A neuroscience approach to managing athletes with low back pain

Pain Neuroscience Education for Acute Pain

In musculoskeletal and sports medicine, pain has traditionally been linked to tissue injury, often assuming a linear correlation between tissue damage and pain intensity. However, modern pain science has illuminated the complexity of the human pain experience, incorporating psychosocial elements, nervous system sensitization, immune responses, and structural changes in the brain as factors. This contemporary understanding of pain has proven highly beneficial for both clinicians treating individuals in pain and those experiencing pain. Pain neuroscience education (PNE) provides individuals in pain with an understanding of the underlying neurobiology and neurophysiology of their pain experience, which has been shown to result in decreased self-reported pain, reduced disability, the alleviation of fear and fear-avoidance behaviors, diminished pain catastrophizing, and improved movement. Currently, research on PNE predominantly focuses on interventions with individuals with persistent or chronic pain conditions. However, those who experience acute, sub-acute, and perioperative pain also have the potential for elevated levels of fear, fear-avoidance, and pain catastrophizing, indicating potential benefits from PNE. This invited commentary seeks to inform readers about the latest advancements in pain science and propose a conceptual model for delivering PNE in acute pain experiences.

Level of Evidence

5.

Effects of an eight-week physical exercise program on low back pain and function in fruit workers: A randomized controlled trial

BACKGROUND

Low back pain is prevalent in workers' health and functional performance.

OBJECTIVE

To evaluate the effects of a physical exercise program on low back pain and disability in fruit workers.

METHODS

This randomized controlled trial assigned 44 workers (37 ± 9 years) to two groups. The experimental group consisted of 10 men and 12 women with an average age of 38 (± 9) years, and the control group consisted of 8 men and 14 women with an average age of 36 (± 10) years. The experimental group (EG) performed a program of strength and flexibility exercises for eight weeks, twice a week. The control group (CG) received minimal care, with a booklet with guidelines for performing exercises. The primary outcomes included changes in perceived disability and the intensity of pain evaluated by the Rolland-Morris questionnaire and the Numerical Pain Scale, respectively. All outcomes were measured at baseline and after eight weeks of intervention.

RESULTS

A significant difference was observed in the within-group analysis, with a mean reduction in pain intensity in the EG and CG of -4.55 (95%CI -7.01 to -2.09) and -3.81 (95%CI 1.72-5.90), respectively. For disability, a reduction of -4.45 (95% CI -8.89 to -0.02) was observed in the EG and of -4.43 (-7.38 to -1.48) in the CG. There were no significant differences in the between-groups analysis.

CONCLUSIONS

The exercise program was not superior to using the educational booklet. However, both interventions showed substantial decreases in pain and disability levels.

Using expletives to enhance therapeutic outcomes: A case report

Background

Swearing deserves attention in the physical therapy setting due to its potential positive effects on pain, physical performance, and therapeutic alliance. The purpose of this case report is to describe the strategic use of swearing in the clinical setting.

Case Presentation

A 44-year-old female completed an episode of physical therapy after undergoing patellofemoral arthroplasty. Swearing was formally included into the plan of care, and the patient swore out loud during the most challenging and painful interventions.

Results

The patient reported that repeating a swear word was funny, distracted the patient, and made the patient feel more confident. The patient and physical therapist self-reported a strong therapeutic alliance.

Conclusion

There is evidence repeating a swear word out loud can strengthen the therapeutic alliance, improve physical performance, and decrease pain. This is, to our knowledge, the first report of a patient swearing during an episode of physical therapy care.

Dynamic postural control in women athletes with and without nonspecific low back pain with high and low pain-related anxiety- A case-control study

BACKGROUND

Low back pain is common among athletes and it has been shown that postural control is altered in the general population with nonspecific low back pain (NSLBP). Psychological factors may also predispose individuals to risk of altered postural control. Dynamic postural control is essential to the performance of athletes. This study aimed to compare the dynamic postural control between women athletes with and without NSLBP with high and low pain-related anxiety.

METHODS

Forty-five female athletes (15 NSLBP with high pain-related anxiety, 15 NSLBP with low pain-related anxiety, and 15 healthy (control)) were included. Pain-related anxiety was assessed using the Pain Anxiety Symptom Scale-20 (PASS-20). Based on the cut-off score of 30 for the total score of PASS-20, NSLBP patients were classified into two groups of low and high pain-related anxiety. Participants performed double-leg vertical drop jump (DVJ) and single-leg vertical jump (SVJ) tests on a Kistler force plate (type 9260AA6, Kistler Instruments Inc, Switzerland). The total root mean square (RMS) of the center of pressure (COP), COP displacement in the anteroposterior (AP), and mediolateral (ML) directions, COP mean velocity, and time to stabilization (TTS) in vertical, AP, and total directions were extracted from COP and ground reaction force data using MATLAB software. One-way Analysis of variance (ANOVA) and Welch's ANOVA were employed to compare the groups. In case of significant findings, post hoc tests were performed.

RESULTS

The results showed that during DJV, athletes with high pain-related anxiety had significantly greater TTS in all total, AP, and ML directions than other groups (P < 0.05). Also, the control group showed greater total RMS distance during DJV than either NSLBP group. However, no significant differences in TTS and COP parameters were found between the groups during SVJ (P > 0.05).

CONCLUSIONS

The findings suggest that pain-related anxiety may contribute to athletes' postural control strategies. Therefore, it is important to consider the level of pain-related anxiety during planning postural control exercises for women athletes with NSLBP.

A PHYSICAL THERAPIST WHO SWEARS: A CASE SERIES

Objective

Swearing deserves attention in the physical therapy setting due to its potential positive psychological, physiological, and social effects. The purpose of this case series is to describe 2 cases in which a physical therapist swears in the clinical setting and its effect on therapeutic alliance.

Patients

Case 1 is a 19-year-old male treated for a hamstring strain, and case 2 is a 23-year-old male treated post-operatively for anterior cruciate ligament reconstruction. The physical therapist utilized social swearing in the clinic with the goal of motivating the patient and enhancing the social connection with the patient, to improve therapeutic alliance.

Results

The patient in case 1 reported a decrease in therapeutic alliance after the physical therapist began swearing during physical therapy treatments, whereas the patient in case 2 reported an increase in therapeutic alliance. Both patients disagreed that physical therapist swearing is unprofessional and disagreed that swearing is offensive, and both patients agreed physical therapists should be able to swear around their patients.

Conclusion

Physical therapist swearing may have positive and negative influences in the clinic setting and may not be considered unprofessional. These are, to our knowledge, the first published cases of a physical therapist swearing in the clinical setting.

Risk Factors to Persistent Pain Following Musculoskeletal Injuries: A Systematic Literature Review

Background: Musculoskeletal (MSK) injury is one of the major causes of persistent pain. Objective: This systematic literature review explored the factors that lead to persistent pain following a MSK injury in the general population, including athletes. Methods: A primary literature search of five electronic databases was performed to identify cohort, prospective, and longitudinal trials. Studies of adults who diagnosed with a MSK injury, such as sprains, strains or trauma, were included. Results: Eighteen studies involving 5372 participants were included in this review. Participants’ ages ranged from 18–95 years. Most of the included studies were of prospective longitudinal design. Participants had a variety of MSK injuries (traumatic and non-traumatic) causing persistent pain. Multiple factors were identified as influencing the development of persistent pain following a MSK injury, including high pain intensity at baseline, post-traumatic stress syndrome, presence of medical comorbidities, and fear of movement. Scarcity of existing literature and the heterogeneity of the studies made meta-analysis not possible. Conclusions: This systematic review highlighted factors that might help predict persistent pain and disability following MSK injury in the general population, including athletes. Identification of these factors may help clinicians and other health care providers prevent the development of persistent pain following a MSK injury.

Frankly, we do give a damn: improving patient outcomes with swearing

Background

Words can change the way a patient thinks, feels, and performs. Swearing, or uttering a word that is considered taboo, is an often-ignored part of our language, even though over 50% of the population swears “sometimes” or “often”. If used correctly, within a biopsychosocial approach to care, swearing has the potential to significantly improve patient outcomes.

Discussion

Swearing can create tighter human bonds and enhance the therapeutic alliance between a patient and a physical therapist. Improvements in social pain, physical pain tolerance, and physical pain threshold can occur by strategic swearing by our patients. Even physical performance measures, such as power and force could be enhanced if patients swear.

Conclusion

Although the mechanism by which swearing is effective is unclear, swearing deserves attention in the physical therapy setting based on evidence indicating potential positive effects on patient outcomes.

[Patient education for acute low back pain : Contents of pain education in patients with acute non-specific low back pain - a scoping review]

OBJECTIVE

The objective of the review is to map the content of intervention education in people with acute nonspecific lumbar low back pain (LBP) to make it available in a synopsis.

BACKGROUND

In the care of people with acute non-specific LBP, education is recommended as an elementary treatment component. However, the proposed content is proving to be heterogenic and the question arises as to how education should be designed in the future.

METHOD

A systematic literature search and content analysis of studies with content on pain education was conducted as part of a scoping review. Inclusion criteria were: provision of relevant information on the content of pain education, patients with acute nonspecific low back pain, 18 years or older, publication in English or German. The search was conducted in the Medline, CINAHL, Cochrane Library, and PEDro databases and supplemented by a hand search. The search was completed in February 2021.

RESULTS

A total of 4239 hits were identified, of which 90 studies were included. A wide range of content was found and clustered into ten categories. The most frequent statements were in the categories "recommendations for dealing with LRS," "education, reassuring aspects, and relieving basic messages," and "information and recommendations about medications."

CONCLUSION

The teaching of pathoanatomical information can potentially trigger or increase anxiety and worry, whereas information on neurophysiological mechanisms of pain development and processing is more likely to have an anxiety-reducing effect. The results can contribute to the design of the intervention in different settings.

Assessment and classification of peripheral pain in athletes: a scoping review protocol

Pain is often presumed to be part of the sport injury experience. The time-loss definition of injury leads to under-reported athletic pain impacting performance and quality of life. Whilst research regarding the assessment and classification of back pain in athletes is emerging, little has been reported regarding how peripheral pain is assessed and classified in research and practice. Six databases will be searched for relevant articles. Title and abstract screening followed by full-text screening will be completed by two independent reviewers. Data charting will be carried out using a modified standardised form. Descriptive results and frequencies will be reported. Pain measures identified in the studies will be mapped against the IOC Athlete Pain Framework alongside a narrative summary. Published peer-reviewed primary research studies alongside systematic reviews and clinical practice guidelines reporting the assessment or classification of pain in athletes of any age with chronic or acute peripheral pain across all study contexts in the English language on human participants from inception of the databases will be included. The results of this study are part of a body of research which will be used to inform the development of a pain assessment framework. The scoping review will be submitted for peer-reviewed journal publication and presented at sports medicine conferences. This review will inform researchers and clinicians working with athletes in pain how pain assessment and classification is currently conducted and positioned against the IOC Athlete Pain Framework.

Physical therapist guided active intervention of chronic temporomandibular disorder presenting as ear pain: A case report

This case report describes the successful physical therapy management of a 40-year-old female who presented with left ear pain referred from the temporomandibular joint. Diagnosis was primarily based on clinical examination findings and ruling out of red flags. Guidance was given on active self-care approaches consisting of pain neuroscience education designed with individualized pain curriculum, exercise therapy, manual therapy, and breathing exercises for a period of  sixweeks. Clinically meaningful improvements were obtained in the outcome measures of Numeric Pain Rating Scale (NPRS), Patient-Specific Functional Scale (PSFS), and Global Rating of Change (GROC) scale and progress in Pain-Self Efficacy Questionnaire (PSEQ) and Tampa Scale for Kinesiophobia (TSK) scores. Positive changes were achieved with functional activities (chewing, eating, yawing, brushing teeth and physical intimacy), and the patient was pain-free on discharge, which was maintained at a six-month follow-up.

A critical review of the biopsychosocial model of low back pain care: time for a new approach?

PURPOSE

Low back pain (LBP) is the leading cause of disability worldwide. Clinical research advocates using the biopsychosocial model (BPS) to manage LBP, however there is still no clear consensus regarding the meaning of this model in physiotherapy and how best to apply it. The aim of this study was to investigate how physiotherapy LBP literature enacts the BPS model.

MATERIAL AND METHODS

We conducted a critical review using discourse analysis of 66 articles retrieved from the PubMed and Web of Science databases.

RESULTS

Analysis suggest that many texts conflated the BPS with the biomedical model [Discourse 1: Conflating the BPS with the biomedical model]. Psychological aspects were almost exclusively conceptualised as cognitive and behavioural [Discourse 2: Cognition, behaviour, yellow flags and rapport]. Social context was rarely mentioned [Discourse 3: Brief and occasional social underpinnings]; and other broader aspects of care such as culture and power dynamics received little attention within the texts [Discourse 4: Expanded aspects of care].

CONCLUSION

Results imply that multiple important factors such as interpersonal or institutional power relations, cultural considerations, ethical, and social aspects of health may not be incorporated into physiotherapy research and practice when working with people with LBP.IMPLICATIONS FOR REHABILITATIONWhen using the biopsychosocial model with patients with low back pain, researchers narrowly focus on biological and cognitive behavioural aspects of the model.Social and broader aspects such as cultural, interpersonal and institutional power dynamics, appear to be neglected by researchers when taking a biopsychosocial approach to the care of patients with low back pain.The biopsychosocial model may be inadequate to address complexities of people with low back pain, and a reworking of the model may be necessary.There is a lack of research conceptualising how physiotherapy applies the biopsychosocial model in research and practice.

Landing Stiffness Between Individuals With and Without a History of Low Back Pain

CONTEXT

Reduced spinal stabilization, delayed onset of muscle activation, and increased knee joint stiffness have been reported in individuals with a history of low back pain (LBP). Biomechanical adaptations resulting from LBP may increase the risk for future injury due to suboptimal loading of the lower-extremity or lumbar spine. Assessing landing mechanics in these individuals could help identify which structures might be susceptible to future injury.

OBJECTIVE

To compare vertical and joint stiffness of the lower-extremity and lumbar spine between individuals with and without a previous history of LBP.

DESIGN

Cross-sectional study.

SETTING

Research laboratory.

PARTICIPANTS

There were 45 participants (24 without a previous history of LBP-age 23 [8] y, height 169.0 [8.5] cm, mass 69.8 [13.8] kg; 21 with a previous history of LBP-age 25[9] y, height 170.0 [8.0] cm, mass 70.2 [11.8] kg).

INTERVENTIONS

Single-limb landing trials on the dominant and nondominant limb from a 30-cm box.

MAIN OUTCOME MEASURES

Vertical stiffness and joint stiffness of the ankle, knee, hip, and lumbar spine.

RESULTS

Individuals with a previous history of LBP had lower vertical stiffness (P = .04), but not joint stiffness measures compared with those without a previous history of LBP (P > .05). Overall females had lower vertical (P = .01), ankle (P = .02), and hip stiffness (P = .04) compared with males among all participants. Males with a previous history of LBP had lower vertical stiffness compared with males without a previous history LBP (P = .01). Among all individuals without a previous history of LBP, females had lower vertical (P < .01) and ankle stiffness measures (P = .04) compared with males.

CONCLUSIONS

Landing stiffness may differ among males and females and a previous history of LBP. Comparisons between individuals with and without previous LBP should be considered when assessing landing strategies, and future research should focus on how LBP impacts landing mechanics.

Psychological pain responses in athletes and non-athletes with low back pain: Avoidance and endurance matter

BACKGROUND

Dysfunctional psychological pain responses, namely fear-avoidance (FAR), including catastrophizing and helplessness, as well as endurance-related responses (ER), including thought suppression and overactivity, have been shown to be risk factors for persistent low back pain (LBP). Literature suggests that athletes may differ from non-athletes regarding psychological responses to pain.

OBJECTIVES

This study set out to compare FAR and ER between athletes and non-athletes with LBP. It was hypothesized that athletes would report less frequent FAR and more frequent ER, and that both FAR and ER are associated with LBP intensity and disability.

METHODS

The 173 athletes and 93 non-athletes cross-sectionally reported how frequently they employ FAR and ER on the Avoidance-Endurance Questionnaire (AEQ), as well as LBP intensity and disability on the Chronic Pain Grade Questionnaire (CPGS). MANOVA was applied to compare FAR and ER between athletes and non-athletes. Hierarchical multiple linear regression models were used to determine the unique associations between FAR and ER with LBP intensity and disability.

RESULTS

Athletes reported lower frequencies of behavioural avoidance than non-athletes, but no other FAR variables differed between the groups. Frequencies of ER did not differ between athletes and non-athletes. Regression analysis indicated substantial associations of FAR with LBP intensity, as well as of FAR and ER with disability in athletes and non-athletes.

CONCLUSIONS

The results of the present study suggest that athletes and non-athletes with LBP differ regarding behavioural avoidance, but overall, differences regarding pain responses are marginal. FAR and ER are both reported in athletes and non-athletes and contribute to disability in both groups.

SIGNIFICANCE

Athletes train to endure pain in the course of athletic socialization, at least in the context of exercise. However, there is sparsity of knowledge about psychological pain responses in athletes with low back pain and whether they differ from those in non-athletes. The results of this comparative study suggest that endurance responses are more frequent than avoidance responses among athletes and non-athletes alike. However, both types of responses seem relevant to clinical pain management in athletes as well as non-athletes.

Examining the Presence of Back Pain in Competitive Athletes: A Focus on Stress and Recovery

CONTEXT

Explanatory approaches for back pain (BP) in athletes focus on biomechanical factors while neglecting psychological perspectives. Psychological factors have gained importance in the prediction of injuries in athletes and BP in the general population, with stress and recovery emerging as central risk factors. However, scarce evidence exists regarding the role of these aspects for the prevalent burden of BP.

OBJECTIVE

To investigate the association between stress and recovery parameters and the presence of BP.

DESIGN

Cross-sectional design.

SETTING

The questionnaires were distributed after the training sessions.

PARTICIPANTS

A total of 345 competitive athletes (mean age = 18.31 y [SD = 5.40]) were investigated. The classification of the athletes' competitive status was based on performance level.

INTERVENTIONS

Data were collected using questionnaires for the assessment of stress, recovery, and BP.

MAIN OUTCOME MEASURES

The authors performed a multiple logistic regression to obtain odds ratios for stress and recovery parameters with regard to the outcome variable BP status.

RESULTS

For stress, the dimension "overall stress" (odds ratio = 1.83; 95% confidence interval, 1.30-2.59; P = .001) and the scale "physical complaints" (odds ratio = 1.68; 95% confidence interval, 1.25-2.25; P = .001) of the general version of the Recovery-Stress Questionnaire resulted to be significantly associated with BP. None of the recovery-related scales displayed a statistically significant relationship with BP.

CONCLUSION

The outcomes of this study imply a modest association between stress and the presence of BP in competitive athletes. Practitioners may take these findings into account regarding the conception of training and for monitoring purposes.

Perspectives of participants with rotator cuff-related pain to a neuroscience-informed pain education session: an exploratory mixed method study

Purpose: To explore perceptions and initial outcomes of patients with rotator cuff-related pain to a pain education session.Materials and Methods: Ten individuals with persistent rotator cuff-related pain (≥3 months duration) attended an individual pain education session. They completed patient-reported outcomes measures on a weekly basis, three weeks prior and three weeks following the session. Individual semi-structured interviews were conducted three weeks following the pain education. Interviews were recorded, transcribed verbatim, and analyzed using the General Inductive Approach.Results: There were two over-arching key themes: firstly, 'Participants' Perspectives' of the session generated four themes: Improved understanding of 'the whole'; Mindful self-awareness; Taking charge; "The pain is still there". Their understanding of pain was reconceptualised, evident by their ability to describe the role of neurophysiological mechanisms, stress and general well-being towards their pain. The second over-arching key theme, 'Participants' Recommendations', had two themes: Integrating neuroscience with pathoanatomical knowledge and Educating other health professionals. Pain levels decreased post-pain education compared to pre-pain education.Conclusions: Following the pain education session, participants had greater understanding of factors influencing their shoulder pain. Pain education, in addition to pathoanatomical information may be useful as part of treatment for persistent rotator cuff-related pain.

Sticks and Stones: The Impact of Language in Musculoskeletal Rehabilitation

Throughout the often complex and challenging process of musculoskeletal rehabilitation, the words that we use can have a significant impact on the clinical outcome. Words contain both the ability to heal and harm. Gaining an improved understanding of the frequently hidden influence that language can have on musculoskeletal rehabilitation is of paramount importance. This Viewpoint article highlights the powerful consequences of the words that we use in clinical practice and discusses the practical considerations for adapting the current language of musculoskeletal rehabilitation. J Orthop Sports Phys Ther 2018;48(7):519-522. doi:10.2519/jospt.2018.0610.

Stress and risk for depression in competitive athletes suffering from back pain - Do age and gender matter?

Back pain (BP), a prominent problem for competitive athletes, is a primary reason for limitations in athletic performance and daily life restrictions. As studies on the relationship between psychological variables and BP in athletes are scarce, the aim of this study was to investigate stress and depression in competitive athletes with BP. In a cross-sectional design, data of 154 competitive athletes (51% female; M_age= 18.81 years, SD_age= 5.05 years) were collected, assessing Performance stress, Socio-emotional stress, Risk for depression and Psychological well-being and the two BP parameters BP Intensity and Disability. Two multiple linear regressions were conducted to predict (1) BP Intensity and (2) Disability from Performance stress, Socio-emotional stress, Risk for depression and Psychological well-being. Multiple linear regressions demonstrated that Performance stress (β = .21, p = .01) was the only significant predictor of BP Intensity (F_1,142= 6.68, p = .01, R² = .05), whilst Risk for depression (β = .24, p = .01) was the only significant predictor of Disability (F_1,142= 8.46, p = .01, R² = .06). Neither gender nor age explained a significant amount of variance in the models. Study results showed that, as in the general population, the variables stress and depression are related to BP in competitive athletes. In particular, BP intensity was found to be associated with stress and BP-related disability was associated with depression, whereas age and gender showed no association with the BP parameters. A longitudinal investigation is warranted to determine the direction of the observed relationships.

Sham Surgery in Orthopedics: A Systematic Review of the Literature

Objective

To evaluate the evidence for the effectiveness of sham surgery in orthopedics by conducting a systematic review of literature.

Methods

Systematic searches were conducted on Biomed Central, BMJ.com, CINAHL, the Cochrane Library, NLM Central Gateway, OVID, ProQuest (Digital Dissertations), PsycInfo, PubMed/Medline, ScienceDirect and Web of Science. Secondary searching (PEARLing) was undertaken, whereby reference lists of the selected articles were reviewed for additional references not identified in the primary search. All randomized controlled trials comparing surgery versus sham surgery in orthopedics were included. Data were extracted and methodological quality was assessed by two reviewers using the Critical Review Form-Quantitative Studies. Levels of scientific evidence, based on the direction of outcomes of the trials, were established following the Australian National Health and Medical Research Council (NHMRC) Hierarchy of Evidence (Australian National Health and Medical Research Council, 1999).

Results

This review includes six randomized controlled trials (RCTs) involving 277 subjects. All six studies were rated as very good on methodological quality. Heterogeneity across the studies, with respect to participants, interventions evaluated, and outcome measures used, prevented meta-analyses. Narrative synthesis of results, based on effect size, demonstrated that sham surgery in orthopedics was as effective as actual surgery in reducing pain and improving disability.

Conclusions

This review suggests that sham surgery has shown to be just as effective as actual surgery in reducing pain and disability; however, care should be taken to generalize findings because of the limited number of studies.

Rehabilitation of a Young Athlete With Extension-Based Low Back Pain Addressing Motor-Control Impairments and Central Sensitization

OBJECTIVE

  To describe the conservative management of a young athlete with extension-based (EB) low back pain (LBP).

BACKGROUND

  We present the case of a 15-year-old female high school gymnast with a 4-year history of EB LBP. Magnetic resonance imaging revealed a healed spondylolysis and significant atrophy with fatty infiltrate of the lumbar multifidi muscles (LMM). She had several courses of outpatient orthopaedic rehabilitation that focused on core muscle strengthening (improving activation and strength of the LMM and transversus abdominus muscle in a neutral pelvic position) without long-lasting improvement. She was unable to tolerate higher levels of training or compete.

DIFFERENTIAL DIAGNOSIS

  The LMM are rich in muscle spindles and provide continuous feedback to the central nervous system about body position. Atrophy and fatty infiltrate of the LMM can compromise neuromuscular function and contribute to dysfunctional movement patterns that place a greater demand on lumbar spine structures. Ongoing motor-control impairments perpetuate nociceptive input, leading to central sensitization.

TREATMENT

  The athlete had difficulty controlling trunk extension during sport-specific activities; she moved early and to a greater extent in the lumbar spine. The aim of the treatment was to teach the athlete how to control her tendency to overload her lumbar spine when bending backward, thus reducing nociceptive input from lumbar spine structures and desensitizing the nervous system.

UNIQUENESS

  Treating EB LBP by addressing motor-control impairments and cognitive-affective factors as opposed to core strengthening.

CONCLUSIONS

  Activity modification, bracing, and traditional core-strengthening exercises may not be the most appropriate treatment for athletes experiencing EB LBP. Addressing cognitive-affective factors in addition to correcting maladaptive motor behavior and moving in a pain-free range reduces nociceptive input, desensitizes the nervous system, and allows athletes to gain control over their pain.

Pain Neurophysiology Education and Therapeutic Exercise for Patients With Chronic Low Back Pain: A Single-Blind Randomized Controlled Trial

OBJECTIVE

To assess the effect of a pain neurophysiology education (PNE) program plus therapeutic exercise (TE) for patients with chronic low back pain (CLBP).

DESIGN

Single-blind randomized controlled trial.

SETTING

Private clinic and university.

PARTICIPANTS

Patients with CLBP for ≥6 months (N=56).

INTERVENTIONS

Participants were randomized to receive either a TE program consisting of motor control, stretching, and aerobic exercises (n=28) or the same TE program in addition to a PNE program (n=28), conducted in two 30- to 50-minute sessions in groups of 4 to 6 participants.

MAIN OUTCOMES MEASURES

The primary outcome was pain intensity rated on the numerical pain rating scale which was completed immediately after treatment and at 1- and 3-month follow-up. Secondary outcome measures were pressure pain threshold, finger-to-floor distance, Roland-Morris Disability Questionnaire, Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia, and Patient Global Impression of Change.

RESULTS

At 3-month follow-up, a large change in pain intensity (numerical pain rating scale: -2.2; -2.93 to -1.28; P<.001; d=1.37) was observed for the PNE plus TE group, and a moderate effect size was observed for the secondary outcome measures.

CONCLUSIONS

Combining PNE with TE resulted in significantly better results for participants with CLBP, with a large effect size, compared with TE alone.

Evaluation of factors associated with severe and frequent back pain in high school athletes

Several studies have shown that half of all young athletes experience back pain (BP). However, high intensity and frequency of BP may be harmful, and the factors associated with BP severity have not been investigated in detail. Here, we investigated the factors associated with a high intensity and high frequency of BP in high school athletes. We included 251 athletes (173 boys and 78 girls [14-20 years old]) in this cross-sectional study. The dependent variables were a high frequency and high intensity of BP, and the independent variables were demographic, socioeconomic, psychosocial, hereditary, anthropometric, behavioural, and postural factors and the level of exercise. The effect measure is presented as prevalence ratio (PR) with 95% confidence interval (CI). Of 251 athletes, 104 reported BP; thus, only these athletes were included in the present analysis. Results of multivariable analysis showed an association between high BP intensity and time spent using a computer (PR: 1.15, CI: 1.01-1.33), posture while writing (PR: 1.41, CI: 1.27-1.58), and posture while using a computer (PR: 1.39, CI: 1.26-1.54). Multivariable analysis also revealed an association of high BP frequency with studying in bed (PR: 1.19, CI: 1.01-1.40) and the method of carrying a backpack (PR: 1.19, CI: 1.01-1.40). In conclusion, we found that behavioural and postural factors are associated with a high intensity and frequency of BP. To the best of our knowledge, this study is the first to compare different intensities and frequencies of BP, and our results may help physicians and coaches to better understand BP in high school athletes.

Stress-related psychological factors for back pain among athletes: Important topic with scarce evidence

Health issues represent a frequent problem for athletes, as this particular demographic is repeatedly confronted with physically and psychologically stressful situations. Back pain (BP) materialises as comparatively common health problem being regarded as functionally limiting and psychologically straining burden for athletes. According to research conducted on athletes with BP, biomechanical and physiological mechanisms emerge as influential, whereas stress-related psychological factors appear to be neglected. For athletic injuries, the essential impact of psychological processes on injury occurrence and return from injury has already been corroborated. Hence, the aim of this literature review is to: (1) introduce a conceptual differentiation between injuries and BP; (2) summarise the results obtained regarding stress-related psychological aspects for injuries; and (3) connect the injury research to the state-of-the-art evidence regarding stress-related factors for BP among athletes. A distinction between injuries and BP could be established based on previous definitions, despite the fact that a considerable overlap between both concepts prevails. Injuries can be attributed to a physical origin, whereas BP frequently lacks this physical criterion. For BP, our enquiry yielded four studies including psychological measures of stress - with two studies specifically examining the association between BP and psychological stress among athletes longitudinally. Abundant findings from the general population support the importance of considering psychological and specifically stress-related factors in BP prevention and rehabilitation, but evidence related to the athletic field remains elusive. Further scientific investigations with a wider methodological approach are needed to deepen the knowledge about the crucial relationship between psychological stress, BP, and athletes.

Combining manual therapy with pain neuroscience education in the treatment of chronic low back pain: A narrative review of the literature

Teaching people with chronic low back pain (CLBP) about the neurobiology and neurophysiology of their pain is referred to as pain neuroscience education (PNE). There is growing evidence that when PNE is provided to patients with chronic musculoskeletal pain, it can result in decreased pain, pain catastrophization, disability, and improved physical performance. Because the aim of PNE is to shift the patient's focus from the tissues in the low back as the source of their pain to the brain's interpretation of inputs, many clinicians could mistakenly believe that PNE should be a "hands-off," education-only approach. An argument can be made that by providing manual therapy or exercise to address local tissue pathology, the patient's focus could be brought back to the low back tissues as the source of their problem. In this narrative literature review, we present the case for a balanced approach that combines PNE with manual therapy and exercise by considering how manual therapy can also be incorporated for interventions with patients with CLBP. We propose that as well as producing local mechanical effects, providing manual therapy within a PNE context can be seen as meeting or perhaps enhancing patient expectations, and also refreshing or sharpening body schema maps within the brain. Ideally, all of this should lead to better outcomes in patients with CLBP.

Listening is therapy: Patient interviewing from a pain science perspective

The interview of a patient attending physical therapy is the cornerstone of the physical examination, diagnosis, plan of care, prognosis, and overall efficacy of the therapeutic experience. A thorough, skilled interview drives the objective tests and measures chosen, as well as provides context for the interpretation of those tests and measures, during the physical examination. Information from the interview powerfully influences the treatment modalities chosen by the physical therapist (PT) and thus also impacts the overall outcome and prognosis of the therapy sessions. Traditional physical therapy focuses heavily on biomedical information to educate people about their pain, and this predominant model focusing on anatomy, biomechanics, and pathoanatomy permeates the interview and physical examination. Although this model may have a significant effect on people with acute, sub-acute or postoperative pain, this type of examination may not only gather insufficient information regarding the pain experience and suffering, but negatively impact a patient's pain experience. In recent years, physical therapy treatment for pain has increasingly focused on pain science education, with increasing evidence of pain science education positively affecting pain, disability, pain catastrophization, movement limitations, and overall healthcare cost. In line with the ever-increasing focus of pain science in physical therapy, it is time for the examination, both subjective and objective, to embrace a biopsychosocial approach beyond the realm of only a biomedical approach. A patient interview is far more than "just" collecting information. It also is a critical component to establishing an alliance with a patient and a fundamental first step in therapeutic neuroscience education (TNE) for patients in pain. This article highlights the interview process focusing on a pain science perspective as it relates to screening patients, establishing psychosocial barriers to improvement, and pain mechanism assessment.

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

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, MAge = 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.

Myofascial trigger points: peripheral or central phenomenon?

Trigger points (TrP) are hyperirritable spots in a taut band of a skeletal muscle, which usually have referred pain. There is controversy over whether TrP are a peripheral or central nervous system phenomenon. Referred pain, the most characteristic sign of TrP, is a central phenomenon initiated and activated by peripheral sensitization, whereby the peripheral nociceptive input from the muscle can sensitize dorsal horn neurons that were previously silent. TrP are a peripheral source of nociception, and act as ongoing nociceptive stimuli contributing to pain propagation and widespread pain. Several studies support the hypothesis that TrP can induce central sensitization, and appropriate TrP treatment reduces central sensitization. In contrast, preliminary evidence suggests that central sensitization can also promote TrP activity, although further studies are needed. Proper TrP management may prevent and reverse the development of pain propagation in chronic pain conditions, because inactivation of TrP attenuates central sensitization.

A modern neuroscience approach to chronic spinal pain: combining pain neuroscience education with cognition-targeted motor control training

Chronic spinal pain (CSP) is a severely disabling disorder, including nontraumatic chronic low back and neck pain, failed back surgery, and chronic whiplash-associated disorders. Much of the current therapy is focused on input mechanisms (treating peripheral elements such as muscles and joints) and output mechanisms (addressing motor control), while there is less attention to processing (central) mechanisms. In addition to the compelling evidence for impaired motor control of spinal muscles in patients with CSP, there is increasing evidence that central mechanisms (ie, hyperexcitability of the central nervous system and brain abnormalities) play a role in CSP. Hence, treatments for CSP should address not only peripheral dysfunctions but also the brain. Therefore, a modern neuroscience approach, comprising therapeutic pain neuroscience education followed by cognition-targeted motor control training, is proposed. This perspective article explains why and how such an approach to CSP can be applied in physical therapist practice.

Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions

In recent years, increased knowledge of the pathogenesis of upper quadrant pain syndromes has translated to better management strategies. Recent studies have demonstrated evidence of peripheral and central sensitization mechanisms in different local pain syndromes of the upper quadrant such as idiopathic neck pain, lateral epicondylalgia, whiplash-associated disorders, shoulder impingement, and carpal tunnel syndrome. Therefore, a treatment-based classification approach where subjects receive matched interventions has been developed and, it has been found that these patients experience better outcomes than those receiving non-matched interventions. There is evidence suggesting that the cervical and thoracic spine is involved in upper quadrant pain. Spinal manipulation has been found to be effective for patients with elbow pain, neck pain, or cervicobrachial pain. Additionally, it is known that spinal manipulative therapy exerts neurophysiological effects that can activate pain modulation mechanisms. This paper exposes some manual therapies for upper quadrant pain syndromes, based on a nociceptive pain rationale for modulating central nervous system including trigger point therapy, dry needling, mobilization or manipulation, and cognitive pain approaches.