THE PREVA LENCE OF LOW BACK PAIN IN CRICKETERS - AN U N D ERG RADUA TE EPIDEM IO LO G IC AL STUDY by Ian Harris, Dept o f Physiotherapy, University o f Cape Town INTRODUCTION C ricket in South Africa plays a major socio-econom ic role and, through innova­ tions such as the one day limited overs and day-night gam es, is increasingly draw ing the attention of large crow ds throughout the country. Cricket is becom ing far m ore aggressive and faster1 and is placing greater strains on the cricketer's body. The lum bar area of the cricketer is one of the areas that is being placed under increased strain, especially in the fast bow ling action2. This is taking place at a time w hen, w ith increased p ro­ fessionalism , cricketers can least afford to be affected by disabling injuries, such as Low Back Pain (LBP). LBP in itself has far reaching affects on the general com m unity w ith as m uch as 5% of all time absent from w ork being attributed to LBP3. W ith thead ded stresses and strains o f m odern cricket, epidem ic levels o f LBP are expected am ongst cric­ keters. The problem o f LBP is further ag­ gravated by the d ifficulty of m aking an accurate diagnosis. LBP is often charac­ terised by the stooped appearance associ­ ated w ith old age w hich could be harm ful to the self esteem o f a cricketer w ith LBP. Therefore, LBP is not frequently discussed by the cricketing fraternity, m aking it ex­ trem ely difficult to ascertain the tru eextent of LBP in cricketers. T h e dearth o f research on cricket in South Africa and the changing nature of the gam e challenges science and m edicine to explore the various aspects o f the game. METHOD A questionnaire w as given directly to 110 cricketers, 55 from the first team s of five cricket clubs and from five schools in the W estern Cape during the 1991/92 sea­ son. The questionnaire consisted of an in­ itial set of close-ended questions as well as a fu rth er set of op en -en d ed q u estio ns w hich allow ed the respondents to voice their opinions. A grading scale of pain severity was used to m easure LBP. The pain being graded as follows: G rade 1, an ache but could con tin u e playing, G rad e 2, pain w hich forced the player to leave the field and G rade 3, pain w hich prevented the playing of a match. Each respondent w as classified as either a fast bowler (FB), slow bow ler (SB), batsm en (BAT) and a w icket keeper (WK). N um erous cricket practices and mat­ ches w ere visited in order to gain general inform ation on w arm -up m ethods, differ­ ent techniques show n and to obtain a feel for the cricketers' personalties and idio­ syncrasies. The data obtained from the question­ naire w as presented by means of descrip­ tive statistics w ith null hypotheses being formulated and tested b y appropriate stat­ istical tests. RESULTS The return response w as 90%. The mean age w as 20.2 years w ith a range of betw een 15 and 35 years, with 55.6% o f respondents being above 18 years old and 44.4% w ere younger than 18 years. The m ean num ber o f years playing cricket w as 12.3 years with a range betw een 3 and 27. The respondents consisted of 37.4% FB, 58,6% BAT, 27.3% SB and 11.1% WK. PREVALENCE OF INJURY LBP w as present in 61.6% o f the cric­ keters and, o f these, 78,7% cited cricket as being the cause o f the LBP. SEVERITY OF INJURY G rade 1 injuries w ere most prevalent (72.1% ), alth ou gh G rad e 3 inju ries oc- ABSTRACT ^ The prevalence of Low Back Pain (LBP) in cricketer's was determ ined and possible cau­ sa tive factors w ere in vestigated. Q u estion­ naires were sent to 110 cricketers playing for their first times of both clubs and schools during the 1991/92 season. The return response was 90% with a prevalence of LBP at 61.6% . Of these 78.7% cited cricket as being the primary cause of their LBP. The injuries were predom i­ nantly grade 1 (72.1% ), followed by grade 3 (23.1 %) and grade 2 (6.6% ). G rading w as made according to the effect the pain had on the cricketers game. Fast bowlers proved to be more at risk of developing LBP with a group prevalence of 75.6% followed by w icket keepers at 63.6% , batsmen at 56.8% and slow bowlers at 48.1%. Cricketers had rather a poor general knowledge of ways of protecting their backs. Recom mendations were made to help reduce the high prevalence of LBP, especially amongst Fast bowlers and in cricketers in general. curred in a large group (21.3% ). A further indicator o f severity is the large num ber (62.3%) o f cricketers w ho required treat­ m ent for their LBP. GROUP PREVALENCE The la rg e s t p ro p o rtio n o f LBP w as am ongst the fast b ow lers (75.6% ) which proved to be statistically significant with an obtained p-value of 0.06 using the Chi- squared test. Furtherm ore, it w as found that there w as a higher prevalence of LBP in F B 's w ith a front-on action (85.7% ) than in those w ith a sid e-on action (72.4% ). The group o f front-on bow lers w as too small for statistical testing. OTHER FACTORS O f the factors investiga ted (age, num ber o f years playing, w arm -up, various types of exercises, know led ge o f prevention of injuries), the only one that proved to be significant w as the lack o f know ledge that cricketers had o f w ays to protect their backs. O f those cricketers w ho had LBP, only 55.7% said they knew how to protect their backs. Age did n ot prove to be a significant predictor of LBP. ...continued from page 64 the knee-joint. P hysiotherapists treating cycling-related injuries should not treat purely sym ptom atically, and a thorough know ledge of the above-m entioned factors is im perative. The d istinguishing trade­ mark o f the effective practitioner in this c a s e w ill n o t b e h e r k n o w le d g e o f physiotherapy, b u t her know ledge of the sport. REFERENCES 1. Friedm an GD. P rim er o f Epidem iology 1980. M cG raw Hill, New York. 2. K iburz Z, Jaco b s R, R eckling F et al. Bicycle A ccidents and Inju ries am ong Adult Riders. Am ]nl Sports M ed 1986;14(5):416-419. 3. van V elden DP, Roberts T, H um an E et at. F ietsry v irA Im al (1st Ed.) 1990. T afelb erg U it- gew ers, K aapstad. 4. M cLeod W D , Blackburn TA. Biom echanics of K nee Rehabilitation w ith Cycling. A m Jnl Sports M ed 1980;8(3):175-180. 5. Reilly T. Sports Fitness an d Sports Injuries (3rd Ed.) 1981. F aber & Faber, London. 6. Bohlm an JT. Injuries in C om p etitive Cycling. The Phys & Sports M ed 1981;9(5):117-126. 7. Tow n GP. Science o f Triathlon Training and Competition (1st Ed.) 1985. H um an K inetics Publishers, Cham paign, Illinois. 8. H annaford DR, M oran GT, Hlavad HF. Video A nalysis and Treatm ent of O ver-u se Knee Injury in Cycling: A Lim ited C linical Study Clin in Podiatric M ed an d Surg 1986;34:671- 678. 9. M cLen nan JG , M cLen nan JC , U ngersm a J. A ccident P reven tion in C om p etitive C ycling Am Jnl Sports M ed 1988:16(3):266-273. 10. K ruze DL, M cBeath A A . Bicycle A ccidents and Inju ries A m Jnl Sports M ed 1980;8:342- 344. 11. T u cci JJ, Barone JE. A Stu dy o f U rb an Bicy­ c l i n g A c c i d e n t s A m J n l S p o r t s M e d 1988;16(2):181-184. 12. B alham A, A bsou d E m , K otecha MB. A Stu dy o f Bicycle A ccidents Injury A m Jnl Sports M ed 1988;16(6):405-408. 13. M alh oney F. B icycling M agazine's com plete G uide to Riding an d R acing Techniques. 1979. 14. D ubb I, Jacob s L, Sutton P. Inju ries in C y ­ clists. P hysio Forum 1989;3/90:12. 15. N oakes T, Beneke G, Beneke M et al. Lore o f C ycling 1990. O xford U n iv ersity Press, Cape Tow n. I R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) DISCUSSION P R EVALEN CE O F LOW BACK PAIN T h e p re v a le n c e o f L B P fou n d in this s tu d y c o m p a re s w ell w ith th e 4 8 serio u s and less s e r io u s b a c k in ju rie s fo u n d in a s tu d y o f 92 first c la s s c r ic k e te rs b y S tre tc h 4. T h e larg e p ro p o r tio n o f g r a d e 1 in ju ries m ay b e a ttrib u te d to s o ft tissu e p ro b le m s su ch as the m y o fa s c ia l p a in s y n d ro m e , w ith th e b a c k s h o w in g s ig n s o f s tiffn e s s and w e a k n e s s 5. A n o th e r p o s sib le e x p la n a tio n for the h ig h in c id e n c e o f m in o r in ju rie s is the e x ­ tro v ert p e rs o n a lity ty p e o f m o st cric k e te rs, w h ic h m a k e s th em tend to u n d e rp la y their in ju ries. It m u s t a lso b e b o rn e in m in d that L B P , e v en if it is an in n o c u o u s s tra in , can b e to tally d is a b lin g . T h e h ig h p e rc e n ta g e o f c r i c k e t e r s r e q u i r i n g t r e a t m e n t a d d s s tre n g th to the a b o v e s ta te m e n t. G R O U P P R EVALEN CE T h e b o w le r s (75.6% ) p ro v e d to b e the m o st at risk o f d e v e lo p in g L B P . T h is w as c o n firm e d in the s tu d y o f first c la s s c r ic k e t­ in g in ju rie s in S o u th A frica b y S tre tch , w h ic h sh o w e d 6 5 .7 % o f L B P w as c a u s ed by b o w lin g 4. T h e stu d ie s d o n e b y S tre tch and this s tu d y w e re fo cu ss e d on a s se s sm en t o f s ev e rity ra th e r th an a d ia g n o sis o f L B P . If m o r e a c c u r a t e d ia g n o s is o f p a th o lo g y u sin g c o m p u te r is e d to p o g ra p h y w a s used the fin d in g s m a y h a v e b een d iffe re n t6. T h e h ig h p re v a le n c e o f L B P in fa s t b o w ­ lers is n o t s u rp r is in g w h e n o n e co n sid ers th at the fa s t b o w lin g a b s o r b s three tim es th eir b o d y w e ig h t at ru n -u p and up to fou r tim es th eir b o d y w e ig h t at fro n t and rear fo o t c o n ta ct d u rin g the d e liv e r y strid e. T h e s e a b s o rp tio n fo rc e s, to g e th e r w ith a s p in e th at is la te r a lly flex in g , ro ta tin g , e x t e n d i n g a n d b e in g c o m p r e s s e d , c an ca u se trau m a w h ic h , d e s p ite b e in g b elo w the th resh o ld that m u sc le s and jo in ts can to lerate, is a b le to p ro d u c e in ju ry d u e to the r e p e titiv e n a tu r e o f fa s t b o w lin g 7. T h e re p e titiv e n a tu re o f fast b o w lin g can be illu stra ted b y a w o rk to re st ratio w h ic h has b e e n c a lc u la te d as 1:38. T h is m e a n s that, a lth o u g h the rep ea ted trau m a is b e lo w the th r e s h o ld th a t jo i n t s a n d m u s c u lo te n ­ d in o u s s tru c tu re s c a n to le ra te , in ju ry m ay w e ll o ccu r. F o s te r s u g g e sts th at there is a c o m b in a ­ tion o f fa c to rs re s p o n s ib le for L B P , in c lu d ­ in g o n e o r m o r e in a d e q u a t e p h y s ic a l a n d / o r p h y s i o l o g i c a l a t t r i b u t e s , p o o r b o w lin g te c h n iq u e , h i g h p h y s i c a l d e ­ m a n d s an d s u d d e n in c re a se s in tra in in g 7. T h is w a s c o n firm e d b y M e u le m a n w h o s tated th at c h a n g e s in b o w lin g tech n iq u e h a v e cau sed m a n y o f the fa s t b o w le r in­ ju rie s 9. D e s p ite the fa c t th at the fro n t-o n and the s id e -o n te ch n iq u e h a v e sim ila r fo rc es on fro n t fo o t im p a c t, th e sid e-o n te c h n iq u e a llo w s the b o d y to s u m m a te b o d y fo rc es m o re e ffe c tiv e ly 2. KNO W LE D G E O F P R O TE C TIO N A lth o u g h k n o w le d g e o f p ro te c tio n m ay b e a n u n u su a l c o n c e p t to in v e stig a te , it n eed s to b e fu rth er e x p lo red . P h y s io th e ra ­ p ists h ave-for y e a rs b een in v o lv ed in tre a t­ in g L B P an d m o re re c e n tly h a v e em b a rk e d o n p re v e n ta tiv e p ro g ra m m e s, th ro u g h in ­ c r e a s in g the p u b lic 's a w a r e n e s s o f the p o s s ib le c a u s e s o f L B P . H o w e v e r , n o t m u ch h as b e e n d o n e in o rd e r to ed u c a te s p o rtsm e n re g a rd in g the d a n g e rs that their b a c k s are ex p o sed to d u e to the s p e cific m e c h a n ic s o f their sp o rt. T h e d is tin ct lack o f k n o w le d g e fou n d in this s tu d y , to g eth er w ith p o o r b o w lin g tech n iq u e and in a d e q u ­ a te s tr e n g th and fle x ib ility tra in in g are c a u s e s o f L B P in crick eters. C le a rly w e h a v e a re s p o n s ib ility to in c re a se the a w a re ­ n ess o f c ric k e te rs re g a rd in g the p ro b le m o f L B P . O T H E R FACTORS T h e re w a s no re la tio n sh ip b e tw e e n the ag e g ro u p and the p re v a le n c e o f LBP. T h is is in k e e p in g w ith M ich eli w h o n o ted an in c re a se in a d u lt ty p e in ju rie s n o w o c c u r­ rin g in c h ild re n 10. O v e ru s e in ju rie s in a reas su ch as s tre ss fra c tu re s to th e p a rs in terar- ticu la ris and the g ro w th c a rtila g e a re on th e in c r e a s e , as c h ild r e n b e co m e m o re h e a v ily in v o lv ed in crick et. C h ild re n are m o re s u s ce p tib le to o v eru s e in ju rie s than a d u lts b e c a u se o f the e ffe ct it h a s o n s tru c ­ tu res th at are n o t y et m atu re. T h e re w a s a lso n o r e la tio n sh ip b e tw e e n th e n u m b e r o f y e a r s th a t c r ic k e t w a s p lay ed and L BP . H o w e v e r, the n u m b e r o f y e a rs o f p la y in g c ric k e t w a s n 't tru ly re p re ­ s en ta tiv e o f the re p e titiv e n a tu re o f crick et, and d o es n o t d es c rib e the n u m b e r o f re p e ­ titive activ ities in v olv ed in a c ric k e te r's y ear. CONCLUSION T h is s tu d y c an b e see n as a s tep p in g s ton e to fu rth e r re s e a rch in the c o m p lex area o f L BP . F o rtu n a te ly S o u th A frica n s h a v e a d eep d es ire to p ro d u c e c h a m p io n s, and this d es ire in b o th th e c ric k e tin g a u th ­ o ritie s and the p la y e rs w ill re c o g n is e and s u p p o rt fu rth er stu d ies. R E C O M M E N D A T IO N S T h e re is a g r e a t need for c o n tin u in g r e ­ s e a r c h in to the p o s sib le c a u s es o f L B P in c ric k e te rs , e sp ec ia lly in fast b o w lers w ith p o p u la tio n s w h ic h are far m o re d iv erse an d ra n g in g fro m s c h o o lb o y c r ic k e te rs rig h t th ro u g h to in te rn a tio n a l lev el c ric ­ k eters. T h e h e a lth p ro fe s sio n s m u st re a lise that th eir in v o lv e m e n t in trea tin g c ric k e t in ­ ju rie s is an im p o rta n t o n e, n o t o n ly by d e c re a s in g the c r ic k e te r's p ain b u t also by r e s to rin g h im to n o rm al fu n ctio n in g on the c ric k e t field . T h e w a y this c an b e ach ieved is b y ta k in g in to a c c o u n t the c ric k e te r, his p e r s o n a lity an d th e c ric k e tin g e n v iro n ­ m ent. C o a c h e s , c ric k e te rs an d a d m in istra to rs w ill h a v e to a c c e p t th eir ro le in ta c k lin g the p ro b le m o f L BP . S c ie n c e o f the s p o rt s u g ­ g ests g o o d leg, b a c k an d tru n k flex ib ility as w ell as s tre n g th to re d u c e th e la rg e forces p la ced o n the low b a c k . E x c e s s iv e ly lon g b o w lin g s p e lls m u s t b e a v o id e d , e s p e c ia lly in the y o u n g and th o se w h o a r e n 't a c cu s­ tom ed to a h e a v y w o rk lo a d . G o o d tech ­ n iq u e, w ith o u t d e s tro y in g in d iv id u a l flair an d a q u a lity w a rm up s h o u ld b e u n d e r­ tak en at all tim es, an d c r ic k e te rs th em ­ selv e s e n c o u ra g e d to ta k e re s p o n s ib ility for p ro te c tin g th eir b a c k s. C O M M E N T FR O M R E F E R E E S If the a im o f the s tu d y w a s o n ly to id e n t­ ify the p re v a le n c e o f low b a c k p a in in c ric ­ k eters, then it w o u ld h a v e b e e n w o r th ­ w h ile to p ro v id e n o rm a tiv e d ata for the a g e g r o u p s t u d ie d . T h e s c a l e u s e d to m e a s u re pain is lim ite d an d a m o r e a c c u r­ a te m e a s u r e m e n t w o u ld h a v e e n h a n ce d the stu d y . R E F E R E N C E S 1. T e m p le R. C r ic k e t in ju r ie s : F a st P itch e s C hange the G entlem e n 's Sp ort. T he Physician an d Sports M edicin e Ju n e 1982;6(10). 2. Elliot BC, Foster DH . A B io m ech anical A na­ lysis o f the Fro nt-o n and sid e-o n bo w ling te c h n iq u e s , j o u r n a l o f M o v e m e n t S tu d ies 1984;10:83-94. 3. Calliet R. Low Back Pain Syndrom e. FA D avis C om p any, Philadelp hia 1981:5. 4. Stretch RA. In ju ries to So u th A frican cric­ keters p laying at F irst C lass Level. South A f­ rican jou rn al o f Sports M edicin e 1 989;4(l):3-20. 5. Travell JG , Sim ons DG. M y o fascial O rigins of Low Back Pain. P ostgradu ate M edicin e Feb 1983;73(2). 6. F oster D, E lliot B, A ckland et al. B ack Injuries to Fast B ow lers in C ricket: A P rospective Study. British Jou rn al o f Sports M edicin e Sept 1989;2(4):40-47. 8. Radin EL, Sim on SR , R ose R M et al. Practical B iom echanics f o r the O rthopaedic Surgeon. J W iley and Sons, N ew York 1979. 9. M eu lem an K. Q u ick ies are the w orkhorses. In th e S u n d a y I n d e p e n d e n t N e w s p a p e r 6 M arch 1983, Perth. 10. M icheli LJ et al. A etio logical assessm en t of overuse stress fractu res in ath letes.’Nou Sco­ tia M ed Bull 1983;59:43-47. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )