Trunk muscle onset and cessation in golfers with and without low back pain

Potential neurophysiological and biomechanical risk factors for sport-related back problems: A scoping review

This scoping review aims (1) to map the literature dealing with neurophysiological and biomechanical aspects of back problems in athletes in order to identify valid risk-factors for their prevention, plus (2) to identify gaps in the existing research and propose suggestions for future studies. A literature search conducted with Scopus, Web of Science, MEDLINE and Cochrane Library was completed by Elsevier, SpringerLink and Google Scholar. The main neurophysiological risk factors identified leading to back problems in athletes are neuromuscular imbalance, increased muscle fatigability, muscle dysfunction and impaired motor control, whilst biomechanical risk factors include maladaptive spinal, spinopelvic and lower limb kinematics, side-to-side imbalances in axial strength and hip rotation range of motion, spinal overloading and deficits in movement pattern. However, most studies focused on back pain in the lumbar region, whereas less attention has been paid to thoracic and cervical spine problems. The range of sports where this topic has been studied is relatively small. There is a lack of research in sports in which the core muscles are highly involved in specific movements such as lifting weights or trunk rotations. A limited number of studies include female athletes and master athletes of both genders. In addition to chronic back pain patients, it is equally important to conduct research on healthy athletes with a predisposition to spine problems. Investigators should focus their empirical work on identifying modifiable risk factors, predict which athletes are at risk for back problems, and develop personalized sport-specific assessment tools and targeted prevention strategies for them. This review was registered using the Open Science Framework Registries (https://osf.io/ha5n7).

Biomechanical parameters of the golf swing associated with lower back pain: A systematic review

Low back pain (LBP) is the most common injury in golfers of all abilities. The primary aim of this review was to improve understanding of human golf swing biomechanics associated with LBP. A systematic review using the PRISMA guidelines was performed. Nine studies satisfying inclusion criteria and dually reporting golf swing biomechanics and LBP were identified. Human golf swing biomechanics potentially associated with LBP include: reduced lumbar flexion velocity; reduced transition phase length; reduced lumbar torsional load; earlier onset of erector spinae contraction; increased lumbar lateral flexion velocity; reduced or greater erector spinae activity; and earlier onset of external oblique contraction. These potential associations were undermined by a very limited and conflicting quality of evidence, study designs which introduced a severe potential for bias and a lack of prospective study design. There is no conclusive evidence to support the commonly held belief that LBP is associated with "poor" golf swing technique. The potential associations identified should be further investigated by prospective studies of robust design, recruiting participants of both sexes and dexterities. Once firm associations have been identified, further research is required to establish how this knowledge can be best integrated into injury prevention and rehabilitation.

A Targeted Approach to Evaluating the Golfing Athlete with Low Back Pain: A Resident's Case Report

BACKGROUND AND PURPOSE

Low back pain is one of the most common conditions occurring in the golfing population. Many approaches have been utilized throughout the years to address this condition including the concept of regional interdependence. The purpose of this case report is to describe the evaluation process and treatment approach of a golfer with low back pain using the principles of regional interdependence.

CASE DESCRIPTION

A thirty-year-old male with right-sided low back pain was evaluated using a comprehensive approach including golf specific movement screening and a swing evaluation. The patient had mobility restrictions in his thoracic spine and hips that appeared to be contributing to a hypermobility in the lower lumbar spine. Based on the evaluation, he was placed into the treatment-based classification (TBC) of stabilization but would also benefit from mobilization/manipulation techniques.

OUTCOMES

After seven visits over a four-week span, the patient's mobility and core stability both improved and he was able to play golf and workout pain free. His outcome measures also improved, including the revised Oswestry Disability index from 26% disabled to 10%, the Fear Avoidance Behavior Questionnaire (FABQ) Work from 10/42 to 3/42, and the FABQ Physical Activity from 19/24 to 6/24.

DISCUSSION

Evaluating and developing a plan of care to address low back pain in an avid golfer can be challenging as a variety of demands are placed on the spine during the movement. This case report describes the evaluation process and treatment approach to specifically target the demands that are required during the golf swing. Utilizing a targeted approach that includes golf specific movement screening and a swing evaluation can help guide the therapist in their treatment and improve the patient's outcome.

LEVEL OF EVIDENCE

Level 4.

Is average club head speed a risk factor for lower back injuries in professional golfers? A retrospective case control study

BACKGROUND

Our hypothesis was that higher average club head speed is correlated with lower back injuries in professional golfers.

METHODS

This was a retrospective case control study of male professional golfers who suffered lower back injuries while playing golf. The injured group was composed of 14 Professional Golfers' Association (PGA) golfers who withdrew from a PGA tour event due to a back injury during the years 2017-2019. The case-control matching procedure was used to randomly match cases and controls with a 2:1 allocation ratio, respectively, based on age. Variables were chosen based on currently proposed risk factors. Data was statistically analyzed using SPSS 25.

RESULTS

There were 14 PGA golfers who suffered lower back injuries during the years 2017-2019 who were included in this study. There was no significant difference in age, height, weight or BMI between the injured and control group. The injured group had a higher mean club head speed than the control group (P < 0.01).

CONCLUSION

This study found that average club head speed was significantly higher in PGA golfers who suffered back injuries while golfing during a two-year period (2017-2019) when compared with age-matched controls.

Transverse abdominis activity and ultrasound biofeedback in college golfers with and without low back pain

OBJECTIVES

To compare transverse abdominis (TrA) muscle activity in college golfers with and without a history of low back pain (LBP) and examine the effects of ultrasound biofeedback and a functional golf-setup position on TrA activity.

DESIGN

Crossover study.

SETTING

Laboratory.

PARTICIPANTS

Thirty-two (n = 32) collegiate golfers were stratified into either the LBP group (n = 16, 4.6 ± 4.5 LBP episodes) or non-LBP group (n = 16, 0.1 ± 0.3 LBP episodes) based on LBP episodes in the last 6-months.

MAIN OUTCOME MEASURES

Ultrasound measures of TrA activity were performed during standard contractions and contractions with ultrasound biofeedback. Contraction-type order was randomized between two visits. Testing was performed in two positions, supine and golf-setup positions.

RESULTS

We observed no significant differences in TrA activity between the LBP and non-LBP groups. Overall, TrA activity was greater during biofeedback contractions compared to standard contractions, and TrA activity was lower in the golf-setup position compared to the supine position.

CONCLUSIONS

We observed no differences in TrA activity between college golfers with and without LBP. College golfers with and without LBP demonstrated a greater ability to contract their TrA with real-time ultrasound biofeedback and a lower ability to contract their TrA in the functional golf-setup position compared to the traditional supine position.

Return to Recreational Sport Following Lumbar Fusion

STUDY DESIGN

This was a retrospective questionnaire study at a single academic medical center.

OBJECTIVE

The objective of this study was to obtain information on rates of return to sport following lumbar fusion as well as sport-specific effects to improve evidence-based preoperative patient counseling.

SUMMARY OF BACKGROUND DATA

Lumbar spinal fusion is one of the fastest-growing surgical procedures, with the majority being in patients aged 60 years and older. Remaining active is an important consideration for elderly patients undergoing lumbar spinal fusion. Golf, swimming, and biking are common forms of recreational exercise for an older population in whom lumbar fusion is often performed. There is a lack of data in the current literature regarding rates of return to recreational sporting activities following elective lumbar fusion.

METHODS

Following Institutional Review Board approval, all patients undergoing lumbar fusion at a single institution from 2012 to 2016 were screened and included in this study. A minimum of 1-year postoperative follow-up was required. A total of 117 patients were identified undergoing single-level or multilevel lumbar fusion during this time period. The average age was 63 years. Questionnaires were obtained to screen and identify patients who participated in 1 of 3 recreational sports before surgery (golf, swimming, and biking). Preoperative and postoperative collected outcome measures were then compared using the Student t test.

RESULTS

Of the 117 identified lumbar fusion patients, 32 patients (27%) participated in 1 of the 3 most common recreational sporting activities of golf, swimming, or biking. Within the golf cohort (n=13), 100% of patients returned to recreational golfing postoperatively. There was a statistically significant reduction in Visual Analog Scale (VAS) pain scores postoperatively (6.3±3.7-1.8±2.4, P=0.01). Driving distance was reduced postoperatively (223.3±42.7-212.1±44.4 yards, P=0.042) and handicaps increased (12.8±8.4-17.0±11.4, P=0.02). Within the swimming cohort (n=9), 100% of patients returned to recreational swimming following lumbar fusion. There was a statistically significant reduction in VAS pain scores postoperatively (9.1±1.7-2.2±2.3, P=0.01). There was a trend towards increased amounts of swimming (times per week) postoperatively, however, this was not statistically significant (2.1±1.7-3.7±1.5, P=0.10). Within the biking cohort (n=10), 100% of patients returned to recreational biking following lumbar fusion. There was a statistically significant reduction in VAS pain scores postoperatively (6.7±4.0-1.3±1.7, P=0.03). There was a trend towards increased amounts of biking (times per week) postoperatively, however, this was not statistically significant (2.5±1.8-3.7±1.6 postoperatively, P=0.20).

CONCLUSIONS

In the cohort of patients from this study who partook in golfing, swimming or bicycling, 100% were able to return to their respective sport by 3-9 months postoperatively and all had a significant reduction in pain. With regards to golfers, lumbar fusion likely has an adverse effect on their golfing ability with an increase in handicap and an expected reduction in driving distance.

Low back pain and golf: A review of biomechanical risk factors

Golf is an international sport played by a variety of age groups and fitness levels, and although golf has a low to moderate aerobic intensity level, injuries are common among professional and amateur golfers. High amounts of force experienced during the golf swing can lead to injury when golfers lack appropriate strength or technique with the lower back most commonly injured. Research has indicated that trunk muscle activation, hip strength and mobility, and pelvis and trunk rotation are associated with low back pain (LBP). Based on anecdotal evidence, golf practitioners specifically address issues in weight shift, lumbar positioning, and pelvis sequencing for golfers with LBP. This review aims to elucidate the effects of proper and improper golf swing technique on LBP and to help golf practitioners understand how to approach the alleviation of LBP in their clientele.

Risk Factors Associated With Low Back Pain in Golfers: A Systematic Review and Meta-analysis

Context:

Low back pain is common in golfers. The risk factors for golf-related low back pain are unclear but may include individual demographic, anthropometric, and practice factors as well as movement characteristics of the golf swing.

Objective:

The aims of this systematic review were to summarize and synthesize evidence for factors associated with low back pain in recreational and professional golfers.

Data Sources:

A systematic literature search was conducted using the PubMed, CINAHL, and SPORTDiscus electronic databases through September 2017.

Study Selection:

Studies were included if they quantified demographic, anthropometric, biomechanical, or practice variables in individuals with and without golf-related low back pain.

Study Design:

Systematic review and meta-analysis.

Level of Evidence:

Level 3.

Data Extraction:

Studies were independently reviewed for inclusion by 2 authors, and the following data were extracted: characterization of low back pain, participant demographics, anthropometrics, biomechanics, strength/flexibility, and practice characteristics. The methodological quality of studies was appraised by 3 authors using a previously published checklist. Where possible, individual and pooled effect sizes of select variables of interest were calculated for differences between golfers with and without pain.

Results:

The search retrieved 73 articles, 19 of which met the inclusion criteria (12 case-control studies, 5 cross-sectional studies, and 2 prospective longitudinal studies). Methodological quality scores ranged from 12.5% to 100.0%. Pooled analyses demonstrated a significant association between increased age and body mass and golf-related low back pain in cross-sectional/case-control studies. Prospective data indicated that previous history of back pain predicts future episodes of pain.

Conclusion:

Individual demographic and anthropometric characteristics may be associated with low back pain, but this does not support a relationship between swing characteristics and the development of golf-related pain. Additional high-quality prospective studies are needed to clarify risk factors for back pain in golfers.

INVESTIGATION OF WEIGHT-BEARING SYMMETRY IN A GROUP OF ATHLETES WITH LOW BACK PAIN AND HEALTHY PEOPLE DURING GAIT

The asymmetrical loading applied to legs was proposed as a risk factor for low back pain development. However, this proposed mechanical risk factor was not investigated in the athletes with LBP engaged in rotational demand activities. The aim of the present study was to examine symmetry of weight-bearing in patients with rotational demand activities compared to that in healthy people during gait. In total, 35 subjects, 15 males with LBP and 20 males without LBP, participated in the study. The participants were asked to walk 12 trials in gait lab. Forces applied to legs were recorded by a force plate. Then, the peaks of anteroposterior, mediolateral, and vertical forces were measured. Next, the asymmetrical loads applied to the legs were calculated. The results of our study demonstrated that people with LBP exhibit more asymmetry of vertical peak forces in heel strike and mid-stance. They also exhibited more asymmetry of loading in the anterior direction. But the mean values of ASI of mediolateral and posterior forces in these participants were not significantly different compared to those in the control group. It can be concluded that, in comparison to the healthy subjects, patients with LBP walk with a greater magnitude of asymmetrical weight-bearing at a comfortable speed.

The Biomechanics of the Modern Golf Swing: Implications for Lower Back Injuries

The modern golf swing is a complex and asymmetrical movement that places an emphasis on restricting pelvic turn while increasing thorax rotation during the backswing to generate higher clubhead speeds at impact. Increasing thorax rotation relative to pelvic rotation preloads the trunk muscles by accentuating their length and allowing them to use the energy stored in their elastic elements to produce more power. As the thorax and pelvis turn back towards the ball during the downswing, more skilled golfers are known to laterally slide their pelvis toward the target, which further contributes to final clubhead speed. However, despite the apparent performance benefits associated with these sequences, it has been argued that the lumbar spine is incapable of safely accommodating the forces they produce. This notion supports a link between the repeated performance of the golf swing and the development of golf-related low back injuries. Of the complaints reported by golfers, low back injuries continue to be the most prevalent, but the mechanism of these injuries is still poorly understood. This review highlights that there is a paucity of research directly evaluating the apparent link between the modern golf swing and golf-related low back pain. Furthermore, there has been a general lack of consensus within the literature with respect to the methods used to objectively assess the golf swing and the methods used to derived common outcome measures. Future research would benefit from a clear set of guidelines to help reduce the variability between studies.

How to quantify the transition phase during golf swing performance: Torsional load affects low back complaints during the transition phase

The transition phase of a golf swing is considered to be a decisive instant required for a powerful swing. However, at the same time, the low back torsional loads during this phase can have a considerable effect on golf-related low back pain (LBP). Previous efforts to quantify the transition phase were hampered by problems with accuracy due to methodological limitations. In this study, vector-coding technique (VCT) method was proposed as a comprehensive methodology to quantify the precise transition phase and examine low back torsional load. Towards this end, transition phases were assessed using three different methods (VCT, lead hand speed and X-factor stretch) and compared; then, low back torsional load during the transition phase was examined. As a result, the importance of accurate transition phase quantification has been documented. The largest torsional loads were observed in healthy professional golfers (10.23 ± 1.69 N · kg^-1), followed by professional golfers with a history of LBP (7.93 ± 1.79 N · kg^-1), healthy amateur golfers (1.79 ± 1.05 N · kg^-1) and amateur golfers with a history of LBP (0.99 ± 0.87 N · kg^-1), which order was equal to that of the transition phase magnitudes of each group. These results indicate the relationship between the transition phase and LBP history and the dependency of the torsional load magnitude on the transition phase.

Return to Golf After Lumbar Fusion

Background:

Spinal fusion surgery is being increasingly performed, yet few studies have focused on return to recreational sports after lumbar fusion and none have specifically analyzed return to golf.

Hypothesis:

Most golfers successfully return to sport after lumbar fusion surgery.

Study Design:

Case series.

Level of Evidence:

Level 4.

Methods:

All patients who underwent 1- or 2-level primary lumbar fusion surgery for degenerative pathologies performed by a single surgeon between January 2008 and October 2012 and had at least 1-year follow-up were included. Patients completed a specifically designed golf survey. Surveys were mailed, given during follow-up clinic, or answered during telephone contact.

Results:

A total of 353 patients met the inclusion and exclusion criteria, with 200 responses (57%) to the questionnaire producing 34 golfers. The average age of golfers was 57 years (range, 32-79 years). In 79% of golfers, preoperative back and/or leg pain significantly affected their ability to play golf. Within 1 year from surgery, 65% of patients returned to practice and 52% returned to course play. Only 29% of patients stated that continued back/leg pain limited their play. Twenty-five patients (77%) were able to play the same amount of golf or more than before fusion surgery. Of those providing handicaps, 12 (80%) reported the same or an improved handicap.

Conclusion:

More than 50% of golfers return to on-course play within 1 year of lumbar fusion surgery. The majority of golfers can return to preoperative levels in terms of performance (handicap) and frequency of play.

Clinical Relevance:

This investigation offers insight into when golfers return to sport after lumbar fusion surgery and provides surgeons with information to set realistic expectations postoperatively.

Comparison of Muscle Onset Activation Sequences between a Golf or Tennis Swing and Common Training Exercises Using Surface Electromyography: A Pilot Study

Aim. The purpose of this pilot study is to use surface electromyography to determine an individual athlete's typical muscle onset activation sequence when performing a golf or tennis forward swing and to use the method to assess to what degree the sequence is reproduced with common conditioning exercises and a machine designed for this purpose. Methods. Data for 18 healthy male subjects were collected for 15 muscles of the trunk and lower extremities. Data were filtered and processed to determine the average onset of muscle activation for each motion. A Spearman correlation estimated congruence of activation order between the swing and each exercise. Correlations of each group were pooled with 95% confidence intervals using a random effects meta-analytic strategy. Results. The averaged sequences differed among each athlete tested, but pooled correlations demonstrated a positive association between each exercise and the participants' natural muscle onset activation sequence. Conclusion. The selected training exercises and Turning Point™ device all partially reproduced our athletes' averaged muscle onset activation sequences for both sports. The results support consideration of a larger, adequately powered study using this method to quantify to what degree each of the selected exercises is appropriate for use in both golf and tennis.

Multi-segment trunk models used to investigate the crunch factor in golf and their relationship with selected swing and launch parameters

The use of multi-segment trunk models to investigate the crunch factor in golf may be warranted. The first aim of the study was to investigate the relationship between the trunk and lower trunk for crunch factor-related variables (trunk lateral bending and trunk axial rotation velocity). The second aim was to determine the level of association between crunch factor-related variables with swing (clubhead velocity) and launch (launch angle). Thirty-five high-level amateur male golfers (Mean ± SD: age = 23.8 ± 2.1 years, registered golfing handicap = 5 ± 1.9) without low back pain had kinematic data collected from their golf swing using a 10-camera motion analysis system operating at 500 Hz. Clubhead velocity and launch angle were collected using a validated real-time launch monitor. A positive relationship was found between the trunk and lower trunk for axial rotation velocity (r(35) = .47, P < .01). Cross-correlation analysis revealed a strong coupling relationship for the crunch factor (R(2) = 0.98) between the trunk and lower trunk. Using generalised linear model analysis, it was evident that faster clubhead velocities and lower launch angles of the golf ball were related to reduced lateral bending of the lower trunk.

Recurrence quantification analysis and support vector machines for golf handicap and low back pain EMG classification

The quantification of non-linear characteristics of electromyography (EMG) must contain information allowing to discriminate neuromuscular strategies during dynamic skills. There are a lack of studies about muscle coordination under motor constrains during dynamic contractions. In golf, both handicap (Hc) and low back pain (LBP) are the main factors associated with the occurrence of injuries. The aim of this study was to analyze the accuracy of support vector machines SVM on EMG-based classification to discriminate Hc (low and high handicap) and LBP (with and without LPB) in the main phases of golf swing. For this purpose recurrence quantification analysis (RQA) features of the trunk and the lower limb muscles were used to feed a SVM classifier. Recurrence rate (RR) and the ratio between determinism (DET) and RR showed a high discriminant power. The Hc accuracy for the swing, backswing, and downswing were 94.4±2.7%, 97.1±2.3%, and 95.3±2.6%, respectively. For LBP, the accuracy was 96.9±3.8% for the swing, and 99.7±0.4% in the backswing. External oblique (EO), biceps femoris (BF), semitendinosus (ST) and rectus femoris (RF) showed high accuracy depending on the laterality within the phase. RQA features and SVM showed a high muscle discriminant capacity within swing phases by Hc and by LBP. Low back pain golfers showed different neuromuscular coordination strategies when compared with asymptomatic.

Lumbopelvic kinematic characteristics of golfers with limited hip rotation

BACKGROUND

While the biomechanical characteristics of the golf swing are well established, the lumbopelvic kinematic characteristics of professional golfers with limited hip internal rotation warrant further investigation.

PURPOSE

The specific aim was to ascertain mechanical differences in lumbopelvic-hip movement of asymptomatic professional golfers with and without limited hip internal rotation during the golf swing.

STUDY DESIGN

Controlled laboratory study.

METHODS

Thirty professional male golfers (aged 25-35 years and 0 handicap matched) were classified into either the limited hip internal motion (LHIM) group (range of motion<20°) or the normal hip internal motion (NHIM) group (range of motion≥30°). All participants underwent clinical tests (muscle strength, muscle length, and range of motion) and a biomechanical assessment using 8 infrared optic cameras in a motion analysis system. Independent t tests were performed to determine potential mean differences in muscle strength, length, and range of motion and lumbopelvic kinematics at P<.05.

RESULTS

Kinematic analysis revealed that the LHIM group showed significantly greater lumbar flexion (P<.001), right and left axial rotation (P<.025), and right-side lateral bending (P=.003) than the NHIM group. A greater pelvic posterior tilt was observed in the LHIM group when compared with the NHIM group (P=.021). Clinical tests showed reduced internal rotator muscle strength and shorter muscle length in the iliopsoas (P=.017) and hamstring (P<.001) among those in the LHIM group when compared with the NHIM group.

CLINICAL RELEVANCE

The study data suggest that constraints to hip joint internal rotation, along with muscle strength imbalances between the agonist and antagonist muscles and muscle tightness, are associated with substantially greater lumbopelvic movement during the golf swing.

Biomechanical effect of altered lumbar lordosis on intervertebral lumbar joints during the golf swing: a simulation study

Although the lumbar spine region is the most common site of injury in golfers, little research has been done on intervertebral loads in relation to the anatomical-morphological differences in the region. This study aimed to examine the biomechanical effects of anatomical-morphological differences in the lumbar lordosis on the lumbar spinal joints during a golf swing. The golf swing motions of ten professional golfers were analyzed. Using a subject-specific 3D musculoskeletal system model, inverse dynamic analyses were performed to compare the intervertebral load, the load on the lumbar spine, and the load in each swing phase. In the intervertebral load, the value was the highest at the L5-S1 and gradually decreased toward the T12. In each lumbar spine model, the load value was the greatest on the kypholordosis (KPL) followed by normal lordosis (NRL), hypolordosis (HPL), and excessive lordosis (EXL) before the impact phase. However, results after the follow-through (FT) phase were shown in reverse order. Finally, the load in each swing phase was greatest during the FT phase in all the lumbar spine models. The findings can be utilized in the training and rehabilitation of golfers to help reduce the risk of injury by considering individual anatomical-morphological characteristics.

The crunch factor's role in golf-related low back pain

BACKGROUND CONTEXT

The golf swing exposes the spine to complex torsional, compressive, and shearing loads that increase a player's risk of injury. The crunch factor (CF) has been described as a measure to evaluate the risk of low back injuries in golfers and is based on the notion that lateral flexion and axial trunk rotation jointly contribute to spinal degeneration. However, few studies have evaluated the appropriateness of this measure in golfers with low back pain (LBP).

PURPOSE

To objectively examine the usefulness of the CF as a measure for assessing the risk of low back injury in golfers.

STUDY DESIGN

Field-based research using a cross-sectional design.

METHODS

This research used three-dimensional motion analysis to assess the golf swings of 12 golfers with LBP and 15 asymptomatic controls. Three-dimensional kinematics were derived using Vicon Motus, and the CF was calculated as the instantaneous product of axial trunk rotation velocity and lateral trunk flexion angle.

RESULTS

Maximum CFs and their timings were not significantly different between the symptomatic and asymptomatic groups. Furthermore, for those golfers who produced higher CFs (irrespective of the group), the increased magnitude could not be attributed to an increased axial angular trunk velocity or lateral flexion angle, but rather to a concomitant increase in both of these variables.

CONCLUSIONS

The findings suggested that although the fundamental concepts that underpin the CF seem sensible, this measure does not appear to be sensitive enough to distinguish golfers with LBP from the asymptomatic players.