 (15)
18.4 (25)
18.4 (21)
LBP low back pain, MRI magnetic resonance imaging
20.7 (29)
From class
8.8 (11)
14.1 (12)
14.0 (19)
14.9 (17)
26.4 (33)
27.1 (23)
25.7 (35)
36.0 (41)
13.6 (19)
6.4 (8)
7.1 (6)
11.8 (16)
17.5 (20)
10.7 (15)
Absence due to LBP From training 28.6 (40) session
From competition
20.8 (26)
30.6 (26)
MRI
33.6 (42)
25.9 (22)
34.2 (39)
15.2 (19)
22.4 (19)
25.0 (34)
19.1 (26)
26.4 (37)
Plain radiography
Badminton (n = 125)
Tennis (n = 85)
Futsal (n = 136)
36.0 (49)
35.0 (49)
Use of medication
33.3 (38)
Volleyball (n = 114)
21.9 (25)
27.9 (32)
Visiting LBP specialist
Care seeking behaviors
Variables
18.8 (26)
13.8 (19)
23.9 (33)
10.1 (14)
25.4 (35)
24.6 (34)
23.2 (32)
Swimming (n = 138)
Table 3 Percentage (number) of absence due to LBP and care seeking behaviors in different sports groups
13.2 (16)
9.9 (12)
26.4 (32)
11.6 (14)
21.5 (26)
30.6 (37)
19.8 (24)
Track and field (n = 121)
9.9 (9)
8.8 (8)
17.6 (16)
7.7 (7)
15.4 (14)
23.1 (21)
17.6 (16)
Shooting (n = 91)
23.9 (26)
19.3 (21)
38.5 (42)
24.8 (27)
35.8 (39)
45.0 (49)
37.6 (41)
Karate (n = 109)
18.0 (191)
13.0 (138)
27.9 (295)
12.0 (127)
24.0 (254)
32.3 (342)
24.7 (262)
All (n = 1059)
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Fig. 1 Comparison of the point prevalence of LBP for different sports
Present study finds that 24.7 % of subjects have visited an LBP specialist and 32.3 % of the athletes have used medications for management of their LBP. Evaluating the imaging study of the athletes, it was found that 24 and 12 % of the athletes had undergone plain radiography and MRI to check the etiology of their back pain. Skoffer et al. [34] reported that 1.1 % of their subjects had contacted a medical specialist for treatment of LBP. Differences in the pain-coping behaviors between present study and the study by Skoffer et al. [34] might be due to differences in the health system and insurance policies between the communities. Also, the subjects of the current study were students of medical universities with easy access to all imaging techniques. This might be considered as another reason of higher rate of imaging tests of our subjects compared to previous studies. The results of the current study provided information regarding the prevalence of LBP among young female
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Fig. 2 Comparison of the life-time prevalence of LBP for different sports
Fig. 3 Comparison of the sports-life prevalence of LBP for different sports
athletes at university competitions. This finding could be beneficial for developing sport-specific clinical guidelines for approach to LBP in athletes. Recall bias is a particular concern in any retrospective study which is one of the limitations of the current study as well, and might lead to underestimation of the results. Also, in this study no control group (non-athletic subjects) was recruited and results of other sports were compared with the basketball group. In addition, the pain intensity and functional disability of the subjects were not measured to compare the impact of the LBP on the performance of the athletes. These could be mentioned as another limitation of the study. Future studies may consider investigating the association between LBP
and its correlates in different sport fields with addressing the aforementioned limitations.
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Conclusion Our results indicate that LBP is a common symptom among female college athletes (mean age of 23.1 years) in Iran. The prevalence of LBP among athletes who practice basketball and karate is more than other sports. Also, the rate of imaging tests and visiting the LBP specialists due to back pain is relatively high. Our findings could be beneficial in developing sport-specific clinical guidelines for
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Fig. 4 Comparison of the 1 year prevalence of LBP for different sports
approach to LBP in athletes. We suggest that future studies consider sport-specific postures and movements while investigating factors that may cause LBP in athletes of each field of sport. Acknowledgments This research has been supported by Tehran University of Medical Sciences and health Services grant. Conflict of interest declare.
The authors have no conflicts of interest to
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29. Hangai M, Kaneoka K, Okubo Y, Miyakawa S, Hinotsu S, Mukai N, Sakane M, Ochiai N (2010) Relationship between low back pain and competitive sports activities during youth. Am J Sports Med 38(4):791–796. doi:10.1177/0363546509350297 30. Narita T, Kaneoka K, Takemura M, Sakata Y, Nomura T, Miyakawa S (2013) Critical factors for the prevention of low back pain in elite junior divers. Br J Sports Med 25:25 31. Murray E, Birley E, Twycross-Lewis R, Morrissey D (2009) The relationship between hip rotation range of movement and low back pain prevalence in amateur golfers: an observational study. Phys Ther Sport 10(4):131–135. doi:10.1016/j.ptsp.2009.08.002 (Epub 2009 Oct 1019) 32. C¸ali A, Gelecek N, Subasi S (2013) Non-specific low back pain in male professional football players in the Turkish super league. Sci Sports 28(4):e93–e98 33. Evans K, Refshauge KM, Adams R, Aliprandi L (2005) Predictors of low back pain in young elite golfers: a preliminary study. Phys Ther Sport 6(3):122–130 34. Skoffer B, Foldspang A (2008) Physical activity and low-back pain in schoolchildren. Eur Spine J 17(3):373–379. doi:10.1007/ s00586-007-0583-8 35. Haus BM, Micheli LJ (2012) Back pain in the pediatric and adolescent athlete. Clin Sports Med 31(3):423–440. doi:10.1016/ j.csm.2012.03.011
ORIGINAL ARTICLE
Low back pain status of female university students in relation to different sport activities Pardis Noormohammadpour1,2,3 • Mohsen Rostami1,3 • Mohammad Ali Mansournia4 • Farzin Farahbakhsh1,3 • Mohammad Hosein Pourgharib Shahi1,2 • Ramin Kordi1,3
Received: 18 December 2014 / Revised: 13 May 2015 / Accepted: 14 May 2015 Ó Springer-Verlag Berlin Heidelberg 2015
Abstract Purpose To investigate the prevalence of low back pain (LBP) and its absence rate among female university student athletes in different types of sports. Methods A cross-sectional study based on a standard selfreporting questionnaire was performed among 1335 athletes. Participants were female athletes who attended the National Sports Olympiad of Female University Students in basketball, volleyball, futsal, tennis, badminton, swimming, track and field, shooting, and karate. Results One thousand and fifty-nine athletes with the mean (SD) age of 23.1 (3.8) years responded to the questionnaire (response rate 79 %). The 12-month prevalence of LBP was 39.0 %; in addition, lifetime and point prevalence of LBP were 59.7 and 17.8 %, respectively. Basketball (47.9 %) and karate (44.0 %) players had
reported the highest 12-month prevalence of LBP. Also, LBP prevalences in shooting (29.7 %) and badminton (42.4 %) players were not negligible. Results show that, LBP led to relatively high absence rate from training sessions (27.9 %) and matches (13.0 %). Conclusion While most of the existing literatures regarding female athletes’ LBP have focused on particular sports with specific low back demands (such as skiing and rowing), many other sports have not been studied very well in this regard. Investigating LBP prevalence and related factors in other types of sports, such as combat sports, badminton and shooting, can help us better understand the prevalence of low back pain and provide us with necessary insight to take effective steps towards its prevention in athletes. Keywords Competitive sports Lumbar pain Prevalence
Electronic supplementary material The online version of this article (doi:10.1007/s00586-015-4034-7) contains supplementary material, which is available to authorized users. & Ramin Kordi [email protected] 1
Sports Medicine Research Center, Neuroscience Institute, Tehran University of Medical Sciences, No 7, Al-e Ahmad St., Tehran, Iran
2
Department of Sports and Exercise Medicine, School of Medicine, Tehran University of Medical Sciences, Imam Khomeini Hospital, Bagher Khan St., Chamran Highway, Tehran, Iran
3
Spine Division, Noorafshar Rehabilitation and Sports Medicine Hospital, 17th St., Khodaverdi St., Niavaran, Tehran, Iran
4
Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Poursina St., Shanzdah-e Azar St., Tehran, Iran
Introduction Low back pain (LBP) is a common musculoskeletal problem throughout the world [1]. The prevalence of LBP in the general population has been investigated in several studies and systematic reviews [1, 2]. Although comprehensive studies exist regarding LBP in the non-athletic population, few studies have discussed LBP prevalence, correlates and epidemiology in athletes. Several studies have assessed the LBP prevalence and risk factors in particular fields of sports regarding the awkward spine posturing and putting significant load on lumbar spine. Cyclic flexion and rotation loading of the lumbar spine during the rowing strokes [3–5], static flexed position of the back in skiing [6, 7], gymnast’s frequent landing [8], twisting and
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high load movements in football and handball players [9], and pressing load in the lifting phase with possible lordotic posture while holding heavy weights in weightlifters [10], have all been suggested as predisposing LBP factors in athletes. Interestingly, Greene et al. showed that there was no significant difference among LBP incidence rates between contact and non-contact sports [11]. While a previous study showed LBP frequency is less among general population who participated in sport activities [12], improper movements involving end range of motions in spine, repetitive compressive loading, high volume of training, and lack of time for full recovery could be the causes of spinal overuse injuries and consequently persistent, chronic or recurrent LBP in athletes [13]. To the best of our knowledge, none of previous studies investigates the prevalence of low back pain in sports without significant spinal demands such as shooting and futsal. In addition, only few studies [14, 15] assessed the LBP prevalence in female athletes participated in the combat sports, while high mechanical loading (due to repetitive rotations and hyper extensions) on lumbar spine and the role this area plays as a source of dynamic power and static control of trunk could be a possible cause of low back pain in such sports [16]. Several potential consequences of LBP, such as recurrent episodes or chronic LBP [17] have been mentioned in previous studies compromising athlete’s performance [18] and causing vulnerability to other injuries via changes in neuromuscular control and stabilization of lumbar-pelvic complex [19]. Investigating the prevalence of LBP and its risk factors among different types of sports, particularly in special groups such as females, adolescents, and professionals could be beneficial regarding development of prevention strategies for LBP and its adverse consequences [9]. Unfortunately, many of earlier studies which addressed the prevalence of low back pain in athletes have a small sample size (fewer than 100 subjects) [15, 20–22]. Also, in other studies with larger sample size, the response rate was not high enough [5, 23]. In addition, several previous studies in this field have not used the standard [24] definition of LBP [6, 7, 22] or have not stated their study’s definition of LBP clearly (or at all) [21, 23, 25]. Finally, almost all former studies have evaluated the prevalence of low back pain in developed countries [20, 26, 27] whose conclusions may not hold for underdeveloped or developing countries. Therefore, more epidemiologic studies with a large sample size and an internationally acceptable low back pain definition [24] can help us better understand the prevalence of low back pain and correlates, and provide us with necessary insight to take effective steps towards its prevention and management in athletes. Present study aims to investigate the prevalence of LBP among female athletes who attended the National Sports
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Olympiad of Female University Students in nine different fields of sports, and assess their care seeking behaviors and sick leaves due to LBP.
Materials and methods This study was designed as a cross-sectional survey of female university athletes competing at the National Sports Olympiad of Female University Students in Shahrekord, Iran. All female athletes who attended the Olympiad were asked to participate in the study. This Olympiad holds in 9 fields of sports among selected students of all medical universities all around the country. In total, 1335 female students from 30 universities were competing in the 9 following sports: Volleyball, Basketball, Futsal, Tennis, Badminton, Swimming, Tracking, shooting, and Karate. The study’s questionnaire (which is available in the supplementary materials) was designed based on previous studies [3, 8, 24, 26] and expert panel consultation. Initially, information gathered about general characteristics such as age, height, weight, field of sport, training hours per week, age of starting to compete, and years of experience in sport training. In the questionnaire, a human figure (mannequin) was used to define LBP for the subjects [28]. In this regard, LBP was defined as ‘‘The low back pain is a pain between the last rib and lower gluteal fold as you can see in the following mannequin (gray area), which is bad enough to limit or change athletes’ daily routine or sports activities for more than 1 day and is not due to menstruation’’ [24]. After defining LBP, there were questions regarding LBP prevalence such as having LBP during the last 48 h, during last 12 months, during any time after beginning sports participation, and during any time throughout the life. Finally, questions about visiting a LBP specialist, medication intake, para-clinical tests (plain radiography or MRI), and absenteeism from training sessions, competitions and classes as a result of LBP, were asked. Prior to the study, the questionnaire’s reliability was examined by a test retest pilot study. Fifty female athletes answered the questionnaire twice within 10 days apart. All questions were answered with high temporal reliability (ICC [ 0.9). Statistical analysis of data was performed via SPSS software version 16 (SPSS Inc, Illinois, US). Descriptive data are expressed by mean (SD) and p \ 0.05 is considered as statistically significant. Point prevalence was calculated by number of athletes who reported LBP during last 48 h based on questionnaire. Furthermore, 12-month, life-time and sport-life prevalence of LBP were calculated in the same way. Using logistic regression analysis, the relationship
7.1 (4.9) 7.9 (3.9) 5.4 (4.3) 6.4 (5.0) 7.8 (6.2) 6.7 (5.3) 7.5 (4.8) 6.8 (4.7)
SD standard deviation
Values are represented as mean (SD)
23.2 (3.3) 7.2 (4.0) Experience in sport training (years)
5.2 (3.7)
16.0 (4.2) 14.8 (4.0) 18.4 (3.7) 16.8 (3.9) 15.3 (5.0) 16.2 (4.9) 15.6 (3.8) 16.4 (3.7) 7.8 (4.5) 15.5 (3.5) Age of starting to compete (years)
22.1 (2.5) 21.8 (2.1)
5.5 (3.7) 5.5 (4.5)
22.7 (2.4) 21.3 (2.3)
5.8 (3.5) 4.1 (2.5)
22.6 (2.1) 22.3 (3.5)
5.8 (5.0) 4.3 (2.8)
22.3 (2.2) 22.5 (2.4)
5.0 (3.7) 15.4 (3.9)
5.2 (3.1) 21.7 (2.2)
5.2 (3.4)
23.1 (3.8)
BMI (kg/m2)
Training/week (hours)
162.2 (8.0) 58.4 (12.6)
22.8 (4.0) 23.8 (4.0)
163.0 (8.8) 60.5 (9.6) 169.4 (8.8) 58.1 (8.9)
23.2 (3.6) 23.1 (4.0)
165.0 (9.3) 62.0 (10.7) 162.0 (9.9) 58.3 (8.7)
22.9 (4.9) 23.1 (3.7)
164.2 (8.5) 60.3 (10.2) 164.9 (9.5) 61.5 (9.9)
23.2 (3.6) 23.2 (3.3)
169.9 (11.4) 63.8 (15.3)
22.7 (2.7)
170.8 (9.2) 64.5 (12.9) Height (cm) Weight (kg)
Badminton (n = 125) Tennis (n = 85) Futsal (n = 136) Volleyball (n = 114) Basketball (n = 140)
In this study, we found that the point prevalence of LBP among female student athletes with the mean (SD) age of 23.1 (3.1) was 17.8 %. Also, the 1-year prevalence, sports-
Variables
Discussion
Table 1 The basic characteristics of the participants in the study
In total, 1059 athletes completed the questionnaire (response rate = 79.3 %). Subjects had a mean (SD) age of 23.1 (3.8) and a mean (SD) BMI of 22.1 (2.5) (Table 1). Table 2 presents the responses to the study’s questionnaire. More than half of the athletes in each field had experienced LBP during their life time. More than 30 % of the subjects had experienced LBP during the previous 12-months and 10–25 % reported LBP during the past 48 h. Female basketball and karate players reported the highest prevalence of LBP in different time periods and they had highest consumption of medication and sick leaves due to LBP (Table 3). On the other hand, swimmers and shooters experienced less LBP (Table 2). Training hours per week and years of experience in sports fields is showed in Table 1. Badminton and track and field players had the maximum training hours per week, whereas, karate players had the largest amount of experience in sport. Karate players reported the highest care seeking behaviors, including visiting an LBP specialist, use of medication and taking a lumbar radiology or MRI test, and largest number of absences from training sessions, matches or university classes among all different sports (Table 3). Comparison of LBP odds ratios in various time periods and among different sports have been shown in Figs. 1, 2, 3 and 4. As seen in figures, the odds ratio of LBP among shooters was lower than other players over all time periods. Also, there were no differences in occurrence of LBP between the karate (combat sport), track and field (non-contact sport), volleyball (limited-contact sport), and basketball (contact sport) players over all time periods.
Swimming (n = 138)
Results
Age (years)
Track and field (n = 121)
Shooting (n = 91)
Karate (n = 109)
All (n = 1059)
between the type of sport and different characteristics of LBP was investigated. The odds ratios (ORs) and 95 % confidence intervals (CIs) were calculated for each of the variables, while models were adjusted for factors including age, BMI, training hours per week, and years of experience in sports training. Since, the largest portion of participants in our study sample were basketball players, this group was considered as the reference group in the logistic regression analysis. All subjects received written and oral information about the study procedures before participation. The study protocol was approved by the Ethical Committee of Tehran University of Medical Sciences.
165.4 (9.8) 60.9 (11.4)
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Eur Spine J Table 2 LBP prevalence in different time periods in sports groups Variables
Basketball (n = 140)
Volleyball (n = 114)
Futsal (n = 136)
Tennis (n = 85)
Badminton (n = 125)
Swimming (n = 138)
Track and field (n = 121)
Shooting (n = 91)
Karate (n = 109)
All (n = 1059)
Point prevalence
22.9 (32)
20.2 (23)
16.9 (23)
18.8 (16)
12.8 (16)
18.1 (25)
14.9 (18)
9.9 (9)
24.8 (27)
17.8 (189)
1 year prevalence
47.9 (67)
40.4 (46)
36.0 (49)
30.6 (26)
42.4 (53)
34.1 (47)
41.3 (50)
29.7 (27)
44.0 (48)
39.0 (413)
Sports-life prevalence
48.6 (68)
47.4 (54)
37.5 (51)
32.9 (28)
46.4 (58)
32.6 (45)
46.3 (56)
31.9 (29)
47.7 (52)
41.6 (441)
Life-time prevalence
68.6 (96)
63.2 (72)
54.4 (74)
52.9 (45)
62.34 (78)
47.8 (66)
66.9 (81)
50.5 (46)
67.9 (74)
59.7 (632)
Values are represented as percentage (number) LBP low back pain
life prevalence and life-time prevalence of the subjects were 29, 41.6 and 59.7 %, respectively. Hangai et al. [29] reported that the life-time prevalence of LBP among female students with the mean age of 18.3 years was 63 %. In the study by Schmidt et al. [26], which investigated the prevalence of LBP among adolescent athletes, the point prevalence, 1-year prevalence and life-time prevalence of LBP among female athletes with the mean age of 15.4 were reported to be 9.7, 58.4 and 66.4 %, respectively. While it has been previously shown that the prevalence of LBP increases with age [1], the lower prevalence of LBP among our subjects (who are older than female athletes of other studies) could be explained by the differences in the definition of LBP and also the fields of sports which have been investigated in this study. Recent study shows that shooting players have a significantly lower prevalence of LBP. This can explain by the lower mean of LBP prevalence in present study in comparison with prior studies, since our results also account for shooting players among other sports. In addition, earlier studies have shown that some demographic factors such as age [30], body weight [31], and BMI [32, 33] can increase the probability of LBP in athletes. While previous studies in non-athlete populations confirm the role of social and environmental risk factors (such as smoking) in LBP prevalence [1, 2], studies in this regard are little in athletes and further studies seems to be required in this field. Finally, several sports related [29] factors such as active years [32], types of sport [29], and duration of training (hours per week) [31, 34], have been investigated in former studies. Due to diverse list of related factors, subjects in different studies are heterogeneous and this may be considered as another reason for divergent findings among different studies. Comparing different sports, we found that basketball players had the highest life-time (68.6 %), 1-year (47.9 %), and sports-life (48.6 %) prevalence of LBP. The
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high prevalence of LBP among adolescent basketball players has been shown before [14]. It has been previously reported that some movements such as sudden and repetitive lumber flexion, hyperextension, rotation, and axial load are associated with the higher incidence of LBP among young athletes [35]. Considering the nature of basketball, it could be suggested that the higher prevalence of LBP among basketball players might be due to the special movements of the players during competitions and training sessions. Also, karate players had the highest point prevalence of LBP (24.8 %). Our data showed a high prevalence of LBP during the life-time (67.9 %), 1-year (44 %) and sports-life (47.7 %) of karate players. This might be due to the nature of combat sports and high risk of direct trauma of the athletes in course of competitions [29]. These findings are consistent with the previous report which reported an odds ratio of 1.57 for the risk of experiencing LBP among adolescent karate players [14]. To the best of our knowledge, this is the first study showing that shooting players have the lowest point prevalence (9.9 %), 1-year prevalence (29.7 %) and sports-life prevalence (31.9 %) of LBP, despite the higher mean age of shooting players. This could be explained by low-loading movements of this non-contact sport. Considering the relatively high life-time prevalence of LBP (50 %) in comparison with non-athletes [1], it could be suggested that LBP prevention programs should not be ignored in shooting players. Also, the lowest life-time prevalence (47.8 %) of LBP was found among swimmers who had the least training hours per week. This finding is in agreement with the study by Skoffer et al. [34] which reported an odds ratio of 0.6 for the LBP among schoolchildren swimmers and suggested swimming as a preventing sport for LBP. However, Sato et al. [14] reported an odds ratio of 1.4 for the LBP among adolescent swimmers.
Basketball (n = 140)
19.2 (24)
17.6 (15)
18.4 (25)
18.4 (21)
LBP low back pain, MRI magnetic resonance imaging
20.7 (29)
From class
8.8 (11)
14.1 (12)
14.0 (19)
14.9 (17)
26.4 (33)
27.1 (23)
25.7 (35)
36.0 (41)
13.6 (19)
6.4 (8)
7.1 (6)
11.8 (16)
17.5 (20)
10.7 (15)
Absence due to LBP From training 28.6 (40) session
From competition
20.8 (26)
30.6 (26)
MRI
33.6 (42)
25.9 (22)
34.2 (39)
15.2 (19)
22.4 (19)
25.0 (34)
19.1 (26)
26.4 (37)
Plain radiography
Badminton (n = 125)
Tennis (n = 85)
Futsal (n = 136)
36.0 (49)
35.0 (49)
Use of medication
33.3 (38)
Volleyball (n = 114)
21.9 (25)
27.9 (32)
Visiting LBP specialist
Care seeking behaviors
Variables
18.8 (26)
13.8 (19)
23.9 (33)
10.1 (14)
25.4 (35)
24.6 (34)
23.2 (32)
Swimming (n = 138)
Table 3 Percentage (number) of absence due to LBP and care seeking behaviors in different sports groups
13.2 (16)
9.9 (12)
26.4 (32)
11.6 (14)
21.5 (26)
30.6 (37)
19.8 (24)
Track and field (n = 121)
9.9 (9)
8.8 (8)
17.6 (16)
7.7 (7)
15.4 (14)
23.1 (21)
17.6 (16)
Shooting (n = 91)
23.9 (26)
19.3 (21)
38.5 (42)
24.8 (27)
35.8 (39)
45.0 (49)
37.6 (41)
Karate (n = 109)
18.0 (191)
13.0 (138)
27.9 (295)
12.0 (127)
24.0 (254)
32.3 (342)
24.7 (262)
All (n = 1059)
Eur Spine J
Fig. 1 Comparison of the point prevalence of LBP for different sports
Present study finds that 24.7 % of subjects have visited an LBP specialist and 32.3 % of the athletes have used medications for management of their LBP. Evaluating the imaging study of the athletes, it was found that 24 and 12 % of the athletes had undergone plain radiography and MRI to check the etiology of their back pain. Skoffer et al. [34] reported that 1.1 % of their subjects had contacted a medical specialist for treatment of LBP. Differences in the pain-coping behaviors between present study and the study by Skoffer et al. [34] might be due to differences in the health system and insurance policies between the communities. Also, the subjects of the current study were students of medical universities with easy access to all imaging techniques. This might be considered as another reason of higher rate of imaging tests of our subjects compared to previous studies. The results of the current study provided information regarding the prevalence of LBP among young female
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Fig. 2 Comparison of the life-time prevalence of LBP for different sports
Fig. 3 Comparison of the sports-life prevalence of LBP for different sports
athletes at university competitions. This finding could be beneficial for developing sport-specific clinical guidelines for approach to LBP in athletes. Recall bias is a particular concern in any retrospective study which is one of the limitations of the current study as well, and might lead to underestimation of the results. Also, in this study no control group (non-athletic subjects) was recruited and results of other sports were compared with the basketball group. In addition, the pain intensity and functional disability of the subjects were not measured to compare the impact of the LBP on the performance of the athletes. These could be mentioned as another limitation of the study. Future studies may consider investigating the association between LBP
and its correlates in different sport fields with addressing the aforementioned limitations.
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Conclusion Our results indicate that LBP is a common symptom among female college athletes (mean age of 23.1 years) in Iran. The prevalence of LBP among athletes who practice basketball and karate is more than other sports. Also, the rate of imaging tests and visiting the LBP specialists due to back pain is relatively high. Our findings could be beneficial in developing sport-specific clinical guidelines for
Eur Spine J
Fig. 4 Comparison of the 1 year prevalence of LBP for different sports
approach to LBP in athletes. We suggest that future studies consider sport-specific postures and movements while investigating factors that may cause LBP in athletes of each field of sport. Acknowledgments This research has been supported by Tehran University of Medical Sciences and health Services grant. Conflict of interest declare.
The authors have no conflicts of interest to
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