Resistance training in musculoskeletal rehabilitation: a systematic review

Exercise for chronic musculoskeletal pain: A biopsychosocial approach

Chronic musculoskeletal pain (CMP) refers to ongoing pain felt in the bones, joints and tissues of the body that persists longer than 3 months. For these conditions, it is widely accepted that secondary pathologies or the consequences of persistent pain, including fear of movement, pain catastrophizing, anxiety and nervous system sensitization appear to be the main contributors to pain and disability. While exercise is a primary treatment modality for CMP, the intent is often to improve physical function with less attention to secondary pathologies. Exercise interventions for CMP which address secondary pathologies align with contemporary pain rehabilitation practices and have greater potential to improve patient outcomes above exercise alone. Biopsychosocial treatment which acknowledges and addresses the biological, psychological and social contributions to pain and disability is currently seen as the most efficacious approach to chronic pain. This clinical update discusses key aspects of a biopsychosocial approach concerning exercise prescription for CMP and considers both patient needs and clinician competencies. There is consensus for individualized, supervised exercise based on patient presentation, goals and preference that is perceived as safe and non-threatening to avoid fostering unhelpful associations between physical activity and pain. The weight of evidence supporting exercise for CMP has been provided by aerobic and resistance exercise studies, although there is considerable uncertainty on how to best apply the findings to exercise prescription. In this clinical update, we also provide evidence-based guidance on exercise prescription for CMP through a synthesis of published work within the field of exercise and CMP rehabilitation.

Increased Interstitial Concentrations of Glutamate and Pyruvate in Vastus Lateralis of Women with Fibromyalgia Syndrome Are Normalized after an Exercise Intervention - A Case-Control Study

BACKGROUND

Fibromyalgia syndrome (FMS) is associated with central alterations, but controversies exist regarding the presence and role of peripheral factors. Microdialysis (MD) can be used in vivo to study muscle alterations in FMS. Furthermore for chronic pain conditions such as FMS, the mechanisms for the positive effects of exercise are unclear. This study investigates the interstitial concentrations of algesics and metabolites in the vastus lateralis muscle of 29 women with FMS and 28 healthy women before and after an exercise intervention.

METHODS

All the participants went through a clinical examination and completed a questionnaire. In addition, their pressure pain thresholds (PPTs) in their upper and lower extremities were determined. For both groups, MD was conducted in the vastus lateralis muscle before and after a 15-week exercise intervention of mainly resistance training of the lower limbs. Muscle blood flow and interstitial muscle concentrations of lactate, pyruvate, glutamate, glucose, and glycerol were determined.

RESULTS

FMS was associated with significantly increased interstitial concentrations of glutamate, pyruvate, and lactate. After the exercise intervention, the FMS group exhibited significant decreases in pain intensity and in mean interstitial concentrations of glutamate, pyruvate, and glucose. The decrease in pain intensity in FMS correlated significantly with the decreases in pyruvate and glucose. In addition, the FMS group increased their strength and endurance.

CONCLUSION

This study supports the suggestion that peripheral metabolic and algesic muscle alterations are present in FMS patients and that these alterations contribute to pain. After an exercise intervention, alterations normalized, pain intensity decreased (but not abolished), and strength and endurance improved, all findings that suggest the effects of exercise are partially peripheral.

Description of load progression and pain response during progressive resistance training early after total hip arthroplasty: secondary analyses from a randomized controlled trial

Objective:

To describe a progressive resistance training intervention implemented shortly after total hip arthroplasty, including a detailed description of load progression, pain response and adverse events to the training.

Design:

Secondary analyses of data from the intervention group in a randomized controlled trial.

Subjects:

This study reports data from the intervention group ( n = 37).

Interventions:

The protocol described supervised progressive resistance training of the operated leg two days/week in addition to home-based exercise five days/week and for 10 weeks. The relative load progressed from 12 repetition maximum to 8 repetition maximum during 10 weeks for the exercises: knee extension, hip abduction, -flexion and -extension.

Main measures:

Training load in kilograms (kg) for each exercise, hip pain during, before and after exercise using the Visual Analog Scale and adverse events during the initial four weeks of training.

Results:

The majority of patients experienced only moderate hip pain during exercise (range in median across exercises and sessions: 5–35 mm Visual Analog Scale) and mild pain at rest (median: 1–18 mm Visual Analog Scale), both of which decreased over time ( p < 0.001), despite a substantial increase in absolute training load (67%–166 % across exercises, p < 0.001). Out of 152 training sessions, short term pain response (an increase >20 mm Visual Analog Scale) occurred in 13 patients in 24 training sessions.

Conclusion:

Progressive resistance training as described in the present study can be implemented shortly following total hip arthroplasty with substantial load progression and no overall exacerbation of postoperative pain. Some patients may experience a short term pain response.

Trial Registration (primary trial):

NCT01214954

A Systematic Summary of Systematic Reviews on the Topic of the Anterior Cruciate Ligament

BACKGROUND

There has been a substantial increase in the amount of systematic reviews and meta-analyses published on the anterior cruciate ligament (ACL).

PURPOSE

To quantify the number of systematic reviews and meta-analyses published on the ACL in the past decade and to provide an overall summary of this literature.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of all ACL-related systematic reviews and meta-analyses published between January 2004 and September 2014 was performed using PubMed, MEDLINE, and the Cochrane Database. Narrative reviews and non-English articles were excluded.

RESULTS

A total of 1031 articles were found, of which 240 met the inclusion criteria. Included articles were summarized and divided into 17 topics: anatomy, epidemiology, prevention, associated injuries, diagnosis, operative versus nonoperative management, graft choice, surgical technique, fixation methods, computer-assisted surgery, platelet-rich plasma, rehabilitation, return to play, outcomes assessment, arthritis, complications, and miscellaneous.

CONCLUSION

A summary of systematic reviews on the ACL can supply the surgeon with a single source for the most up-to-date synthesis of the literature.

The effects of a strength and neuromuscular exercise programme for the lower extremity on knee load, pain and function in obese children and adolescents: study protocol for a randomised controlled trial

BACKGROUND

Childhood obesity is one of the most critical and accelerating health challenges throughout the world. It is a major risk factor for developing varus/valgus misalignments of the knee joint. The combination of misalignment at the knee and excess body mass may result in increased joint stresses and damage to articular cartilage. A training programme, which aims at developing a more neutral alignment of the trunk and lower limbs during movement tasks may be able to reduce knee loading during locomotion. Despite the large number of guidelines for muscle strength training and neuromuscular exercises that exist, most are not specifically designed to target the obese children and adolescent demographic. Therefore, the aim of this study is to evaluate a training programme which combines strength and neuromuscular exercises specifically designed to the needs and limitations of obese children and adolescents and analyse the effects of the training programme from a biomechanical and clinical point of view.

METHODS/DESIGN

A single assessor-blinded, pre-test and post-test randomised controlled trial, with one control and one intervention group will be conducted with 48 boys and girls aged between 10 and 18 years. Intervention group participants will receive a 12-week neuromuscular and quadriceps/hip strength training programme. Three-dimensional (3D) gait analyses during level walking and stair climbing will be performed at baseline and follow-up sessions. The primary outcome parameters for this study will be the overall peak external frontal knee moment and impulse during walking. Secondary outcomes include the subscales of the Knee injury and Osteoarthritis Outcome Score (KOOS), frontal and sagittal kinematics and kinetics for the lower extremities during walking and stair climbing, ratings of change in knee-related well-being, pain and function and adherence to the training programme. In addition, the training programme will be evaulated from a clinical and health status perspective by including the following analyses: cardiopulmonary testing to quantify aerobic fitness effects, anthropometric measures, nutritional status and psychological status to characterise the study sample.

DISCUSSION

The findings will help to determine whether a neuromuscular and strength training exercise programme for the obese children population can reduce joint loading during locomotion, and thereby decrease the possible risk of developing degenerative joint diseases later in adulthood.

TRIAL REGISTRATION

ClinicalTrials NCT02545764 , Date of registration: 24 September 2015.

The effects of a free-weight-based resistance training intervention on pain, squat biomechanics and MRI-defined lumbar fat infiltration and functional cross-sectional area in those with chronic low back

Background

Low back pain is one of the most prevalent musculoskeletal conditions in the world. Many exercise treatment options exist but few interventions have utilised free-weight resistance training. To investigate the effects of a free-weight-based resistance training intervention on pain and lumbar fat infiltration in those with chronic low back pain.

Methods

Thirty participants entered the study, 11 females (age=39.6±12.4 years, height=164 cm±5.3 cm, body mass=70.9±8.2 kg,) and 19 males (age=39.7±9.7 years, height=179±5.9 cm, body mass=86.6±15.9 kg). A 16-week, progressive, free-weight-based resistance training intervention was used. Participants completed three training sessions per week. Participants completed a Visual Analogue Pain Scale, Oswestry Disability Index and Euro-Qol V2 quality of life measure at baseline and every 4 weeks throughout the study. Three-dimensional kinematic and kinetic measures were used for biomechanical analysis of a bodyweight squat movement. Maximum strength was measured using an isometric mid-thigh pull, and lumbar paraspinal endurance was measured using a Biering-Sorensen test. Lumbar paraspinal fat infiltration was measured preintervention and postintervention using MRIs.

Results

Postintervention pain, disability and quality of life were all significantly improved. In addition, there was a significant reduction in fat infiltration at the L3L4 and L4L5 levels and increase in lumbar extension time to exhaustion of 18%.

Conclusions

A free-weight-based resistance training intervention can be successfully utilised to improve pain, disability and quality of life in those with low back pain.

Resistance exercise improves muscle strength, health status and pain intensity in fibromyalgia--a randomized controlled trial

Introduction

Fibromyalgia (FM) is characterized by persistent widespread pain, increased pain sensitivity and tenderness. Muscle strength in women with FM is reduced compared to healthy women. The aim of this study was to examine the effects of a progressive resistance exercise program on muscle strength, health status, and current pain intensity in women with FM.

Methods

A total of 130 women with FM (age 22–64 years, symptom duration 0–35 years) were included in this assessor-blinded randomized controlled multi-center trial examining the effects of progressive resistance group exercise compared with an active control group. A person-centred model of exercise was used to support the participants’ self-confidence for management of exercise because of known risks of activity-induced pain in FM. The intervention was performed twice a week for 15 weeks and was supervised by experienced physiotherapists. Primary outcome measure was isometric knee-extension force (Steve Strong®), secondary outcome measures were health status (FIQ total score), current pain intensity (VAS), 6MWT, isometric elbow-flexion force, hand-grip force, health related quality of life, pain disability, pain acceptance, fear avoidance beliefs, and patient global impression of change (PGIC). Outcomes were assessed at baseline and immediately after the intervention. Long-term follow up comprised the self-reported questionnaires only and was conducted after 13–18 months. Between-group and within-group differences were calculated using non-parametric statistics.

Results

Significant improvements were found for isometric knee-extension force (p = 0.010), health status (p = 0.038), current pain intensity (p = 0.033), 6MWT (p = 0.003), isometric elbow flexion force (p = 0.02), pain disability (p = 0.005), and pain acceptance (p = 0.043) in the resistance exercise group (n = 56) when compared to the control group (n = 49). PGIC differed significantly (p = 0.001) in favor of the resistance exercise group at post-treatment examinations. No significant differences between the resistance exercise group and the active control group were found regarding change in self-reported questionnaires from baseline to 13–18 months.

Conclusions

Person-centered progressive resistance exercise was found to be a feasible mode of exercise for women with FM, improving muscle strength, health status, and current pain intensity when assessed immediately after the intervention.

Trial registration

ClinicalTrials.gov identification number: NCT01226784, Oct 21, 2010.

Effectiveness of land-based physiotherapy exercise following hospital discharge following hip arthroplasty for osteoarthritis: an updated systematic review

BACKGROUND

Existing review required updating.

OBJECTIVE

To evaluate the effectiveness of physiotherapy exercise after discharge from hospital on function, walking, range of motion, quality of life and muscle strength, for patients following elective primary total hip arthroplasty for osteoarthritis.

DESIGN

Systematic review from January 2007 to November 2013.

DATA SOURCES

AMED, CINAHL, EMBASE, MEDLINE, Kingsfund Database, and PEDro. Cochrane CENTRAL, BioMed Central (BMC), The Department of Health National Research Register and Clinical Trials.gov register. Searches were overseen by a librarian. Authors were contacted for missing information. No language restrictions were applied.

ELIGIBILITY CRITERIA

Trials comparing physiotherapy exercise vs usual/standard care, or comparing two types of relevant exercise physiotherapy, following discharge from hospital after elective primary total hip replacement for osteoarthritis were reviewed.

OUTCOMES

Functional activities of daily living, walking, quality of life, muscle strength and joint range of motion.

STUDY APPRAISAL

Quality and risk of bias for studies were evaluated. Data were extracted and meta-analyses considered.

RESULTS

11 trials are included in the review. Trial quality was mixed. Newly included studies were assessed as having lower risk of bias than previous studies. Narrative review indicates that physiotherapy exercise after discharge following total hip replacement may potentially benefit patients in terms of function, walking and muscle strengthening.

LIMITATIONS

The overall quality and quantity of trials, and their diversity, prevented meta-analyses.

CONCLUSIONS

Disappointingly, insufficient evidence still prevents the effectiveness of physiotherapy exercise following discharge to be determined for this patient group. High quality, adequately powered, trials with long term follow up are required.

Progressive resistance strength training and the related injuries in older adults: the susceptibility of the shoulder

The benefits of progressive resistance training (PRT) among the older adults are evident, especially in the prevention of sarcopenia and improving muscle strength, which reverse the age-related loss of functional ability. However, PRT carries some risk, particularly when participants are older adults with a certain degree of muscle weakness. The purpose of this article is to discuss the PRT-related injuries, and present an overview of documented shoulder injuries among the elderly, discerning possible mechanisms of injury and risk factors. A literature search was conducted in the PUBMED database to identify the relevant literature using combinations of keywords: strength-training injuries, resistance-training injuries, sports injuries in the elderly, shoulder complex, shoulder injury, and shoulder disorder. Acute and chronic injuries attributed to PRT have been cited in the epidemiological literature. The shoulder complex, has been alluded to as one of the most prevalent regions of injury, particularly in exercises that place the arm extended above the head and posterior to the trunk. However, the risk for injuries appears to be higher for testing than for training itself. One-repetition maximum strength testing may result in a greater injury risk. This technique, though acceptable, needs additional precautions in inexperience older adults to prevent injury. Thus, the best treatment for PRT age-related injuries is prevention. Appropriate and individualized training programs, the use of safe equipment, careful warming up and cooling down, correct range of motion, progressive intensity training, cardiovascular and musculoskeletal fitness are essential aspects of injury prevention among the elderly.

Documentation of strength training for research purposes after ACL reconstruction

PURPOSE

The purpose of this systematic literature review was to evaluate strength training protocol documentation during rehabilitation after anterior cruciate ligament (ACL) reconstruction. The aim was further to present recommendations concerning what components (i.e. methods, principles and training variables) could be considered vital to document when it comes to strength training for research purposes after ACL reconstruction.

METHODS

A search of the PUBMED/MEDLINE, CINAHL and SportDiscus databases was made of relevant literature relating to strength training after ACL reconstruction. The database search was based on relevant medical subject headings terms (strength/resistance/weight training, anterior cruciate ligament reconstruction/rehabilitation). The literature was reviewed regarding the way methods and variables were documented in strength training protocols during rehabilitation after ACL reconstruction in peer-reviewed original prospective articles.

RESULTS

The systematic literature search identified 139 citations published between January 1983 and May 2012. Six studies contained a strength training programme-part of the rehabilitation protocol after ACL reconstruction that met the inclusion criteria. Basic information (i.e. training frequency, intensity, volume, progression or the duration of the training period) regarding the strength training protocols used during rehabilitation after ACL reconstruction was not documented in full in four of the studies.

CONCLUSION

The results clearly indicate the need of a more standardised and detailed way of documenting strength training for research purposes after ACL reconstruction in order to increase the value of future studies on this subject. This review gives recommendations on strength training protocol documentation after ACL reconstruction to facilitate this goal.

LEVEL OF EVIDENCE

IV.

A review of pharmacotherapy for chronic low back pain with considerations for sports medicine

Up to 30% of athletes experience low back pain (LBP) depending on sport type, sex, training intensity and frequency, and technique. United States clinical guidelines define back pain as chronic if it persists for ≥ 12 weeks, and subacute if it persists 4 to < 12 weeks. Certain sports injuries are likely to lead to chronic pain. Persistent or chronic symptoms are frequently associated with degenerative lumbar disc disease or spondylolytic stress lesions. Exercise therapy is widely used and is the most conservative form of treatment for chronic LBP (cLBP). Pharmacotherapies for cLBP include acetaminophen, nonsteroidal anti-inflammatory drugs, and opioids. Acetaminophen is a well-tolerated first-line pharmacotherapy, but high-dose, long-term use is associated with hepatic toxicity. Nonsteroidal anti-inflammatory drugs can be an effective second-line option if acetaminophen proves inadequate but they have well-known risks of gastrointestinal, cardiovascular, and other systemic adverse effects that increase with patient age, dose amount, and duration of use. The serotonin-norepinephrine reuptake inhibitor, duloxetine, has demonstrated modest efficacy and is associated with systematic adverse events, including serotonin syndrome, which can be dose related or result from interaction with other analgesics. Opioids may be an effective choice for moderate to severe pain but also have significant risks of adverse events and carry a substantial risk of addiction and abuse. Because the course of cLBP may be protracted, patients may require treatment over years or decades, and it is critical that the risk/benefit profiles of pharmacotherapies are closely evaluated to ensure that short- and long-term treatments are optimized for each patient. This article reviews the clinical evidence and the guideline recommendations for pharmacotherapy of cLBP.