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SPHXXX10.1177/1941738116676260Streisfeld et alSports Health

vol. 9 • no. 1 SPORTS HEALTH

[ Physical Therapy ]

Relationship Between Body Positioning,
Muscle Activity, and Spinal Kinematics in
Cyclists With and Without Low Back Pain:
A Systematic Review
Gabriel M. Streisfeld, DPT,*† Caitlin Bartoszek, DPT,† Emily Creran, DPT,† Brianna Inge, DPT,†
Marc D. McShane, DPT,† and Therese Johnston, PT, PhD, MBA†

Context: Low back pain is reported by more than half of cyclists. The pathomechanics and association of risk factors of
lumbar spine overuse injuries in cycling are not clearly understood.
Objective: To determine whether relationships exist between body positioning, spinal kinematics, and muscle activity in
active cyclists with nontraumatic low back pain.
Data Sources: In August of 2015 and April of 2016, a comprehensive search of the PubMed, CINAHL, Ovid MEDLINE, and
Scopus databases was performed independently by 5 reviewers.
Study Selection: Included articles consisted of biomechanical studies examining factors relating to low back pain in
cyclists as agreed upon by group consensus.
Study Design: Systematic review.
Level of Evidence: Level 4.
Data Extraction: Five reviewers appraised by consensus each article using the Downs and Black checklist.
Results: Eight studies met criteria for this review. There is evidence that cyclists with lower handlebar heights displayed
increased lumbosacral flexion angles during cycling. Core muscle activation imbalances, back extensor endurance deficits,
and increased lumbar flexion while cycling were found to be present in cyclists with low back pain.
Conclusion: Spinal and core muscle activation imbalances in a prolonged flexed posture associated with cycling may lead
to maladaptive spinal kinematics and increased spinal stresses contributing to overuse low back pain.
Keywords: cycling; low back pain; muscle activity; spinal kinematics

n cycling, the occurrence of traumatic and nontraumatic During cycling, various positions are used to achieve proper
(overuse) injuries is about equal,12 with approximately 23 million aerodynamics to increase speed and efficiency, including
cyclists developing at least 1 overuse injury in their lifetime in lumbar spine flexion.7,20,31,32 A flexed spinal position commonly
the United States alone.6,22,35 The majority (51.5%) of cycling- adopted by cyclists inverts the physiologic intervertebral angle,
related injuries reported over a 4-year period were considered due changing the area of spinal loading.32 Sustained or repeated
to overuse.5,12 Of these overuse injuries, low back pain (LBP) is lumbar flexion is associated with LBP,8,11,29 and the term flexion
the most prevalent.10,13 Fifty-eight percent of professional cyclists pattern disorder describes positional changes that occur in
reported LBP, of which 41% sought medical attention, and up to conjunction with nontraumatic LBP.7,14,28 Core stability is
22% of cyclists with LBP lost time from activity.10 essential to increase cycling power.1,32 Bicycle component
From the †Department of Physical Therapy, Thomas Jefferson University, Philadelphia, Pennsylvania
*Address correspondence to Gabriel M. Streisfeld, DPT, 8355 Applebrook Terrace, Apartment #106, Raleigh, NC 27617 (email:
The authors report no potential conflicts of interest in the development and publication of this article.
DOI: 10.1177/1941738116676260
© 2016 The Author(s)


and professional competitive off-road. 1. review is to determine whether relationships exist between The number of subjects ranged from 1 to 120 subjects. aged 18 to 57 years (weight. and spinal muscle activity total of 255 subjects. Ovid MEDLINE. resulting in 50 Four studies3. flexibility. studies were of low to moderate quality.43- Methods 72. nonspecific LBP. flexibility. muscle fatigue. focusing on cyclists with nontraumatic LBP. and overactivation of back extensors. with a body positioning. or overuse LBP. there is (see the Appendix.34 and Scopus. lead to Data Collection lumbar overuse injury. Streisfeld et al Jan • Feb 2017 settings affect spine position during cycling.33.16 The Downs and Black scale is considered a Another mechanism is the flexion-relaxation phenomenon. bike fit shows the strongest relationship with LBP in cyclists. and conclusions risk to ligaments and intervertebral discs.18 Data extracted from articles included shift to the passive spine structures of the spine. abstracts were screened based on blinding occurred in any studies. Search results were compiled and screened for titles of relevance using group consensus. it is hypothesized that altered search (Figure 1).25 professional.22. including muscle activation asymmetries. spinal kinematics or core muscle activation patterns. several risk factors are related to LBP in cyclists.21.34 had sample sizes of less than 20 participants.13. The median Downs and Black score of the studies was 12 of 27.22 From the the impact of bike fit on overuse LBP in cyclists in relation to second search. disc quality and risk of bias.25.19 Thus. however. in cyclists with nontraumatic LBP and how bike fit affects these Study Characteristics factors.6-1. ranging from elite. cross-sectional studies.31 However.33.85 m). Furthermore. spinal kinematics. Three studies4. 76 . and bicycle in subjects experiencing Four studies3. Nine articles were excluded due to in 29 of 40 cyclists and decreased pain in 8 others. The frames included a rigid frame (rigid fork. spinal position or angles. thus increasing participant population. search included the general terms cycling.4 with no definitions provided for these categories. which subsequently April 1. and 1 was a Search Strategy single case study.30. Studies included Methodology and Outcomes were comparison studies. LBP.57 kg. fixed rear. bicycling AND back pain.18 No Of the 50 articles selected. combined with the prolonged repetitive nature of the activity. 2016. the other risk factors is unclear.sagepub.34 reported cycling experience ranging from 6 combinations across databases: cycling AND low back pain.17. CINAHL. in valid and reliable checklist for nonrandomized studies and was which deactivation of the erector spinae and/or multifidus deemed most appropriate due to the observational nature of the muscles with a flexed spine causes vertebral body loading to included studies.31 Of the 50 articles in the initial search. Studies prior ultrasound. inclusion in the review by Marsden and Schwellnus. the aim of this systematic resulting in a total of 8 included studies (see the Appendix). Six studies included participants with cycling The initial search was performed on July 16. and biofeedback techniques to measure muscle to 2007 that were included in the systematic review by Marsden fatigue. 1 additional article was deemed eligible. bicycle fit. Results and training volume.4.33 compared participants with and cyclists AND low back pain. using the experience.22 However. the evidence in an early Study Selection systematic review was not strong. Another study3 examined 3 and Schwellnus22 were excluded to focus on the most current different frame types and their impact on muscle activity using literature (Figure 1). Five reviewers read and then discussed articles meeting the Several mechanisms are hypothesized for the pathomechanics selection criteria. cyclists AND overuse injury. without LBP.30 competitive.9 included participants without cycling experience.22. Selection Criteria Therefore. 2015. and back pain in the following Four studies23.34 utilized surface electromyography (sEMG). and case. 16 were deemed eligible A 10° to 15° change in anterior tilt of the saddle eliminated LBP based on inclusion criteria.15. The initial unspecified. 3 a case-control design. articles (Figure 1). Studies included only men. which limits statistical power. Four studies utilized a within- participant study little scientific evidence to support these mechanisms. group consensus. using the same methodology as the original impacts cycling efficiency. Thus. variables measured. to 17 years. Measured Across Studies based studies evaluating muscle activity and characteristics.15. inclusion criteria of biomechanical studies examining LBP in cyclists as agreed upon by group consensus. Articles were graded using the Downs and of LBP in cyclists. overuse injury.4.24 Of these risk factors. An additional search was conducted on sEMG.25 master. including mechanical creep (a deformation or Black quality assessment scale for assessment of methodological strain of ligaments that occurs with constant loading). height.22 by/supplemental-data).23 following databases: PubMed. and/or strength. bicycling. Methodology and outcomes measured varied across studies.16. Assessment of Included Studies Duplicates across databases were removed. cyclists. nontraumatic LBP. and all grades were assigned based on ischemia. 54. with the highest score of 20.30. available at http://sph. Two studies3.

1 SPORTS HEALTH Database search of Pubmed.25 Measures used to assess pain also difference in height between the handlebars and the saddle. Two of 3 studies23. and lower handlebar-hand position.34 also including an aerodynamic position with forearms on aerobars. CINAHL. as agreed upon by group consensus: n=9 n=1 Total included: n=8 Figure 1. Subjects with LBP experienced fatigue posture-monitoring system. April 2016.23. suspension frame (rear triangle attached by changes in spinal flexion during cycling. no suspension).33.vol.23. 9 • no. narrow tires. and Scopus: July 2015 n=434 Titles screened: n=29 Duplicates excluded: n=50 Irrelevant non-biomechanically based research excluded based on abstract: n=34 Full-text sources reviewed: n=16 Articles overlapped in Marsden and Schwellnus22 review Articles found in additional 2010 excluded: search.9 varied across studies and included the Rehabilitation was inconsistent across studies.25 used an Bioengineering Group pain scale3 and the Numeric Pain Rating upper. and sports video motion capture to measure spinal angles9 or a surface- frame (racing handlebar.23 The remaining study9 analyzed 5 specific handlebar Bicycle Fit. Muscle Activity.3 based computerized technique using a mouse placed over Three studies9. defined as the intervertebral angles. middle. Two studies3. and Low Back Pain height conditions.4 Balasubramanian et al3 reported greatest arm and 77 . Other studies used links to rear shock for a progressive spring rate).4 applied sEMG to spinal and arm musculature to One kinematic study33 measured spinal flexion using a measure muscle fatigue. Selected handlebar height.25 examined spinal kinematics with different landmarks to identify sagittal spinal range of motion and handlebar heights. Ovid Medline. with 1 study Scale.  Flowchart of the systematic search and article inclusion for the studies analyzed in this systematic review. which consisted of a lightweight in arm and spinal musculature associated with postural support strain gauge attached to the cyclist’s lumbar spine that detected and stability. no suspension).

significantly reduced lumbopelvic flexion and reported pain then it is possible that when fatigued. These studies reported that lower handlebar change during the 2-hour cycling task. Improved motor control of evidence than the 2009 review by Marsden and Schwellnus. also some evidence that the prolonged. Overall.24. flexed-spine position Only 1 study in this systematic review included an during cycling is related to LBP.3 Cyclists with sample sizes. These findings thus add more intervention for cyclists with LBP.14. Rostami et al30 nontraumatic LBP has significant support in the literature. including prolonged flexion.32 these alterations may decrease desired generalizability of the results. The variance of participant’s LBP. increased load and stress as stated by the flexion-relaxation hypothesis.34 As the mechanism or associated risk factors other than proper saddle intervention is based on the subject’s conscious motor control of angle positioning. 78 . 0. The correlation between lumbar stability and rigid or suspension frames. Burnett et al7 also demonstrated handlebar heights of 16.30 and decreased selected from the population. spinal kinematics while cycling. The relationship seen between upper extremity potentially contributing to flexion-related lumbar pain.9 and increased anterior pelvic tilt relative to the vertical It is unclear which comes first: muscle imbalances affecting plane (see the Appendix). which matches compensate for pain. 8.33 Another implication is that LBP adopted greater lumbopelvic flexion and spent more time decreased endurance of the low back musculature may play a in end-range lumbopelvic flexion.34 This concept is compared with the asymptomatic group (see the Appendix).30 was also seen when subjects were positioned in an There are limitations in this systematic review.34 a cognitive role in spinal kinematics or spinal loading. There is that may contribute to overuse LBP. Spinal kinematics in subjects hand positions (defined by the position of the hand placement with LBP in the study by Van Hoof et al33 did not significantly on the handlebar). Utilizing ultrasound. and −16 cm. angle. lower. and determined that participants with LBP had reduced abdominal lumbar positioning.4 Increased muscle recruitment and fatigue the findings of Rostami et al. which lead to muscle activation imbalance. and aerodynamic handlebar. including small aerodynamic flexed posture on a sports cycle.22 decreased thickness of the prone to selection bias as participants were not randomly transverse abdominus and lumbar multifidi.7. flexed position at the start of cycling. These findings Spinal kinematics of cyclists with and without nonspecific LBP may indicate maladaptive motor control of the spine during were compared during an on-road cycling task. but the LBP group heights increased lumbar flexion. If there are existing functional therapy intervention using lumbar biofeedback endurance deficits of the musculature supporting the spine. Streisfeld et al Jan • Feb 2017 spinal muscle fatigue with a sports frame as compared with flexion.33 who showed that cyclists who reported significant increases in LBP during a 2-hour cycling Bicycle Fit and Spinal Kinematics task adopted greater lumbopelvic flexion and spent more time Three studies examined the effects of various handlebar heights in end-range lumbopelvic flexion compared with age-matched on pelvic and spinal position. A categorization of cycling based performance. pain increases.25 spinal kinematics or altered spinal kinematics. including a loss of lumbar lordosis34 while cycling. In a case study.9. Furthermore. The fatigue in cyclists with LBP suggests that cycling with LBP may participant may have had difficulty maintaining lumbar lordosis increase exertion by the upper extremity on the handlebars to due to back extensor endurance impairments. position on the cycle and spinal kinematics all demonstrated these limitations impact the ability to compare findings directly that lower handlebar positioning resulted in greater lumbar across studies. and varying areas of study focus. the spine may absorb an after intervention (see the Appendix).23. while Muyor23 increased lumbar spinal flexion and rotation in symptomatic investigated upper. −8. negatively and back musculature thickness at rest and during contraction affects spinal pathology and symptoms. This shift in spinal forces and load displacement Discussion reinforces the concept that it may not be the body positioning The results of this systematic review provide support for the on the bike that matters but the time spent in that position and hypothesis that muscle activation imbalances of the core and concurrent muscle activation imbalances or endurance deficits spinal musculature are risk factors for LBP in cyclists. cyclists compared with controls.23.9. participants and back extensor endurance when compared with cyclists without examiners were not blinded. LBP in cyclists.25 Chen and He9 used asymptomatic controls. Studies were lumbar multifidi muscles. varied LBP also demonstrated asymmetrical co-contraction of the populations.33 Subjects with cycling as a causative factor. supported by Van Hoof et al. and this position does not and Low Back Pain change during cycling. Cyclists with LBP assume a more Spinal Kinematics. differing measurement techniques.22 spinal kinematics during a bout of cycling and improved LBP which found limited empirical support for any proposed symptoms were found after biofeedback training.23 decreased lumbosacral assumed greater lumbopelvic flexion at the start of the task.30 As back extensor muscle activity is proportional to cycling experiences creates another limitation: the pedaling intensity. however.26-28.25 examining the relationship between improve the ability to compare results across studies. on activity level has been proposed by Ansley and Cangley2 to The 3 studies9. Motor Control. there are implications that The 3 studies that examined the relationship between bicycle impaired motor control may result in more end-range flexed positioning and muscle activity provide different insight into posture. middle.

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