Resistance training in musculoskeletal rehabilitation: a systematic review

Could resistance training prevent or improve work-related musculoskeletal disorders among surgeons?

Studies have demonstrated the negative impact that work-related musculoskeletal disorders (WMSDs) have on surgeons. These are also likely to affect some allied healthcare professionals such as interventional radiologists. Problems from WMSDs include pain, diminished technical and cognitive performance, and work absence. These could contribute to burnout, to which surgeons are already vulnerable owing to other working practices such as shift patterns and long hours. WMSDs could negatively affect working performance, and lead to poorer surgical outcomes and patient care. Surgeons are at risk of WMSDs of the neck and back that result from fixed and damaging postures while operating. Some have reduced their operation numbers and working days as result of WMSDs. Theatre ergonomics (e.g. table positioning, operating stools and monitors), intraoperative breaks and stretching may improve WMSDs for some. Strength/resistance training (RT) may be used to prevent or mitigate WMSDs. RT can also enhance general health and concentration, and combat intraoperative fatigue. Low engagement times of moderate-intensity RT of 20 minutes, twice a week, improve neck and back pain from WMSDs. Moreover, RT has been shown to reduce all-cause mortality by up to 15%, increase bone density, improve proprioception and reduce the fear of movement due to pain. Alongside ergonomic improvement and stretching, we recommend RT as an activity to improve general health and WMSDs.

An 8-week physiotherapist-led return to sport group program after anterior cruciate ligament reconstruction improves measures of physical and psychological function: A case series

BACKGROUND

Low return to competitive sport, high reinjury rates and long-term functional impairment of anterior cruciate ligament reconstruction (ACLR) present significant challenges for patients. A program that facilitates a safe return to sport (RTS) following ACLR could potentially improve outcomes.

STUDY DESIGN

Case Series.

METHODS

Sixty participants (median 20-years-old (13-36), 43 males, 18 females, median 7.5 months (4-25) post-ACLR) completed an eight-week exercise program. A battery of physical tests and patient-reported outcome measures were assessed pre and post-program. The number of participants passing RTS criteria was evaluated, and RTS rates were determined. The correlation between the ACL-RSI and measures of physical function was explored.

RESULTS

Improvements in all isometric strength, hop tests, running T-test, and patient reported outcome measures were seen post-program. Five (8%) participants successfully passed all RTS criteria and eighty-five percent of participants returned to their previous level of sport. The ACL-RSI and the IKDC showed correlation across all time points (pre rs = 0.49; post rs = 0.40; change r = 0.40).

CONCLUSIONS

Our study demonstrated improvements in all RTS criteria tests upon completing the 8-week rehabilitation program; however, few participants (8%) passed all RTS criteria. Psychological readiness is more closely related to patient-reported function than functional tests.

Role of strengthening exercises in management and prevention of overuse sports injuries of lower extremity: a systematic review

INTRODUCTION

Overuse injuries are common in sports involving jumping, running, and landing, due to the repetitive nature of these activities and the strain they place on the lower extremity. The objective of the study was to determine the role of strengthening exercises in the management of overuse sports injuries of lower extremity and its effects on prevention of injury recurrence.

EVIDENCE ACQUISITION

This study employed a systematic review design. The author extracted and reviewed the papers for this study in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria, and then used the PEDro scale to rate the articles' quality. For the most recent and well-developed primary data, several electronic databases including Google Scholar, PubMed Central, MEDLINE, Cochrane Library, and PEDro were exhaustively searched. Inclusion criteria were based on PICO (T) model and included study population, intervention nature, outcome measures, time period, methodological quality, and linguistic extent.

EVIDENCE SYNTHESIS

The data synthesis involved analyzing randomized control/clinical trials on strengthening exercises for lower extremity overuse sports injuries in athletes, considering outcomes including muscle strength, pain scores, return to sports, and injury prevention.

CONCLUSIONS

The methodological quality of the recruited articles ranged from excellent to fair on PEDro scale. Three included studies investigated the effects of strengthening exercises on management of lower extremity injuries of athletes. Four studies evaluated its role on prevention from recurrence of injuries. This study has concluded that strength training plays a fundamental role in management and prevention of overuse injuries. It not only improves the muscle performance, fitness level, speed and agility in sports but also decreases the pain, and aids in early recovery from an injury.

Aerobic high-intensity interval training and maximal strength training in patients with unspecific musculoskeletal disorders improve V̇O2peak and maximal strength more than moderate training

Improving peak oxygen uptake (V̇O2peak) and maximal strength are key objectives of rehabilitation for patients with unspecific musculoskeletal disorders (MSDs). Although high-intensity training yield superior outcomes for these factors, patients with MSDs may not tolerate high-intensity due to pain and fear. Therefore, we examined the effect and feasibility of incorporating aerobic high-intensity intervals (HIITs) and maximal strength training (MST) in a standard clinical rehabilitation program for patients with unspecific MSDs. 73 patients (45 ± 10 years) with MSDs partaking in a standard, public, and 4-week rehabilitation program were randomized to high-intensity training (HG: 4 × 4 minutes intervals at ∼90% of maximal heart rate; HRmax, and 4 × 4 repetitions leg press at ∼90% of 1 repetition maximum; 1RM, with maximal intended velocity) or keep todays treatment of low-to moderate-intensity training (MG: various cycling, walking, and/or running activities at ∼70%-80% of HRmax and 3 × 8 - 10 repetitions leg press at ∼75% of 1RM without maximal intended velocity). HG improved V̇O2peak (12 ± 7%) and leg press 1RM (43 ± 34%) more than moderate-intensity group (V̇O2peak; 5 ± 6%, 1RM; 19 ± 18%, both p < 0.001). We observed that no adverse events and no between-group differences in dropout rate or self-reported quality of life (both p > 0.05). There were positive correlations between improved V̇O2peak and improved physical (p = 0.024) and emotional (0.016) role functioning. We conclude that both high-intensity interval training and MST are feasible and improve V̇O2peak and maximal strength more than standard low-to moderate-intensity treatment of patients with unspecific MSDs. Our findings suggest that high-intensity training should be implemented as a part of standard clinical care of this patient population.

Comparison of Blood Flow Restriction Interventions to Standard Rehabilitation After an Anterior Cruciate Ligament Injury: A Systematic Review

BACKGROUND

Blood flow restriction training (BFR-t) data are heterogeneous. It is unclear whether rehabilitation with BFR-t after an anterior cruciate ligament (ACL) injury is more effective in improving muscle strength and muscle size than standard rehabilitation.

PURPOSE

To review outcomes after an ACL injury and subsequent reconstruction in studies comparing rehabilitation with and without BFR-t.

STUDY DESIGN

Systematic review. Level of evidence, 3.

METHODS

A search of English-language human clinical studies published in the past 20 years (2002-2022) was carried out in 5 health sciences databases, involving participants aged 18-65 undergoing rehabilitation for an ACL injury. Outcomes associated with muscle strength, muscle size, and knee-specific patient-reported outcome measures (PROMs) were extracted from studies meeting inclusion criteria and compared.

RESULTS

The literature search identified 279 studies, of which 5 met the selection criteria. Two studies suggested that BFR-t rehabilitation after an ACL injury improved knee or thigh muscle strength and muscle size compared with rehabilitation consisting of comparable and higher load resistance training, with two studies suggesting the opposite. The single study measuring PROMs showed improvement compared to traditional rehabilitation, with no difference in muscle strength or size.

CONCLUSION

BFR-t after an ACL injury seems to benefit muscle strength, muscle size, and PROM scores compared with standard rehabilitation alone. However, only 1 large study included all these outcomes, which has yet to be replicated in other settings. Further studies utilizing similar methods with a common set of outcome measures are required to confirm the effects of BFR-t on ACL rehabilitation.

Revolutionizing Sports Rehabilitation: Unleashing the Power of Tele-Rehabilitation for Optimal Physiotherapy Results

Background: Tele-rehabilitation programs have emerged as a promising approach to improve access to physiotherapy services for athletes with sports-related injuries. This randomized controlled trial aimed to compare the effectiveness of a tele-rehabilitation program with traditional in-person physiotherapy in improving outcomes for this population. Methods: This randomized controlled trial enrolled a large sample of 780 athletes with sports-related injuries to compare the effectiveness of tele-rehabilitation and traditional in-person physiotherapy. Blinding procedures were implemented to minimize bias. The intervention group received tele-rehabilitation physiotherapy, whereas the control group received traditional in-person physiotherapy. Pre- and post-intervention assessments were conducted to measure outcome measures, including range of motion, muscle strength, pain levels, and functional performance. Results: Significant improvements were observed in all outcome measures in both the tele-rehabilitation and in-person groups from baseline to postintervention. Independent t tests demonstrated no significant differences between the two groups in any of the outcome measures. These findings indicate that the tele-rehabilitation program was as effective as traditional in-person physiotherapy in improving the outcomes of athletes with sports-related injuries, even in a large sample size of 780 participants. Conclusion: This study provides robust evidence supporting the feasibility and effectiveness of tele-rehabilitation programs as viable alternatives to traditional in-person physiotherapy for athletes with sports-related injuries. These findings highlight the potential of tele-rehabilitation to significantly expand access to high-quality physiotherapy services for a large number of athletes. Further research should focus on evaluating the long-term effectiveness and cost-effectiveness of tele-rehabilitation programs in sports rehabilitation using larger sample sizes.

Development and feasibility of a conceptual model for planning individualised physical exercise training (IPET) for older adults: a cross-sectional study

OBJECTIVE

Older adults constitute a heterogeneous group, and the focus of the individual physical exercise is often subject to the reasoning and experience of health professionals or exercise physiologists who prescribe them. Thus, this is the first effort to explicitly conceptualise the planning of individualised physical exercise training (IPET) for older adults in an outpatient setting and investigate individual exercise preferences.

DESIGN

The concept of IPET was developed by researchers, exercise physiologists and health professionals from a real-life outpatient setting using an iterative approach. Health indicators assessing aerobic capacity, strength, balance and musculoskeletal pain/discomfort sites form the basis of physical exercise recommendations. A cross-sectional study was conducted to assess the basis of implementing IPET.

SETTING

Outpatient setting.

PARTICIPANTS

We included 115 older adults (70 females) from an outpatient setting with a median age of 74 years.

OUTCOME MEASURES

Health indicators assessing aerobic capacity, strength, balance and musculoskeletal pain/discomfort sites were collected and informed the concept of IPET that structures exercise programmes based on the individual citizen's needs and physical exercise preferences. Exceeding a health indicator cut-point results in exercise content mitigating the risk associated with the health indicator.

RESULTS

We included 115 older adults (70 females) from an outpatient setting median age of 74 years. Approximately two-thirds of participants exceeded at least one health indicator cut-point for aerobic training. One-third of the participants exceeded the cut-point for upper extremity strength, and almost all participants >99% exceeded the cut-point for lower extremity strength. Approximately two-thirds of the participants exceeded the cut-point for functional/balance training. The most prevalent site of musculoskeletal pain was the lower extremities. Eight of 20 training combinations were used, clustering the 115 participants primarily in three main training combinations.

DISCUSSION

This study shows that older adults vary in physical functioning, indicating that exercise preferences and rehabilitation needs are individual.

TRIAL REGISTRATION NUMBER

NCT04862481.

Effects of progressive intensity resistance training on the impact of fibromyalgia: protocol for a blinded randomized controlled trial

BACKGROUND

Fibromyalgia guidelines indicate that exercise is critical in the management of fibromyalgia, and there is evidence that patients with fibromyalgia can perform resistance training at moderate and high intensities. However, despite the biological plausibility that progression of intensity provides greater benefit to individuals, no studies have compared different intensities (progressive versus constant intensities) of the same exercise in this population.

OBJECTIVE

To compare the effect of 24 sessions of resistance training (progressive vs. constant intensity) on impact of fibromyalgia, sleep quality, anxiety, depression, pain, walking ability, and musculoskeletal capacity.

METHODS

A protocol for a blinded randomized controlled trial. The sample will be randomized into three groups: group 1 (progressive intensity, experimental), group 2 (constant intensity, control A), and group 3 (walking, control B). Group 1 will perform resistance training at moderate intensity (50% of maximum dynamic strength), previously determined by the 1 repetition maximum (1-RM) test in the proposed exercises. The strength of each individual will be reassessed every 4 weeks (by 1-RM) and the intensity of each exercise will be positively adjusted by 20% of the value observed in kg (i.e., first month 50%; second month 70%; third month 90% of the maximum dynamic strength). Group 2 will perform the same procedure, but the intensity will be maintained at 50% of the maximum dynamic strength throughout the treatment (i.e., constant intensity from the first to the third month). Group 3 will perform a 40-minute treadmill walk at low intensity, defined by a walking speed corresponding to 60-70% of the maximum heart rate, which we will control with a heart rate monitor. All groups will receive a 45-minute pain education session prior to the exercise program, covering the pathophysiologic mechanisms of chronic pain, strategies for coping with pain, avoiding hypervigilance, and deconstructing beliefs and myths about chronic pain.

DISCUSSION

The results of the present study may help health care professionals adjust the intensity of resistance training and thus plan the most effective intervention (progressive or constant intensity) to reduce the impact of fibromyalgia on patients' lives.

TRIAL REGISTRATION

Brazilian Registry of Clinical Trials (ReBEC) ID: RBR-9pbq9fg, date of registration: October 06, 2022.

Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness

Background

Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy.

Review questions

(i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies?

Methods

A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021.

Results

Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship.

Limitations

Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made.

Conclusion

The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence.

Future work

There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes.

Study registration

This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.

Creation and Evaluation of a Severity Classification of Hyperkyphosis and Hypolordosis for Exercise Therapy

The rise in the occurrence of musculoskeletal disorders, such as thoracic hyperkyphosis (THK) or lumbar hypolordosis (LHL), is a result of demographic changes. Exercise therapy is an effective approach that can reduce related disabilities and costs. To ensure successful therapy, an individualized exercise program adapted to the severity of the disorder is expedient. Nevertheless, appropriate classification systems are scarce. This project aimed to develop and evaluate a severity classification focused on exercise therapy for patients with THK or LHL. A multilevel severity classification was developed and evaluated by means of an online survey. Reference limits of spinal shape angles were established by data from video rasterstereography of 201 healthy participants. A mean kyphosis angle of 50.03° and an average lordosis angle of 40.72° were calculated as healthy references. The strength of the multilevel classification consisting of the combination of subjective pain and objective spinal shape factors was confirmed by the survey (70% agreement). In particular, the included pain parameters were considered relevant by 78% of the experts. Even though the results of the survey provide important evidence for further analyses and optimization options of the classification system, the current version is still acceptable as therapeutic support.

Eccentric resistance training with neurological conditions: A meta analysis

BACKGROUND

People with neurological conditions are exposed to muscle wasting resulting in reduced strength and endurance. Both deficiencies negatively impact gait and balance, each of which can be benefited by strengthening exercises. Unfortunately, people with neurological conditions often do not have the ability to perform traditional weight training as their endurance and strength fail to meet the minimum threshold for improvement. An alternative to traditional, full range of motion lifting is eccentric resistance training (ERT).

RESEARCH QUESTION

The current systematic review and meta-analysis sought to evaluate the efficacy of ERT against conventional therapeutic modalities or weightlifting on walking speed, Timed Up and Go (TUG), and maximum voluntary isometric contraction (MVIC) in individuals with neurological conditions.

METHODS

Web of Science, PubMed, and Academic Search Complete were searched until September 1, 2020, followed by a manual search on December 3, 2021. Publications were included if they were peer reviewed, available in English, consisted of a pre-specified neurological disorder, involved human subjects, had an eccentric and "traditional" therapy; and reported at least one of the outcome measures at both pre- and post-intervention.

RESULTS

Thirteen studies of human subjects (n = 297) and 47 standardized mean differences (SMD) were included in the multilevel model analysis. The analysis revealed a small, albeit non-significant effect on performance (TUG, MVIC, walking speed) when comparing traditional therapies and ERT (SMD: 0.136; 96; 95 % CI: -0.0002, 0.050).

SIGNIFICANCE

There appears to be no difference between ERT and traditional therapy or weightlifting on measured outcomes. In this way, ERT is as effective as traditional therapeutics and full range of motion weightlifting to improve movement in clinical populations. Practitioners working with populations with neurological conditions may consider supplementing or replacing traditional strengthening activities with ERT as clients can complete greater volumes of work with lower metabolic demand.

The effect of specific bioactive collagen peptides on function and muscle remodeling during human resistance training

AIM

Bioactive collagen peptides (CP) have been suggested to augment the functional, structural (size and architecture), and contractile adaptations of skeletal muscle to resistance training (RT), but with limited evidence. This study aimed to determine if CP vs. placebo (PLA) supplementation enhanced the functional and underpinning structural, and contractile adaptations after 15 weeks of lower body RT.

METHODS

Young healthy males were randomized to consume either 15 g of CP (n = 19) or PLA (n = 20) once every day during a standardized program of progressive knee extensor, knee flexor, and hip extensor RT 3 times/wk. Measurements pre- and post-RT included: knee extensor and flexor isometric strength; quadriceps, hamstrings, and gluteus maximus volume with MRI; evoked twitch contractions, 1RM lifting strength, and architecture (with ultrasound) of the quadriceps.

RESULTS

Percentage changes in maximum strength (isometric or 1RM) did not differ between-groups (0.684 ≤ p ≤ 0.929). Increases in muscle volume were greater (quadriceps 15.2% vs. 10.3%; vastus medialis (VM) 15.6% vs. 9.7%; total muscle volume 15.7% vs. 11.4%; [all] p ≤ 0.032) or tended to be greater (hamstring 16.5% vs. 12.8%; gluteus maximus 16.6% vs. 12.9%; 0.089 ≤ p ≤ 0.091) for CP vs. PLA. There were also greater increases in twitch peak torque (22.3% vs. 12.3%; p = 0.038) and angle of pennation of the VM (16.8% vs. 5.8%, p = 0.046), but not other muscles, for CP vs. PLA.

CONCLUSIONS

CP supplementation produced a cluster of consistent effects indicating greater skeletal muscle remodeling with RT compared to PLA. Notably, CP supplementation amplified the quadriceps and total muscle volume increases induced by RT.

Potential causal association between leisure sedentary behaviors, physical activity and musculoskeletal health: A Mendelian randomization study

BACKGROUND

Increasing evidence shows that leisure sedentary behaviors (LSB) and physical activity (PA) are associated with various musculoskeletal disorders. However, the causality between LSB/PA and musculoskeletal health remained unknown. In this study, we aimed to evaluate the causal relationships between LSB/PA and lower back pain (LBP), intervertebral disc disorder (IVDD), rheumatoid arthritis (RA), and bone mineral density (BMD) by using a two-sample Mendelian randomization method.

METHODS

The exposure data were obtained from large-scale genome-wide association studies (GWAS), including the PA dataset (self-reported PA, n  =  377,234; accelerometer-assessed PA, n  = 91,084) and LSB dataset (n  =  422,218). The outcome data were derived from the FinnGen LBP dataset (n  =  248,528), FinnGen IVDD dataset (n  =  256,896), BMD GWAS dataset (n  =  56,284), and RA GWAS dataset (n  =  58,284). The causal relationships were estimated with inverse variance weighted (IVW), MR-Egger, and weighted median methods. Sensitivity analyses were performed with Cochran's Q test, MR-Egger intercept test, and leave-one-out analysis to estimate the robustness of our findings.

RESULTS

Genetically predicted leisure television watching increased the risk of LBP (OR = 1.68, 95% CI 1.41 to 2.01; P = 8.23×10-9) and IVDD (OR  =  1.62, 95% CI 1.37 to 1.91; P  =  2.13 × 10-8). In addition, this study revealed a potential causal relationship between computer use and a reduced risk of IVDD (OR  = 0.60, 95% CI 0.42 to 0.86; P  =  0.005) and RA (OR  = 0.28, 95% CI 0.13 to 0.60; P  =  0.001).

CONCLUSIONS

Our results suggest that leisure television watching is a risk factor for LBP and IVDD, whereas leisure computer use may act as a protective factor against IVDD and RA. These findings emphasized the importance of distinguishing between different sedentary behaviors in musculoskeletal disease studies.

Summarizing the effects of different exercise types in chronic low back pain - a systematic review of systematic reviews

Background

In chronic LBP (CLBP), guideline-endorsed treatment is to stay active, return to normal activity, and to exercise. Several reviews on various exercise types used in CLBP have been published. We aimed to identify systematic reviews of common exercise types used in CLBP, to appraise their quality, and to summarize and compare their effect on pain and disability.

Methods

We searched the databases OVID MEDLINE, EMBASE, COCHRANE LIBRARY, and WEB OF SCIENCE (Core collection) for systematic reviews and meta-analyses on adults between 18 and 70 years of age suffering from chronic or recurrent LBP for a period of at least 12 weeks, which investigated the effects of exercises on pain and disability. All searches were conducted without language restriction. The search was performed up until 2022–01-26. The included reviews were grouped into nine exercise types: aerobic training, aquatic exercises, motor control exercises (MCE), resistance training, Pilates, sling exercises, traditional Chinese exercises (TCE), walking, and yoga. The study quality was assessed with AMSTAR-2. For each exercise type, a narrative analysis was performed, and the level of evidence for the effects of exercise was assessed through GRADE.

Results

Our database search resulted in 3,475 systematic reviews. Out of the 253 full texts that were screened, we included 45 systematic reviews and meta-analyses. The quality of the included reviews ranged from high to critically low. Due to large heterogeneity, no meta-analyses were performed. We found low-to-moderate evidence of mainly short-term and small beneficial effects on pain and disability for MCE, Pilates, resistance training, TCE, and yoga compared to no or minimal intervention.

Conclusions

Our findings show that the effect of various exercise types used in CLBP on pain and disability varies with no major difference between exercise types. Many of the included systematic reviews were of low-to-moderate quality and based on randomized controlled trials with high risk of bias. The conflicting results seen, undermine the certainty of the results leading to very-low-to-moderate quality of evidence for our results. Future systematic reviews should be of higher quality to minimize waste of resources.

Trial registration

PROSPERO: Reg no 190409 Registration date 01AUG 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05722-x.

Unilateral Versus Bilateral Resistance Exercise in Postoperative Rehabilitation After ACL Reconstruction With Bone-Patellar Tendon-Bone Graft: A Randomized Controlled Trial

Background

Lower limb muscle strength symmetry has been suggested as an essential criterion for the safe return to sports after anterior cruciate ligament (ACL) reconstruction. Limited evidence is available regarding the most effective intervention to achieve symmetry after reconstruction with contralateral bone-patellar tendon-bone (BPTB) graft.

Purpose

To verify whether unilateral isotonic resistance exercise is more effective than bilateral exercise for obtaining postoperative functional and muscular strength symmetry between the donor limb and reconstructed limb for patients who received BPTB graft.

Study Design

Randomized controlled trial; Level of evidence, 1.

Methods

A total of 88 patients were randomly divided into a control group (n = 44) and an intervention group (n = 44). All participants performed an 8-week exercise program starting at the beginning of the fourth postoperative month and were evaluated before and after the program. The control group performed bilateral exercises, and the intervention group performed unilateral exercises for the donor limb only (the limb with the greatest disability). The primary outcome was muscle strength (peak torque and hamstrings to quadriceps [H:Q] ratio), and the secondary outcomes were range of motion (ROM; goniometry), KT-1000 arthrometer side-to-side difference in anteroposterior knee laxity, and objective (single-leg hop test) and subjective (Lysholm score) functionality.

Results

Both groups improved significantly from before to after the exercise program. The improvements were significantly greater in the intervention group regarding peak torque, H:Q ratio, flexion ROM, single-leg hop test, and Lysholm score in the donor limb (P < .001 for all), and the improvements were significantly greater in the control group regarding peak torque and single-leg hop test in the reconstructed limb (P < .001 for both). Comparison between the groups showed significantly increased symmetry regarding peak torque, H:Q ratio, and single-leg hop test in the intervention group compared with the control group (P < .001), with large effect sizes (>0.80) except for the H:Q ratio.

Conclusion

Although postoperative, bilateral, isotonic resistance exercise provided better strength gains to the reconstructed limb, unilateral exercise was more effective in obtaining functional and muscle strength between-limb symmetry in patients who underwent ACL reconstruction with contralateral BPTB graft.

Registration

Brazilian Registry of Clinical Trials (number RBR-22rnjh).

Benefits and Mechanisms of Exercise Training for Knee Osteoarthritis

Knee osteoarthritis is a chronic degenerative disease. Cartilage and subchondral bone degeneration, as well as synovitis, are the main pathological changes associated with knee osteoarthritis. Mechanical overload, inflammation, metabolic factors, hormonal changes, and aging play a vital role in aggravating the progression of knee osteoarthritis. The main treatments for knee osteoarthritis include pharmacotherapy, physiotherapy, and surgery. However, pharmacotherapy has many side effects, and surgery is only suitable for patients with end-stage knee osteoarthritis. Exercise training, as a complementary and adjunctive physiotherapy, can prevent cartilage degeneration, inhibit inflammation, and prevent loss of the subchondral bone and metaphyseal bone trabeculae. Increasing evidence indicates that exercise training can improve pain, stiffness, joint dysfunction, and muscle weakness in patients with knee osteoarthritis. There are several exercise trainings options for the treatment of knee osteoarthritis, including aerobic exercise, strength training, neuromuscular exercise, balance training, proprioception training, aquatic exercise, and traditional exercise. For Knee osteoarthritis (KOA) experimental animals, those exercise trainings can reduce inflammation, delay cartilage and bone degeneration, change tendon, and muscle structure. In this review, we summarize the main symptoms of knee osteoarthritis, the mechanisms of exercise training, and the therapeutic effects of different exercise training methods on patients with knee osteoarthritis. We hope this review will allow patients in different situations to receive appropriate exercise therapy for knee osteoarthritis, and provide a reference for further research and clinical application of exercise training for knee osteoarthritis.

Optimizing Backrest Geometry to Minimize Interfacial Pressure Concentrations in the Mid-To-Lumbar Region During Leg Press Resistance Training

The leg press is a resistance training (RT) exercise common to both weight- and powerlifting, where spine-related injuries remain prevalent. Here, the elevated loading has the potential to result in increased pressure on vertebral bodies and introduce the risk of spinal injury. This study therefore investigates back interfacial pressure under leg press loading conditions and offers design recommendations to minimize spatial pressure concentrations. A pressure mat was used to assess the back-backrest interfacial pressure distribution of 15 subjects executing RT leg-presses at 50% bodyweight, over 16 different back-support geometries. Real-time forces, knee angles, and pressures were captured. The resulting data show that more prominent (?2.1 cm) back-supports, positioned 19cm above the seat pan typically produced greater peak pressures (41.8±7.2 kPa). Conversely, less prominent supports (~0.7 cm) generally achieved lower peak pressures (with greater distribution). Our data suggest that the most prudent choice for fixed-shape backrests to best distribute interfacial pressure on leg-press devices is to incorporate shallow convex supports (~0.7 cm), and locate them away from P=19 cm. The result is surprising as this prominence location is a common ergonomic feature. If an adjustable backrest is considered, peak pressures may be reduced by up to 26±8% (9.7±3.1 kPa) compared to flat geometries.

Smartphone-based exercise intervention for chronic pain: PainReApp randomized clinical trial protocol

AIM

To evaluate the effectiveness of PainReApp, an mHealth system, based on physical exercise recommendations for patients with chronic pain (low back pain, fibromyalgia and diabetic neuropathic pain) based on pain intensity, quality of life, anxiety and/or depression, and sleep quality.

DESIGN

Single-blinded randomized controlled trial.

METHODS

One hundred patients from three different chronic conditions (low back pain, fibromyalgia and neuropathic diabetic pain) will be recruited and randomized into two groups to receive the intervention with a physical activity program guided by the PainReApp system (experimental group) or with the program information in paper format (control group). All patients will attend a first face-to-face session in which the smartphone application usage (experimental group) and exercise execution will be explained (both groups). Data will be collected at baseline, 4, 12 and 24 weeks. Nevertheless, the users of the application will have a daily registry of the exercise performed and the self-perceived difficulty. The primary outcomes of the trial will be the intensity of pain and quality of life. Anxiety and/or depression and sleep quality will be also assessed to evaluate the influence of the physical activity at multiple levels.

DISCUSSION

Physical exercise is becoming one of the leading evidence-based interventions to treat chronic pain. It needs to be adapted to the necessities of each pain condition. One of the major problems is the low adherence to the proposed program. New strategies that empower the patients, such as the m-Health, are reliable and useful tools to ease this end.

IMPACT

To the best of our knowledge, this is the first long-term randomized controlled trial researching the impact of an m-health system on chronic pain from different origin. The intervention is based on international physical exercise recommendations and can be performed without specific material, allowing the home-based practice.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry (ACTRN12621000783820).

Usability and Acceptance of an Interactive Tablet-Based Exercise Application: A Mixed Methods Study

Purpose: To investigate usability and acceptance of a newly developed interactive, tablet-based exercise application (app) and to explore personal opinions of therapists when using this app in the clinical setting.

Methods: Twenty participants (10 therapists and 10 inactive healthy adults) tested usability of this app performing different test tasks, using the think aloud method, and rated overall satisfaction with the System Usability Scale and acceptance with a modified Technology Acceptance Model Questionnaire. For a secondary objective, personal opinions of therapists were evaluated with two focus groups, one for team leaders and one for team members.

Results: Overall, the app was judged to be usable. Effectiveness varied between 73 and 90%, overall satisfaction between 70.5 and 85.5/100 points and acceptance between 74 and 80%. Team leader and team member focus groups considered the app as providing a great opportunity for therapy extension, especially because of its blended character. Barriers to its implementation were seen in the existing clinical working processes, personal attitudes of therapists and uncertainty of who would cover expenses for this new form of therapy. Some improvements such as using videos instead of photos, the integration of more interactive tools and the possibility to add additional exercises were suggested in both settings.

Conclusion: The app showed high acceptance and usability in trainees and therapists, although some ideas for upgrading functions were formulated. Before this app can be used in clinical practice, feasibility of this blended approach should be evaluated in a clinical setting.

Prevalence, Characteristics, Association Factors of and Management Strategies for Low Back Pain Among Italian Amateur Cyclists: an Observational Cross-Sectional Study

Background

Low back pain (LBP) is a burdensome problem affecting amateur cyclists. This cross-sectional study analysed Italian amateur cycling cohort’s demographic and sport-specific characteristics, the prevalence and characteristics of LBP among this population, its possible association factors, the management strategies adopted to deal with LBP and the sample’s beliefs among possible LBP triggers. A web-based cross-sectional survey was created. The questionnaire included 56 questions divided into six sections, querying the sample’s demographic, clinical, and cycling characteristics. Binomial logistic regression with a Wald backward method was performed to ascertain the effects of some covariates (“Sex”, “Age”, “Body Mass Index”, “Sleep hours”, “Work type”, “Cycling year”, “Number of training sessions per week”, “Stretching sessions”, “Being supervised by a coach or following a scheduled training”, “Other sports practised regularly”, “Number of cycling competitions per year”, “Past biomechanic visits”, “Specific pedal training”, “LBP before cycling”) on the likelihood of developing LBP in the last 12 months.

Results

A total of 1274 amateur cyclists answered the survey. The prevalence of LBP appeared to be 55.1%, 26.5% and 10.8% in life, in the last 12 months and the last 4 weeks, respectively. The final model of the logistic regression included the covariates “Sex”, “Work type”, “Cycling year”, “Being supervised by a coach or following a scheduled training”, “Other sports practised regularly”, “Specific pedal training”, “LBP before cycling”, among which “Cycling year” (variable “Between 2 and 5 years” vs. “Less than 2 years”, OR 0.48, 95% CI [0.26–0.89]), “Being supervised by a coach or following a scheduled training” (OR 0.53, 95% CI [0.37–0.74]), “Specific pedal training” (OR 0.69, 95% CI [0.51–0.94]), and “LBP before cycling” (OR 4.2, 95% CI [3.21–5.40]) were found to be significant.

Conclusions

The prevalence of LBP among Italian amateur cyclists seems to be less frequent compared to the general population. Moreover, undergoing previous specific pedal training and being supervised by a coach or following scheduled training drew a negative association with LBP development. This evidence highlights the importance of being overseen by specific sport figures that could offer a tailored evidence-based training to reach good physical level and to practise sports safely.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40798-021-00370-2.

Skeletal Muscle Quality: A Biomarker for Assessing Physical Performance Capabilities in Young Populations

Muscle quality (MQ), defined as the amount of strength and/or power per unit of muscle mass, is a novel index of functional capacity that is increasingly relied upon as a critical biomarker of muscle health in low functioning aging and pathophysiological adult populations. Understanding the phenotypical attributes of MQ and how to use it as an assessment tool to explore the efficacy of resistance exercise training interventions that prioritize functional enhancement over increases in muscle size may have implications for populations beyond compromised adults, including healthy young adults who routinely perform physically demanding tasks for competitive or occupational purposes. However, MQ has received far less attention in healthy young populations than it has in compromised adults. Researchers and practitioners continue to rely upon static measures of lean mass or isolated measures of strength and power, rather than using MQ, to assess integrated functional responses to resistance exercise training and physical stress. Therefore, this review will critically examine MQ and the evidence base to establish this metric as a practical and important biomarker for functional capacity and performance in healthy, young populations. Interventions that enhance MQ, such as high-intensity stretch shortening contraction resistance exercise training, will be highlighted. Finally, we will explore the potential to leverage MQ as a practical assessment tool to evaluate function and enhance performance in young populations in non-traditional research settings.

Use of an isometric mid-thigh pull test during musculoskeletal rehabilitation: can the criterion values from the updated British Army physical employment standards be used to inform UK Defence Rehabilitation practice?

INTRODUCTION

Objective outcome measures that can quantify the force generating capacity of the lower limb are required to allow clinicians to accurately measure functional status and treatment adaptations over time. The aim of this prospective observational cohort study is to: (1) evaluate the acceptability of the isometric mid-thigh pull (IMTP) test as a measure of functional strength with military personnel undergoing residential hip pain rehabilitation; (2) compare the peak force values recorded against the updated Army physical employment standards (PES) assessment criteria and (3) assess if the minimum PES required of military personnel has the potential to inform clinical decision making and return to duty criteria within UK Defence Rehabilitation.

METHODS

Acceptability was assessed against patient's adherence to the testing procedures and test burden. Clinician acceptability was assessed against ease of administration and safety of test procedure. Hip pain was recorded before, immediately following and 1 hour after testing. Net peak force was recorded using portable force plates.

RESULTS

Full patient and clinician acceptability to IMTP testing procedures were demonstrated. Minimal changes in visual analogue scale (VAS) pain scores were demonstrated between baseline values at rest and follow-up. Despite being medically downgraded and functionally compromised due to chronic hip pain, 100% of patients met the PES expected on entry to the British Army and 79% met the PES expected at the end of basic training.

CONCLUSION

The IMTP provides rehabilitation clinicians with an objective quantifiable measure of maximum muscle strength that can be used early in the rehabilitation care pathway. Based on our finding, it is unclear if the current British Army PES can be used as a criterion standard in Defence Rehabilitation. Therefore, further research focused on generating clinically relevant patient-specific IMTP score criteria, with a larger sample of diverse diagnostic sub-groups is required.

The influence of pain, kinesiophobia and psychological comorbidities on the accuracy of rating of perceived exertion in UK military spinal rehabilitation

INTRODUCTION

Chronic low back pain (CLBP) is a leading cause of disability in the UK Military. Pain and psychological comorbidities have been reported to influence the rating of perceived exertion (RPE). Exercise rehabilitation can be monitored using RPE; however, the accuracy of RPE in inpatient CLBP rehabilitation is unknown.

METHODS

A prospective cohort correlation study of 40 UK Military inpatients with CLBP was completed. Disability (ODI), kinesiophobia (TSK), anxiety (GAD-7) and depression (PHQ-9) were subjectively reported at the beginning and end of a 3 week intervention. Pain (VAS) and HR were recorded in the first aerobic exercise (AE) session (T1) and the final aerobic exercise session (T2). RPE was reported for each AE session.

RESULTS

At T1, a positive correlation was observed between RPE accuracy (-7.2±20.9), and pre-exercise pain (2.7 mm ±1.6 mm) (p>0.001) and ODI (31.0±16.9) (p>0.05), and a negative relationship between RPE accuracy and average HR (135 bpm ±22 bpm) (p>0.001) was observed. At T2, there was no significant correlation between RPE accuracy (-4.4±22.6) and pre-exercise pain (2.8 mm ±1.6 mm) or ODI (34.0±16.5) (p>0.05). The strong negative relationship between RPE accuracy and average HR (137 bpm ±20 bpm) remained at T2. Improved RPE accuracy over the 3-week rehabilitation programme was correlated to the change in average HR (r=-0.314, p<0.05).

CONCLUSIONS

Comorbidities may negatively affect RPE accuracy in CLBP, but the magnitude of the influence reduces over intensive rehabilitation.

Effects of TheraBand and Theratube Eccentric Exercises on Quadriceps Muscle Strength and Muscle Mass in Young Adults

Purpose

This study was aimed at comparing the effects of TheraBand and theratube eccentric exercises on quadriceps muscle strength in young adults.

Methods

Thirty young adults (19 females, 11 males) participated in this pretest-posttest experimental study. Participants were randomly assigned to one of the two groups: TheraBand and theratube groups. They received the training intervention 3 times a week for 4 weeks (12 sessions) with progression after 2 weeks. Maximum eccentric quadriceps strength was assessed using the Biodex isokinetic dynamometer system. Additionally, quadriceps muscle mass was measured using a tape.

Results

Both groups showed a significant improvement in the peak torque of the eccentric isokinetic quadriceps' strength after weeks 2 and 4. Strength change in the quadriceps was nonsignificant in the theratube group compared to the TheraBand group after 4 weeks of training (p < 0.05). There was no increase in muscle mass during the 4 weeks of training in any group (p > 0.05).

Conclusion

Both the TheraBand and theratube are equally effective in the strengthening of the quadriceps muscle in young adults. Therefore, either the TheraBand or theratube may be used according to the availability and feasibility of the subjects for training intervention.

Heavy resistance training in the management of hip pain in older adults: A case series

Background and Purpose: Resistance training has been shown to improve strength, endurance, and function in healthy older adults. The purpose of this case series was to describe the outcomes of a rehabilitation program consisting of heavy resistance training in older adults for management of hip pain. Case Description: Two male patients, aged 69 and 71, with chronic hip pain, participated in a six-week progressive resistance training rehabilitation program at loads equivalent to 76-81% of their one repetition maximum. Outcomes were assessed at evaluation, three, and six weeks. Outcomes included the Lower Extremity Functional Scale, hip and lumbar mobility, and the Five Times Sit to Stand test. Outcomes: By six weeks, each patient reported 0/10 pain and demonstrated clinically important improvements on the LEFS. Both patients' final scores on the Five Times Sit to Stand test fell below the 15 second value for being at risk for falls. Patient One increased his lifting capacity for the deadlift by 92%, and Patient Two by 56%. Both patients were able to deadlift >70% of their one repetition maximum by the conclusion of this report. Discussion: To our knowledge, this is the first report of the outcomes of utilizing heavy resistance training in elderly adults with hip pain in a rehabilitative setting. Both patients demonstrated clinically important improvements in pain, disability, global lower extremity strength, and function by the conclusion of six weeks duration. Further research is needed regarding the effectiveness of heavy resistance training for the treatment of elderly adults with musculoskeletal pain.

The Benefits of Strength Training on Musculoskeletal System Health: Practical Applications for Interdisciplinary Care

Global health organizations have provided recommendations regarding exercise for the general population. Strength training has been included in several position statements due to its multi-systemic benefits. In this narrative review, we examine the available literature, first explaining how specific mechanical loading is converted into positive cellular responses. Secondly, benefits related to specific musculoskeletal tissues are discussed, with practical applications and training programmes clearly outlined for both common musculoskeletal disorders and primary prevention strategies.

Many physiotherapists lack preparedness to prescribe physical activity and exercise to people with musculoskeletal pain: A multi-national survey

OBJECTIVES

Determine physiotherapists' (i) awareness of physical activity, and exercise prescription guidelines; (ii) perceived role, knowledge, confidence, skills and training in prescribing and progressing aerobic exercise and resistance training to people with musculoskeletal pain; (iii) professional development preferences; and (iv) perceived influences of external factors on exercise prescription for people with musculoskeletal pain.

DESIGN

Multi-national cross-sectional survey.

METHODS

An open online survey was developed specifically for this study.

RESULTS

1,352 physiotherapists from 56 countries participated. The majority of respondents correctly stated physical activity guidelines for adults (60%) and children (53%), but only 37% correctly stated guidelines for older adults. Eleven percent and 16% could name an accepted guideline for aerobic exercise and resistance training, respectively. Most agreed their role included prescribing aerobic exercise (75%) and resistance training (89%). Fewer reported they had the confidence, training or skills to prescribe aerobic exercise (38-50%) and resistance training (49-70%). Workshops were the most preferred (44%) professional development option. Most respondents believed appointment scheduling and access to equipment and professional development (62-79%) affected their ability to prescribe effective exercise.

CONCLUSION

Many physiotherapists lack knowledge and training to provide physical activity advice, and to prescribe aerobic exercise and resistance training to people with musculoskeletal pain.

Hop Performance After Return to Sport in Anterior Cruciate Ligament-Reconstructed Gaelic Football and Hurling Athletes

PURPOSE

Anterior cruciate ligament (ACL) injuries are among the most severe injuries in the Gaelic Athletic Association. Hop tests measure functional performance after ACL reconstruction as they replicate the key requirements for a match situation. However, research examining functional recovery of ACL-reconstructed Gaelic athletes is lacking. The objective of this study is to determine if athletes restore normal hop symmetry after ACL reconstruction and to examine if bilateral deficiencies persist in hop performance following return to sport.

METHODS

A cross-sectional design was used to evaluate hop performance of 30 ACL-reconstructed Gaelic athletes who had returned to competition and 30 uninjured controls in a battery of hop tests including a single, 6-m, triple, and triple-crossover hop test.

RESULTS

In each test, the mean symmetry score of the ACL reconstruction group was above the cutoff for normal performance of 90% adopted by this study (98%, 99%, 97%, and 99% for the single, 6-m, triple, and triple-crossover hop, respectively). No significant differences in absolute hop scores emerged between involved and control limbs, with the exception of the single-hop test where healthy dominant limbs hopped significantly further than ACL-reconstructed dominant limbs (P = .02). No significant deficits were identified on the noninvolved side.

CONCLUSIONS

The majority of ACL-reconstructed Gaelic athletes demonstrate normal levels of hop symmetry after returning to competition. Suboptimal hop performance can persist on the involved side compared with control limbs. Targeted rehabilitation may be warranted after returning to competition to restore performance to levels of healthy uninjured athletes.

EHealth to empower patients with musculoskeletal pain in rural Australia (EMPoweR) a randomised clinical trial: study protocol

BACKGROUND

Low back pain (LBP) and knee osteoarthritis (OA) are major contributors to disability worldwide. These conditions result in a significant burden at both individual and societal levels. Engagement in regular physical activity and exercise programs are known to improve physical function in both chronic LBP and knee OA populations. For people residing in rural areas, musculoskeletal conditions are often more frequent and disabling compared to urban populations, which could be the result of reduced access to appropriate health services and resources in rural settings. EHealth is an innovative solution to help provide equitable access to treatment for people with musculoskeletal pain living in rural settings.

METHODS/DESIGN

We will conduct a randomised clinical trial investigating the effects of an eHealth intervention compared to usual care, for people with chronic non-specific LBP or knee OA in rural Australia. We will recruit 156 participants with non-specific chronic LBP or knee OA. Following the completion of baseline questionnaires, participants will be randomly allocated to either the eHealth intervention group, involving a tailored physical activity and progressive resistance exercise program remotely delivered by a physiotherapist (n = 78), or usual care (n = 78) involving referral to a range of care practices in the community. Outcomes will be measured at baseline, 3 and 6 months post-randomisation. The primary outcome will be physical function assessed by the Patient-Specific Functional Scale (PSFS). Secondary outcomes include pain intensity, physical activity levels, activity limitations, quality of life, pain coping. We will also collect process evaluation data such as recruitment rate, attendance and adherence, follow-up rate, participants' opinions and any barriers encountered throughout the trial.

DISCUSSION

The findings from this trial will establish the effectiveness of eHealth-delivered interventions that are known to be beneficial for people with LBP and knee OA when delivered in person. As a result, this trial will help to inform health care policy and clinical practice in Australia and beyond for those living in non-urban areas.

TRIAL REGISTRATION

This study was prospectively registered on the Australian New Zealand Clinical Trials Registry ( ACTRN12618001494224 ) registered 09.05.2018.

Integration of strength training into UK Defence Rehabilitation practice: current trends and future challenges

The use of strength and conditioning (S&C) in musculoskeletal rehabilitation has gained wide acceptance among the rehabilitation community. However, there is an absence of evidence demonstrating how to best integrate the principles of S&C into rehabilitation practice. This article discusses four broad themes: (1) an overview of the UK Defence Rehabilitation care pathway, (2) the historical and current approaches to physical training to support operational readiness of the British Armed Forces, (3) the current and future challenges of integrating S&C into Defence Rehabilitation practice and (4) research priorities relating to the use of S&C in Defence Rehabilitation. We detail the importance of strength/power-based physical attributes within our military population. We recommend that consideration be given to the benefits of an alternative education/coaching-based model to be used during the current 3-week residential care pathway, which aims to ensure effective implementation of therapeutic S&C over a longer period of care.

Free-Weight Resistance Exercise Is More Effective in Enhancing Inhibitory Control than Machine-Based Training: A Randomized, Controlled Trial

Resistance exercise has been demonstrated to improve brain function. However, the optimal workout characteristics are a matter of debate. This randomized, controlled trial aimed to elucidate differences between free-weight (REfree) and machine-based (REmach) training with regard to their ability to acutely enhance cognitive performance (CP). A total of n = 46 healthy individuals (27 ± 4 years, 26 men) performed a 45-min bout of REfree (military press, barbell squat, bench press) or REmach (shoulder press, leg press, chest press). Pre- and post-intervention, CP was examined using the Stroop test, Trail Making Test and Digit Span test. Mann-Whitney U tests did not reveal between-group differences for performance in the Digit Span test, Trail Making test and the color and word conditions of the Stroop test (p > 0.05). However, REfree was superior to REmach in the Stroop color-word condition (+6.3%, p = 0.02, R = 0.35). Additionally, REfree elicited pre-post changes in all parameters except for the Digit Span test and the word condition of the Stroop test while REmach only improved cognitive performance in part A of the Trail Making test. Using free weights seems to be the more effective RE method to acutely improve cognitive function (i.e., inhibitory control). The mechanisms of this finding merit further investigation.

Strength and Power Training in Rehabilitation: Underpinning Principles and Practical Strategies to Return Athletes to High Performance

Injuries have a detrimental impact on team and individual athletic performance. Deficits in maximal strength, rate of force development (RFD), and reactive strength are commonly reported following several musculoskeletal injuries. This article first examines the available literature to identify common deficits in fundamental physical qualities following injury, specifically strength, rate of force development and reactive strength. Secondly, evidence-based strategies to target a resolution of these residual deficits will be discussed to reduce the risk of future injury. Examples to enhance practical application and training programmes have also been provided to show how these can be addressed.

SOPEZ: study for the optimization of ergonomics in the dental practice - musculoskeletal disorders in dentists and dental assistants: a study protocol

Background

Musculoskeletal disorders (MSD) are common among dental professionals. The most common areas affected are the trunk, neck, shoulders and wrists. Current evidence suggests that the causes of MSD can be found in the physical demands of the profession. Posture and movement during treatment is influenced by the arrangement of the treatment concept (patient chair, equipment and cabinets). It has not been investigated whether the ergonomic risk differs between the treatment concepts.

Methods

To evaluate the prevalence of MSD in dental professionals, 1000 responses will be collected from a nationwide (Germany) online questionnaire (mod. Nordic Questionnaire and mod. Meyer questionnaire). In order to assess the ergonomic risk of the treatment techniques used in the four treatment concepts, 3D movement analyses are carried out with inertial sensors. For this purpose, 20 teams of dentists and dental assistants from four dental fields of specializations (generalists, orthodontists, endodontists and oral surgeons) and a student control group will be recruited. Each team will execute field specific standardized treatments at a dummy head. Measurements are carried out in each of the four treatment concepts. The data will be analyzed using the Rapid Upper Limb Assessment (RULA) which will be modified for the evaluation of objective data.

Conclusions

On the basis of these investigations, a substantial gain of knowledge regarding work-related MSD in the field of dentistry and its potential biomechanical causes is possible. For the first time, objective and differentiated comparisons between the four treatment concepts are possible for different fields of dental specialization. Up to now, statically held positions of the trunk and proximal upper extremities, but also the repetitive movements of the hands have been considered a risk for MSD. Since both are included in the RULA, dental activities can be assessed in a detailed but also global manner with regard to ergonomic risks.

Exercise Intensity Matters in Chronic Nonspecific Low Back Pain Rehabilitation

INTRODUCTION

Exercise therapy (ET) is advocated as a treatment for chronic nonspecific low back pain (CNSLBP). However, therapy effect sizes remain low. In other chronic disorders, training at higher intensity has resulted in greater improvements on both general health related and disease specific outcomes compared to lower-intensity ET. Possibly, high-intensity training also improves effect sizes in CNSLBP.

OBJECTIVE

To compare the effects of a high-intensity ET program with a similar moderate-intensity ET program on disability, pain, function, exercise capacity, and abdominal/back muscle strength in persons with CNSLBP.

METHODS

In a randomized controlled trial, persons with CNSLBP performed a 12-wk ET program (24 sessions, 1.5 h per session, twice per week) at high-intensity training (HIT) or moderate-intensity training (MIT). Questionnaires to assess disability (Modified Oswestry Index [MODI]), pain intensity (Numeric Pain Rating Scale), and function (Patient Specific Functioning Scale), a cardiopulmonary exercise test to assess exercise capacity (V˙O2max, cycling time), and a maximum isometric muscle strength test to assess abdominal/back muscle strength (maximum muscle torque) were administered at baseline and after the training program.

RESULTS

Thirty-eight participants (HIT: n = 19, MIT: n = 19) were included (mean age, 44.1 yr, SD = 9.8, 12 males). Groups did not differ at baseline. Between group differences (P < 0.01) in favor of HIT were found for MODI, V˙O2max, and cycling time. Within group improvements (P < 0.01) were found in both groups on MODI (HIT:-64%, MIT:-33%), Numeric Pain Rating Scale (HIT, -56%; MIT, -39%), Patient-Specific Functioning Scale (HIT:+37%, MIT:+39%), V˙O2max (HIT:+14, MIT:+4%), cycling time (HIT:+18%, MIT:+13%), and back muscle strength (HIT:+10%, MIT:+14%).

CONCLUSIONS

High-intensity training proved to be a feasible, well tolerated, and effective therapy modality in CNSLBP. Moreover, it shows greater improvements on disability and exercise capacity than a similar ET performed at moderate intensity.

Importance of Frequency and Intensity of Strength Training for Reduced Musculoskeletal Pain in the Back, Neck-Shoulder, and Arm-Hand Among Physical Therapists

BACKGROUND

Musculoskeletal pain (MP) is common among health care professionals, including physical therapists (PTs). The physically demanding nature of their work might contribute to increase MP rates. Strength training has a positive effect on musculoskeletal health and MP. However, no studies have evaluated the association of strength training during leisure time on MP among PTs. This study aims to analyze the association between frequency and intensity of strength training during leisure time and MP in the back, neck-shoulder, and arm-hand among PTs.

METHODS

Data on MP and intensity and frequency of strength training were obtained using a questionnaire responded by 1006 PTs. The odds for having lower level of MP as a function of intensity or frequency of the strength training were estimated using binary logistic regression.

RESULTS

High-intensity strength training showed strong associations with lower intensity of MP in neck-shoulder (odds ratio = 5.08; 95% confidence interval, 1.36-18.92), arm-hand (odds ratio = 5.22; 95% confidence interval, 1.11-24.51), and back (odds ratio = 5.22; 95% confidence interval, 1.41-19.28). However, frequency and lower intensities were not significantly associated with MP in any body part.

CONCLUSIONS

High-intensity strength training is strongly associated with lower levels of MP in arm-hand, neck-shoulder, and back, whereas no association was found with frequency or lower intensities.

Periodized resistance training for persistent non-specific low back pain: a mixed methods feasibility study

Background

We investigated the feasibility of a 16-week supervised heavy resistance training program with weekly undulating periodization for individuals with persistent non-specific low-back pain (LBP).

Methods

Twenty-five adults with persistent non-specific LBP participated in this mixed methods feasibility study. Participants trained a whole-body program consisting of squat, bench press, deadlift and pendlay row two times per week for 16 weeks. We assessed pain intensity, pain-related disability, pain self-efficacy and one-repetition maximum strength at baseline, 8 weeks and 16 weeks. Three focus group interviews were conducted at the end of the program. Linear mixed models were used to assess changes in outcomes, and the qualitative data was assessed using systematic text condensation.

Results

We observed clinically meaningful reductions in pain intensity after 8 and 16 weeks of training. The mean difference on the numeric pain rating scale (0–10) in the last 2 weeks from baseline to 8 weeks was 2.6 (95% CI: 1.8–3.6) and from baseline to 16 weeks 3.4 (95% CI: 2.5–4.4). In addition, there were improvements in pain-related disability (3.9, 95% CI: 2.3–5.5), pain self-efficacy (7.7, 95% CI: 5.4–10.1) and muscle strength. In the focus group interviews, participants talked about challenges regarding technique, the importance of supervision and the advantages of periodizing the training. Perceived benefits were improved pain, daily functioning, energy level and sleep, and changes in views on physical activity.

Conclusion

Periodized resistance training with weekly undulating periodization is a feasible training method for this group of individuals with persistent non-specific LBP. A randomized clinical trial should assess the efficacy of such an intervention.

Trial registration

clinicaltrials.gov/ Identifier – NCT04284982, Registered on February 24th 2020.

Let the Body'n'Brain Games Begin: Toward Innovative Training Approaches in eSports Athletes

The phenomenon of eSports is omnipresent today. International championships and their competitive athletes thrill millions of spectators who watch as eSports athletes and their teams try to improve and outperform each other. In order to achieve the necessary cognitive and physical top form and to counteract general health problems caused by several hours of training in front of the PC or console, eSports athletes need optimal cognitive, physical and mental training. However, a gap exists in eSports specific health management, including prevention of health issues and training of these functions. To contribute to this topic, we present in this mini review possible avenues for holistic training approaches for cognitively, physically and mentally fitter and more powerful eSports athletes based on interdisciplinary findings. We discuss exergames as a motivating and promising complementary training approach for eSports athletes, which simultaneously combines physical and cognitive stimulation and challenges in an attractive gaming environment. Furthermore, we propose exergames as innovative full-body eSports-tournament revolution. To conclude, exergames bring new approaches to (physical) eSports, which in turn raise new topics in the growing eSports research and development community.

Associations between Perceptual Fatigue and Accuracy of Estimated Repetitions to Failure during Resistance Exercises

The ability to accurately identify proximity to momentary failure during a set of resistance exercise might be important to maximise training adaptations. This study examined the association between perceptual fatigue and the accuracy of the estimated repetitions to failure (ERF). Twenty-seven males and eleven females performed sets of 10 repetitions at specific loads for the chest press and leg-press. Following the completion of 10 repetitions, participants rated their fatigue and ERF and then proceeded to concentric failure (actual repetitions to failure) to determine the ERF accuracy (i.e., error-ERF). Small correlations were found between perceptual fatigue and error-ERF for the chest-press (r = -0.26, p = 0.001) and the leg-press (r = -0.18, p = 0.013). For actual repetitions to failure and error-ERF, a strong correlation was found for the chest-press (r = 0.68, p < 0.001) and a very strong correlation was foundfor the leg-press (r = 0.73, p < 0.001). Moderate correlations were found between perceptual fatigue and actual repetitions to failure for the chest-press (r = -0.42, p < 0.001) and leg-press (r = -0.40, p < 0.001). Overall, findings suggest that the accuracy of the estimated repetitions to failure is more strongly associated with proximity to task repetition failure rather than subjective feelings of fatigue.

GLA:D® Back group-based patient education integrated with exercises to support self-management of back pain - development, theories and scientific evidence

BACKGROUND

Clinical guidelines recommend that people with back pain be given information and education about their back pain, advice to remain active and at work, and exercises to improve mobility and physical activity. Guidelines, however, rarely describe how this is best delivered. The aim of this paper is to present the development, theories, and underlying evidence for 'GLA:D Back' - a group education and exercise program that translates guideline recommendations into a clinician-delivered program for the promotion of self-management in people with persistent/recurrent back pain.

METHODS

GLA:D Back, which included a rationale and objectives for the program, theory and evidence for the interventions, and program materials, was developed using an iterative process. The content of patient education and exercise programs tested in randomised trials was extracted and a multidisciplinary team of expert researchers and clinicians prioritised common elements hypothesised to improve back pain beliefs and management skills. The program was tested on eight people with persistent back pain in a university clinic and 152 patients from nine primary care physiotherapy and chiropractic clinics. Following feedback from the clinicians and patients involved, the working version of the program was created.

RESULTS

Educational components included pain mechanisms, pain modulation, active coping strategies, imaging, physical activity, and exercise that emphasised a balance between the sum of demands and the individual's capacity. These were operationalised in PowerPoint presentations with supporting text to aid clinicians in delivering two one-hour patient education lectures. The exercise program included 16 supervised one-hour sessions over 8 weeks, each comprising a warm-up section and eight types of exercises for general flexibility and strengthening of six different muscle groups at four levels of difficulty. The aims of the exercises were to improve overall back fitness and, at the same time, encourage patients to explore variations in movement by incorporating education content into the exercise sessions.

CONCLUSION

From current best evidence about prognostic factors in back pain and effective treatments for back pain, research and clinical experts developed a ready-to-use structured program - GLA:D® Back - to support self-management for people with persistent/recurrent back pain.

Low-Load Resistance Training With Blood Flow Restriction Improves Clinical Outcomes in Musculoskeletal Rehabilitation: A Single-Blind Randomized Controlled Trial

Background: There is growing evidence to support the use of low-load blood flow restriction (LL-BFR) exercise in musculoskeletal rehabilitation.

Purpose: The purpose of this study was to evaluate the efficacy and feasibility of low-load blood flow restricted (LL-BFR) training versus conventional high mechanical load resistance training (RT) on the clinical outcomes of patient’s undergoing inpatient multidisciplinary team (MDT) rehabilitation.

Study design: A single-blind randomized controlled study.

Methods: Twenty-eight lower-limb injured adults completed a 3-week intensive MDT rehabilitation program. Participants were randomly allocated into a conventional RT (3-days/week) or twice-daily LL-BFR training group. Outcome measurements were taken at baseline and 3-weeks and included quadriceps and total thigh muscle cross-sectional area (CSA) and volume, muscle strength [five repetition maximum (RM) leg press and knee extension test, isometric hip extension], pain and physical function measures (Y-balance test, multistage locomotion test—MSLT).

Results: A two-way repeated measures analysis of variance revealed no significant differences between groups for any outcome measure post-intervention (p > 0.05). Both groups showed significant improvements in mean scores for muscle CSA/volume, 5-RM leg press, and 5-RM knee extension (p < 0.01) after treatment. LL-BFR group participants also demonstrated significant improvements in MSLT and Y-balance scores (p < 0.01). The Pain scores during training reduced significantly over time in the LL-BFR group (p = 0.024), with no adverse events reported during the study.

Conclusion: Comparable improvements in muscle strength and hypertrophy were shown in LL-BFR and conventional training groups following in-patient rehabilitation. The LL-BFR group also achieved significant improvements in functional capacity. LL-BFR training is a rehabilitation tool that has the potential to induce positive adaptations in the absence of high mechanical loads and therefore could be considered a treatment option for patients suffering significant functional deficits for whom conventional loaded RT is contraindicated.

Trial Registration: ISRCTN Reference: ISRCTN63585315, dated 25 April 2017.

Resistance band training or general exercise in multidisciplinary rehabilitation of low back pain? A randomized trial

Multidisciplinary biopsychosocial rehabilitation has been recommended for chronic low back pain (LBP), including physical exercise. However, which exercise modality that is most advantageous in multidisciplinary biopsychosocial rehabilitation is unclear. In this study, we investigated whether multidisciplinary biopsychosocial rehabilitation could be more effective in reducing pain-related disability when general physical exercise was replaced by strength training in the form of progressive resistance training using elastic resistance bands. In this single-blinded (researchers), randomized controlled trial, 99 consenting adults with moderate-to-severe non-specific LBP were randomized to three weeks of multidisciplinary biopsychosocial rehabilitation with either general physical exercise or progressive resistance band training and were then instructed to continue with their respective home-based programs for nine additional weeks, in which three booster sessions were offered. The primary outcome was between-group difference in change on the Oswestry Disability Index (ODI) at 12 weeks. Due to early dropouts, data from 74 participants (mean age: 45 years, 57% women, mean ODI: 30.4) were obtained at baseline, 61 participants were followed-up at 3 weeks, and 46 at 12 weeks. There was no difference in the change in ODI score between groups at 12 weeks (mean difference 1.9, 95% CI: -3.6, 7.4, P = .49). Likewise, the change in secondary outcomes did not differ between groups, except for the patient-specific functional scale (0-10), which favored general physical exercise (mean difference 1.4, 95% CI: 0.1, 2.7, P = .033). In conclusion, this study does not support that progressive resistance band training compared to general physical exercise improve outcomes in multidisciplinary biopsychosocial rehabilitation for patients with non-specific LBP.

Muscle Activity in Upper-Body Single-Joint Resistance Exercises with Elastic Resistance Bands vs. Free Weights

Elastic resistance bands require little space, are light and portable, but their efficacy has not yet been established for several resistance exercises. The main objective of this study was to compare the muscle activation levels induced by elastic resistance bands versus conventional resistance training equipment (dumbbells) in the upper-body resistance exercises flyes and reverse flyes. The level of muscle activation was measured with surface electromyography in 29 men and women in a cross-over design where resistance loadings with elastic resistance bands and dumbbells were matched using 10-repetition maximum loadings. Elastic resistance bands induced slightly lower muscle activity in the muscles most people aim to activate during flyes and reverse flies, namely pectoralis major and deltoideus posterior, respectively. However, elastic resistance bands increased the muscle activation level substantially in perceived ancillary muscles, that is deltoideus anterior in flyes, and deltoideus medius and trapezius descendens in reverse flyes, possibly due to elastic bands being a more unstable resistance modality. Overall, the results show that elastic resistance bands can be considered a feasible alternative to dumbbells in flyes and reverse flyes.

The effects of low-intensity blood flow restricted exercise compared with conventional resistance training on the clinical outcomes of active UK military personnel following a 3-week in-patient rehabilitation programme: protocol for a randomized controlled feasibility study

Background

A challenge for rehabilitation practitioners lies in designing optimal exercise programmes that facilitate musculoskeletal (MSK) adaptations whilst simultaneously accommodating biological healing and the safe loading of an injured limb. A growing body of evidence supports the use of resistance training at a reduced load in combination with blood flow restriction (BFR) to enhance hypertrophic and strength responses in skeletal muscle. In-patient rehabilitation has a long tradition in the UK Military, however, the efficacy of low intensity (LI) BFR training has not been tested in this rehabilitation setting. The aims of this study are to determine (1) the feasibility of a randomised controlled trial (RCT) investigating LI-BFR training in a residential, multidisciplinary treatment programme and (2) provide preliminary data describing the within and between-group treatment effects of a LI-BFR intervention and a conventional resistance training group in military personnel.

Methods

This is a single-blind randomised controlled feasibility study. A minimum of 28 lower-limb injured UK military personnel, aged 18 to 50 years, attending rehabilitation at the UK Defence Medical Rehabilitation Centre (DMRC) will be recruited into the study. After completion of baseline measurements, participants will be randomised in a 1:1 ratio to receive 3 weeks (15 days) of intensive multidisciplinary team (MDT) in-patient rehabilitation. Group 1 will receive conventional resistance training 3 days per week. Group 2 will perform twice daily LI-BFR training. Both groups will also undertake the same common elements of the existing MDT programme. Repeat follow-up assessments will be undertaken upon completion of treatment. Group 2 participants will be asked to rate their pain response to LI-BFR training every five sessions.

Discussion

The results will provide information on the feasibility of a full-scale RCT. Recommendations for an adequately powered study to determine the efficacy of LI-BFR training during in-patient rehabilitation can then be made. The study may also provide insights into the potential effectiveness of LI-BFR training as a novel exercise modality to induce muscle adaptations in the absence of high mechanical loading of the lower-limb.

Trial registration

ISRCTN Reference: ISRCTN 63585315 dated 25 April 2017.

Effects of Low-Load Motor Control Exercises and a High-Load Lifting Exercise on Lumbar Multifidus Thickness: A Randomized Controlled Trial

STUDY DESIGN

Randomized controlled trial.

OBJECTIVE

The aim of this study was to compare the effects of low-load motor control (LMC) exercises and a high-load lifting (HLL) exercise, on lumbar multifidus (LM) thickness on either side of the spine and whether the effects were affected by pain intensity or change in pain intensity.

SUMMARY OF BACKGROUND DATA

There is evidence that patients with low back pain (LBP) may have a decreased size of the LM muscles with an asymmetry between sides in the lower back. It has also been shown that LMC training can affect this asymmetry. It is, however, not known whether a high-load exercise has the same effect.

METHODS

Sixty-five participants diagnosed with nociceptive mechanical LBP were included and randomized into LMC exercises or a HLL exercise, the deadlift. The LM thickness was measured using rehabilitative ultrasound imaging (RUSI), at baseline and after a 2-month training period.

RESULTS

There were no differences between interventions regarding effect on LM muscle thickness. However, the analysis showed a significant effect for asymmetry. The thickness of the LM muscle on the small side increased significantly compared with the large side in both intervention groups, without influence of pain at baseline, or change in pain intensity.

CONCLUSION

At baseline, there was a difference in thickness of the LM muscles between sides. It seems that exercises focusing on spinal alignment may increase the thickness of the LM muscles on the small side, irrespective of exercise load. The increase in LM thickness does not appear to be mediated by either current pain intensity or the magnitude of change in pain intensity.

LEVEL OF EVIDENCE

2.

Multiple-joint exercises using elastic resistance bands vs. conventional resistance-training equipment: A cross-over study

Previous studies indicate that elastic resistance bands (ERB) can be a viable option to conventional resistance-training equipment (CRE) during single-joint resistance exercises, but their efficacy has not been established for several commonly used multiple-joint resistance exercises. Thus, we compared muscular activation levels in four popular multiple-joint exercises performed with ERB (TheraBand^®) vs. CRE (Olympic barbell or cable pulley machines). In a cross-over design, men and women (n = 29) performed squats, stiff-legged deadlifts, unilateral rows and lateral pulldown using both modalities. Multilevel mixed-effects linear regression analyses of main and interaction effects, and subsequent post hoc analyses were used to assess differences between the two resistance-training modalities. CRE induced higher levels of muscle activation in the prime movers during all exercises (p < .001 for all comparisons), compared to muscle activation levels induced by ERB. The magnitude of the differences was marginal in lateral pulldown and unilateral rows and for the erector spinae during stiff-legged deadlifts. In squats the quadriceps femoris activations were substantially lower for ERB. The differences between ERB and CRE were mostly observed during the parts of the contractions where the bands were relatively slack, whilst the differences were largely eliminated when the bands became elongated in the end ranges of the movements. We conclude that ERB can be a feasible training modality for lateral pulldowns, unilateral rows and to some extent stiff-legged deadlifts, but not for the squat exercise.

Resistance training in addition to multidisciplinary rehabilitation for patients with chronic pain in the low back: Study protocol

INTRODUCTION

Chronic low back pain (LBP) is a major health problem worldwide. Multidisciplinary rehabilitation and exercise is recommended for the management of chronic LBP. However, there is a need to investigate effective exercise interventions that is available in clinics and as home-based training on a large scale. This article presents the design and rationale of the first randomized clinical trial investigating the effects of progressive resistance training with elastic bands in addition to multidisciplinary rehabilitation for patients with moderate to severe chronic LBP.

METHODS AND ANALYSIS

We aim to enroll 100 patients with chronic LBP referred to a specialized outpatient hospital clinic in Norway. Participants will be randomized equally to either; a) 3 tion including whole-body progressive resistance training using elastic bands - followed by home-based progressive resistance training for 9 weeks, or b) 3 weeks of multidisciplinary rehabilitation including general physical exercise - followed by home-based general physical exercise for 9 weeks. Questionnaires and strength tests will be collected at baseline, weeks 3 and 12, and at 6 and 12 months. The primary outcome is between-group changes in pain-related disability at week 12 assessed by the Oswestry disability index. Secondary outcomes include pain, work ability, work status, mental health, health-related quality of life, global rating of change, general health, and muscular strength and pain-related disability up to 12 months of follow-up.

DISCUSSION

This study will provide valuable information for clinicians working with patients with chronic LBP.

TRIAL REGISTRATION

ClinicalTrials.gov, number NCT02420236.