Parameters of low back pain chronicity among athletes: Associations with physical and mental stress

Highlights

• Low back pain (LBP) chronification is associated with stress in athletes.

• Physical stress plays a predominant role for athletes' perceived pain.

• The findings pronounce the value of biopsychosocial approaches for LBP in athletes.

• Monitoring of athletes' stress seems to be important to prevent chronic LBP.

Abstract

Objective

In the general population, physical and mental stress factors are linked to chronic low back pain (LBP). The aim of the present study was to examine this association among athletes.

Design

Longitudinal study with a six-month interval between measurements.

Setting

Questionnaires were filled out at home, either in paper–pencil version or online.

Participants

Eighty-two male and 57 female athletes (N = 139, M_Age = 32.24) who exercise on a competitive (n = 102) or recreational level (n = 37), with a weekly training volume of at least 3 h.

Main outcome measures

At T₀, stress parameters were assessed via the Recovery-Stress Questionnaire (RESTQ-Basic-48) and the Screening Scale of the Trier Inventory for the Assessment of Chronic Stress (TICS-SSCS). At T₀ and T₁, different chronification indicators were measured. Based on these assessments, the sample was split into a chronification and no-chronification group.

Results

ANCOVAs were used to conduct group comparisons with regard to stress levels. The chronification groups showed higher stress values for all chronification indicators. For the variables Physical Complaints and Overall Stress-TICS, the group differences became significant (p < .05).

Conclusion

A relationship between stress parameters and LBP chronification was demonstrated among athletes for the first time.

Introduction

Athletes are frequently confronted with physically challenging tasks. The performance of uncontrollable and demanding movements (e.g., body checking in ice hockey) is part of the training and competition routine in both contact and noncontact sports. As a result, athletes repeatedly suffer from persistent strains, especially in the lower back (Foss, Holme, & Bahr, 2012).

Trainor and Trainor (2004) summarized etiologic data from different studies comparing athletes' low back pain (LBP) prevalence rates. Several factors (e.g., age, type of sport) seem to affect the development of LBP. Bahr, Andersen, Loken, Fossan, Hansen, and Holme (2004) demonstrated that endurance athletes in sports like rowing or cross-country skiing revealed a higher rate of LBP compared to nonathletic control groups. Their findings suggest that LBP appears to be a considerable burden across the abovementioned disciplines, with lifetime prevalence rates ranging between 51% and 65%. Specifically, a regular hyperextension of the back (e.g., figure skating, tennis) can cause injuries in the spine region and back-related problems (Bono, 2004, Hoskins, 2012, Schmidt et al., 2014).

Furthermore, a transition from acute LBP into a chronic condition may lead to several detrimental consequences. An ongoing chronification of LBP can result in diminished performance, injuries, and muscular deficits with regard to strength and flexibility (Ashmen and Swanik, 1996, de Jonge and Kramer, 2014, Nadler et al., 2002). Persistent LBP may even lead to a dropout of affected athletes and under elite conditions, to a loss of their main occupation (Hopkins and White, 1993, Maffulli et al., 2010). Approaches to cope with chronic LBP in athletes are primarily based on biomechanical and anatomical theories, as the development of chronic LBP in athletes is largely explained by these physiological approaches (Bahr et al., 2004, Daniels et al., 2011). Nevertheless, many athletes continue to suffer from pain and disability symptoms without underlying tissue pathology (Iwamoto, Takeda, & Wakano, 2004). For athletes, Puentedura and Louw (2012) recommend a biopsychosocial approach of LBP examination with a special focus on psychosocial factors. Hoskins (2012) and Wiech, Ploner, and Tracey (2008) state that psychological and stress-related factors can potentially be associated with a chronification of LBP among athletes.

Stress is a multifaceted and omnipresent phenomenon for athletes. External factors influence an athlete's experience of stress, for example extensive travel times or a high training volume. Several influences interact and require the athlete's physiological and psychological resources (e.g., stamina, concentration) (Hanton et al., 2005, Mellalieu et al., 2009). A subsequent stress response can manifest on a physiological, emotional, social, or cognitive level (Buckworth, Dishman, O'Connor, & Tomporowski, 2013). In case sufficient recovery fails to appear, chronic stress can develop contributing to several detrimental outcomes (Kellmann, 2000, Kellmann, 2002). Dysfunctional stress patterns among athletes can generate health-related problems that could lead to severe diseases. For example, they may affect the immune system (Clow & Hucklebridge, 2001), the mental health (Hughes & Leavey, 2012), and the musculoskeletal system (Brenner, 2007, Galambos et al., 2005).

For LBP, there is a paucity of studies examining the association with stress in sport participants, although the relationship between acute and chronic LBP and different facets of stress has been comprehensively studied in the general population (Linton, 2000, Pincus et al., 2002). Identically, the role of stress has been considered in thematically-related fields, such as injuries among athletes (Andersen and Williams, 1999, Galambos et al., 2005, Laux et al., 2015, Williams and Andersen, 2007). Only Galambos et al. (2005) emphasize the impact of mood and stress factors for the prediction of back pain. The findings are in line with the assumptions from other research in this field (Hoskins, 2012, Puentedura and Louw, 2012, Standaert et al., 2004) and underline a potential association between stress and LBP in sport samples.

For this reason, the purpose of the present study was to examine the role of stress in the context of LBP chronification among athletes. Specifically, we investigated the prediction of different facets of stress with regard to pain and disability indicators of LBP chronification. It was hypothesized that athletes with higher physical and psychological stress loads tend to show LBP chronification over time. To the best of our knowledge, neither for the onset of LBP, nor for the chronification of LBP, stress-related factors among athletes have been examined.