Graded group exercise and fear avoidance behavior modification in the treatment of chronic low back pain

Effects of Body Weight Support in Running on Achilles Tendon Loading

Achilles tendon (AT) tendinopathy is common in runners. Repetitive AT loading may play a role in etiology. Interventions such as body weight support (BWS) may reduce loading on the AT in running. Examine how ground reaction force, AT loading, foot strike, and cadence variables change in running with BWS. Twenty-four healthy female runners free from injury were examined. Participants ran on an instrumented treadmill with and without BWS using a harness-based system at a standardized speed. The system has 4 elastic cords affixed to a harness that is attached to a frame-like structure. Kinematic data and kinetic data were used in a musculoskeletal model (18 segments and 16 degrees of freedom) to determine AT loading variables, foot strike angle, and cadence. Paired t-tests were used to compare each variable between conditions. Ground reaction force was 9.0% lower with BWS (p<.05). Peak AT stress, force, and impulse were 9.4, 11.7%, and 14.8% lower when using BWS in running compared to no support (p<.05). Foot strike angle was similar (p<.05) despite cadence being reduced (p<.05). BWS may reduce AT loading and impulse variables during running. This may be important in rehabilitation efforts.

The Influence of Exercise Intensity on Psychosocial Outcomes in Musculoskeletal Disorders: A Systematic Review

CONTEXT

Psychosocial parameters play an important role in the onset and persistence of chronic musculoskeletal disorders (CMSDs). Exercise therapy is a valuable therapeutic modality as part of CMSD rehabilitation. Hereby, exercise intensity is an important factor regarding changes in pain and disability in multiple CMSDs. However, the impact of exercise intensity on psychosocial outcomes remains poorly explored.

OBJECTIVE

To identify the effects of different modes of exercise intensity on psychosocial outcomes in persons with CMSDs.

DATA SOURCES

A systematic search was conducted up to November 2020 using the following databases: PubMed/MEDline, PEDro, Cochrane Library, and Web of Science.

STUDY SELECTION

Studies reporting exercise therapy in CMSDs with a predefined display of exercise intensity and an evaluation of at least 1 psychosocial outcome were included.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 2a.

DATA EXTRACTION

Data regarding demographics, exercise intensity, and psychosocial outcomes were included in a descriptive analysis. Methodological quality was assessed using the PEDro scale and Critical Appraisal Skills Programme (CASP) checklist.

RESULTS

A total of 22 studies, involving 985 participants (with fibromyalgia, chronic low back pain, knee osteoarthritis, psoriatic arthritis, and axial spondyloarthritis) were included (mean PEDro score = 5.77/10). The most common psychosocial outcomes were quality of life (QoL) (n = 15), depression (n = 10), and anxiety (n = 9). QoL improved at any exercise intensity in persons with fibromyalgia. However, persons with fibromyalgia benefit more from exercising at low to moderate intensity regarding anxiety and depression. In contrast, persons with chronic low back pain benefit more from exercising at a higher intensity regarding QoL, anxiety, and depression. Other CMSDs only showed limited or conflicting results regarding the value of certain exercise intensities.

CONCLUSION

Psychosocial outcomes are influenced by the intensity of exercise therapy in fibromyalgia and chronic low back pain, but effects differ across other CMSDs. Future research is necessary to determine the exercise intensity that yields optimal exercise therapy outcomes in specific CMSDs.

Offloading Effects on Impact Forces and Patellofemoral Joint Loading During Running in Females

BACKGROUND

Structure-specific loading is being increasingly recognized as playing a role in running related injuries. The use of interventions targeted at reducing patellofemoral joint loads have shown effectiveness in reducing symptoms of patellofemoral pain. Use of bodyweight support (BWS) has the potential to reduce loading on the patellofemoral joint during running to augment rehabilitation efforts.

RESEARCH QUESTION

How is patellofemoral joint loading different when using a harness-based BWS system during running?

METHODS

Twenty-five healthy females free from lower extremity injury were included. Participants completed four running trials on an instrumented treadmill with varying amounts of BWS using a commercially available harness system. Kinematic data from a 3D motion capture system and kinetic data from the treadmill were combined in a computer model to estimate measures of patellofemoral joint loading, knee kinematics, ground reaction force, and stride frequency.

RESULTS

Peak patellofemoral joint stress and time-integral were reduced when running under BWS conditions compared to control conditions. Incremental decreases in patellofemoral loading were not observed with incremental increases in BWS. Peak knee flexion angle was reduced in all BWS conditions compared to control but was not different between BWS conditions. Knee flexion excursion was reduced in only the high BWS condition. Peak ground reaction force and stride frequency incrementally decreased with increased amounts of BWS.

SIGNIFICANCE

Harness-based BWS systems may provide a simple means to reduce patellofemoral joint loading to assist in rehabilitation efforts, such as addressing patellofemoral pain.

In vivo exposure for fear of pain and avoidance of movement in low back pain

OBJECTIVES

to verify the effects of hierarchization and in vivo exposure for fear of pain, avoidance of movement, and anxiety in chronic low back pain.

METHODS

quasi-experimental study. The 27 patients who participated graded the damage associated with the movements in each of the 40 activities of daily living depicted in pictures using a scale from 0 to 100. The patients chose five out of all the activities that received a score higher than 50 to carry out the exposure. The intensities of fear and anxiety were measured before and after each exposure session.

RESULTS

the frequencies of the gender were equal, and the mean age was 44.9 years. The activities chosen more frequently for the exposure were shoveling (33.3%) and running (33.3%). There was reduction of fear and anxiety before and after exposure (p<0.001).

CONCLUSIONS

hierarchization and in vivo exposure were effective in reducing fear and anxiety.

Low Back Pain Treatment by Athletic Trainers and Athletic Therapists: Biomedical or Biopsychosocial Orientation?

CONTEXT

Low back pain (LBP) remains a societal burden due to consistently high rates of recurrence and chronicity. Recent evidence suggested that a provider's treatment orientation influences patient beliefs, the clinical approach, and subsequently, rehabilitation outcomes.

OBJECTIVE

To characterize American athletic trainer (AT) and Canadian athletic therapist (C-AT) treatment orientations toward LBP.

DESIGN

Cross-sectional study.

SETTING

Online survey.

PATIENTS OR OTHER PARTICIPANTS

A total of 273 ATs (response rate = 13.3%) and 382 C-ATs (response rate = 15.3%).

MAIN OUTCOME MEASURE(S)

Participants completed demographic questions and the Pain Attitudes and Beliefs Scale (PABS) for ATs/C-ATs. The PABS measures the biomedical and biopsychosocial treatment orientation of health care providers and is scored on a 6-point Likert scale. Descriptive statistics characterized the participants; t tests and 1-way analyses of variance identified differences between group means; and Spearman correlations assessed relationships between the biomedical and biopsychosocial scores and age, number of LBP patients per year, and years of experience.

RESULTS

Athletic trainers treating 9 to 15 LBP patients per year had higher biomedical scores (35.0 ± 5.7) than ATs treating 16 to 34 (31.9 ± 5.5, P = .039) or >34 (31.7 ± 8.6, P = .018) LBP patients per year. The C-ATs treating 16 to 34 (31.8 ± 6.3, P = .038) and >34 (31.0 ± 6.7, P < .001) LBP patients per year had lower biomedical scores than those treating ≤8 LBP patients per year (34.8 ± 5.9). The C-ATs with ≤5 years of experience had higher biomedical scores than those with 10 to 15 (31.0 ± 6.7, P = .011) and 16 to 24 (29.8 ± 7.5, P < .001) years of experience. Canadian athletic therapists treating the general public had higher (31.7 ± 4.0) biopsychosocial scores than ATs treating athletes (31.3 ± 3.5, P = .006). The C-ATs ≤35.6 years of age had higher biomedical scores (33.1 ± 5.9) than those >35.6 years of age (30.5 ± 7.0, P < .001).

CONCLUSIONS

Athletic trainers and C-ATs who treated more LBP patients per year were more likely to score low on a biomedical treatment orientation subscale. Because this orientation has predicted poor outcomes in other health care providers, further research is needed to determine the effects of ATs' and C-ATs' biomedical orientations on rehabilitation outcomes.

Four-year pain relief after coblation combined with active exercise for cervical discogenic pain: Case report

RATIONALE

Coblation of intervertebral disc is an effective and safe minimally invasive technology for treating discogenic pain. The inactivation of neural ingrowth around annulus and tissue ablation and coagulation are currently considered to be the major causes for success of this treatment. However, it has been found by clinical researchers that its long-term clinical outcome is not optimistic. This report has given us favorable information that this situation can be improved with multimodal therapy.

PATIENT CONCERNS

A 61-year-old man presented with right severe neck and shoulder pain in 2014 which could not be relieved by medications.

DIAGNOSES

According to his symptoms and signs, this patient was diagnosed with cervical discogenic pain. And discography confirmed the diagnosis.

INTERVENTIONS

The patient underwent coblation of cervical intervertebral disc 4-5 (C4-5) and got apparently pain relief after surgery. After 1 month, he began to perform active exercise at least 30 min every day.

OUTCOMES

The right neck and shoulder pain completely relieved for 4 years. The cervical lordosis of this patient was restored in 2018 which was confirmed by MRI compared in 2014 and NDI (neck disability index) decreased from 58 to 10%.

LESSONS

This report demonstrated that it was important and essential for clinicians to educate patients with discogenic pain to perform active exercise after minimally invasive surgery.

Effect of Clinical Pilates training on the fear of movement in patients with ankylosing spondylitis

Background/Aims:

Exercise training has been shown to be beneficial in reducing symptoms in patients with ankylosing spondilitis. However, exercise effect on fear and avoidance of movement has not been assessed. The aim of this study was to evaluate the effect of Pilates training on kinesiophobia, disease activity, functional status and quality of life in patients with ankylosing spondilitis.

Methods:

A total of 21 patients with ankylosing spondilitis with stable medication participated in the study. Tampa Scale for Kinesiophobia, Bath Ankylosing Spondilitis Disease Activity Index, Bath Ankylosing Spondilitis Functional Index, ankylosing spondilitis Quality of Life Questionnaire and Beck Depression Inventory were completed by patients before and after a 6-week modified Pilates training programme.

Findings:

The patients were 41.6 ± 11.8 years old and the mean disease duration was 68 ± 87months. Mobility, disease acitivity and functional scores improved with exercise training (P<0.05). Moreover, quality of life, depression and kinesiophobia levels also showed significant improvement (P<0.05).

Conclusions:

The results of this study showed that 6-week supervised modified Pilates training programme improved clinical symptoms in patients with Aankylosing spondilitis. Moreover, patients benefited from this exercise method regarding quality of life, depression and fear of movement (kinesiophobia) considerably.

Individuals with lumbar spinal stenosis seek education and care focused on self-management-results of focus groups among participants enrolled in a randomized controlled trial

BACKGROUND CONTEXT

The effectiveness of treatments for chronic, degenerative conditions of the lumbar spine can be influenced by patient perceptions and expectations regarding treatment.

PURPOSE

The primary purpose of this study was to understand the factors that are important to individuals with lumbar spinal stenosis (LSS) regarding different nonsurgical treatments. These factors were considered within the context of each treatment received as a part of the parent randomized controlled trial (RCT).

STUDY DESIGN

Focus group study of RCT participants.

PATIENT SAMPLE

Convenience sample of 50 individuals with LSS (28 female, average age 73±7.7 years) from an RCT participated in one of six focus groups. Focus groups consisted of patients previously randomized to one of three nonsurgical treatments: (1) medical care; (2) community-based group exercise; and (3) clinic-based manual therapy and individualized exercise.

OUTCOME MEASURES

Experiences, opinions, and preferences of individuals with LSS who participated in an RCT. Inter-coder agreement for qualitative analysis was conducted with kappa statistics.

METHODS

Participants discussed their experiences and perceptions regarding study treatment and their general experience with LSS using open-ended questions provided by a facilitator. Transcripts were coded according to modified grounded theory in an open approach, using codes that addressed the primary focus group discussion topics (primary coding) and codes for emerging topics (secondary coding). Secondary coding sought to identify themes concerning living with LSS and seeking treatment that were emergent from the focus groups. This study was funded by the Patient-Centered Research Outcomes Institute. The authors report no conflicts of interest.

RESULTS

Three themes related to medical treatment and symptom management arose from analyses: (1) an emotional response to LSS; (2) a desire for education about LSS and motivation to pursue education from any available source; and (3) a desire for individualized care based on self-management techniques and lifestyle changes. Emotional responses were more evident in individuals receiving medical care, whereas the other two themes were consistent across all three treatment groups.

CONCLUSIONS

The chronic pain associated with LSS may result in negative emotional responses. Individuals with LSS may believe misinformation and information from nonmedical sources, especially when medical providers do not spend sufficient time explaining the disease process and the reasoning behind treatment strategies. Receiving individualized care focused on self-management led to fewer negative emotions toward care and the disease process. Clinicians should be prepared to address all three of these aspects when providing care to individuals with LSS.

Fear of movement and its effects on hand function after tendon repair

After tendon injuries, it has been observed clinically that patient-reported disability is more severe than the patient's actual performance. This is thought to result from a fear of movement (kinesiophobia) after surgery. The aim of this study was to investigate the presence of kinesiophobia in this patient population and its effects on the clinical outcomes. Patients (n=118) with tendon repairs were included. All the participants received early passive mobilization and were assessed at the end of the 8th week. Grip and pinch strengths were measured and the Nine-Hole Peg Test (9HPT) was conducted. Patients also filled out the Michigan Hand Outcomes Questionnaire (MHOQ) and Tampa Scale for Kinesiophobia (TSK). Patients were divided according to their kinesiophobia: Group 1 with low kinesiophobia (TSK<37) and Group 2 with high kinesiophobia (TSK≥37). The groups were compared on the assessed parameters. Fifty-nine percent of the patients had a high kinesiophobia level. The performance-based test results were similar between the groups (P>0.05). Patient-reported MHOQ and TSK scores were significantly lower in the high kinesiophobic group (P=0.001 and P=0.000, respectively). Patients with tendon repairs often develop kinesiophobia, which may contribute to difficulty when starting to re-use their hand in daily life. None of the objective results were affected by this fear of movement-only patient-reported disability. Clinicians should be aware that clinical outcomes may be affected by the patient's kinesiophobic thinking and must be cautious during treatment.

Behavioral Therapy Approaches for the Management of Low Back Pain: An Up-To-Date Systematic Review

Low back pain is one of the most common causes for seeking medical treatment and it is estimated that one in two people will experience low back pain at some point during their lifetimes. Management of low back pain includes pharmacological and non-pharmacological approaches. Non-pharmaceutical treatments include interventions such as acupuncture, spinal manipulation, and psychotherapy. The latter is especially important as patients who suffer from low back pain often have impaired quality of life and also suffer from depression. Depressive symptoms can appear because back pain limits patients’ ability to work and engage in their usual social activities. The aim of this systematic review was to overview the behavioral approaches that can be used in the management of patients with low back pain. Approaches such as electromyography (EMG) biofeedback, cognitive behavioral therapy, and mindfulness-based stress reduction are discussed as non-pharmacological options in the management of low back pain.