Download Does it Hurt? Exercise for Chronic Pain

Presenters:
Armando Miciano MD,
Shruti Mutalik MD,
Devi Nampiaparampil MD
2014 AAPMR Annual Assembly Course, November 16, 2014 San Diego, CA
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1. Exercise, Work Activity, & Participation Levels of
Individuals with Chronic Pain: their role in Care Planning.
Armando Miciano, M.D., Nevada Rehabilitation Institute,
Las Vegas NV
2. Resistance to Exercise and the Psychological Factors
that affect Functional Recovery in Individuals with Chronic
Disorders.
Shruti Mutalik, MD, North Shore Long Island Jewish Health
System, Glen Oaks, NY
3. Promoting Exercise Using Social Media, Shared Medical
Visits, and Other Innovative Strategies.
Devi Nampiaparampil M.D, NYU School of Medicine, New
York NY
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1. Identify factors that affect the chronic pain patient's
exercise, activity, and participation levels;
2. Develop a broader understanding of the link between
psychological variables on adherence to exercise regimens
and functional outcomes in chronic pain patients;
3. Incorporate a physical activity prescription into clinical
practice to enhance physiatric care; and,
4. Utilize physiatric interventions and innovative
approaches, including social and other media, to increase
patient exercise, activity, and participation levels and to
educate and motivate patients.
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Inherent patient factors that exist affecting a chronic pain patient's exercise, activity, and
participation levels include: patient-centric values (i.e. patient-reported outcomes),
psychological factors (i.e. mood, cognition, personality, & motivation), and patient
preferences/views (i.e. use of the internet and social media for health information).
Our course will discuss patient-reported outcome measures that can be utilized in clinical
practice to describe the exercise, activity, and participation levels of individuals with chronic
pain. Then, it will explore the spectrum of willingness to exercise – resistance, ambivalence,
degrees of motivation, and review the evidence supporting different targeted strategies, such
as motivational interviewing, in promoting healthy exercise behavior, with a particular focus on
the needs of chronic pain patients. We will also discuss psychological barriers to exercise and
examine frameworks, such as the cognitive behavioral framework, that can help us
conceptualize them and understand how to best help our patients overcome them. Finally, the
course will discuss how to utilize innovative approaches and tools such as social media, to
educate and motivate patients.
Overall, the course will provide attendees with patient-centered clinical approaches in
identifying these factors and with potential rehabilitative interventions. Hence, the Physiatrist
can then help improve the health and well-being of the chronic pain patient by: 1) recording
the physical activity as a "vital sign" and patient preference during patient visits; 2) discussing
the role of exercise and physical activity; and, 3) providing a physical activity prescription as a
potential treatment option and important component of a healthy lifestyle.
Section Presenter:
Armando Miciano, MD
Nevada Rehabilitation Institute, Las Vegas, NV
2014 AAPMR Annual Assembly, San Diego CA November 2014
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Medical Director
Spring Mountain Rehab, Las Vegas NV
Practitioner –
Nevada Rehabilitation Institute, Las Vegas NV
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1. Define physical activity
2. Apply patient-reported outcome (PRO)
measures that can be utilized in clinical
practice to describe the exercise, activity, and
participation levels of individuals with chronic
pain
3. Integrate a physical activity prescription as
a treatment option in individuals with chronic
pain
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Physical Activity
◦ Exercise activity
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Activities of daily living (ADL)
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Instrumental Activities of daily living (IADL)
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Work Activity
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Osteoarthritis (OA) clinical practice guidelines identify a substantial
therapeutic role for physical activity, but objective information about the
physical activity of this population is lacking.
STUDY AIMS:
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METHODS:
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RESULTS:
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CONCLUSION:
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◦ Measure levels of physical activity in adults with knee OA and report the prevalence of
meeting public health physical activity guidelines.
◦ Accelerometry data from 1,111 adults with radiographic knee OA (49-84 years old)
for meeting the aerobic component of the 2008 Physical Activity Guidelines for
Americans (≥150 minutes/week moderate-to-vigorous-intensity activity lasting ≥10
minutes)
◦ Aerobic physical activity guidelines met by 12.9% of men and 7.7% of women with
knee OA.
◦ A substantial proportion of men and women (40.1% and 56.5%, respectively) were
inactive, having done no moderate-to-vigorous activity that lasted 10 minutes or
more during the 7 days.
◦ adults with knee OA were particularly inactive based on objective accelerometry
monitoring.
◦ These findings support intensified public health efforts to increase physical activity
levels among people with knee OA.
Dunlop DD, et al. Arthritis Rheum. 2011 Nov;63(11):3372-82.
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Adults with chronic musculoskeletal
conditions should engage in:
◦ 150 minutes of moderate, low-impact activity (e.g.,
walking, swimming, biking) per week; and
◦ resistance training of major muscle groups 2 days
per week.
Crandall S, et al. Phys Ther. 2013 Jan;93(1):17-21.
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International Physical Activity Questionnaire Short Form
(IPAQ-SF) assessed by self-administered questionnaire,
which asked the subjects how often they engaged in each
activity listed includes questions about the frequency,
duration, and intensity of PA during the previous week
Vigorous PA: defined as at least 20 minutes of vigorous
activity on 3 or more days of the week.
Moderate PA: defined as at least 30 minutes of moderateintensity activity on 5 or more days of the week.
Walking: defined as at least 30 minutes of walking on 5 or
more days of the week.
Strength or flexibility exercises: defined as the
performance of strength exercises or flexibility exercises
on 2 or more days of the week.
[1] Kim W, et al. PM R 2014;6:893-899; [2] Craig CL, et al. Med
Sci Sports Exerc. 2003.
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Total PA metabolic equivalent (MET)-minutes/week was derived
from the IPAQ data. An average MET score was calculated for
each type of activity. The following values were used to analyze
the IPAQ data: walking ¼ 3.3 METs, moderate PA ¼ 4.0 METs,
and vigorous PA ¼ 8.0 METs.
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These values were used to define 4 continuous scores:
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Total PA MET-minutes/week ¼ sum of walking, moderate PA,
vigorous PA MET-minutes/week scores
◦ Walking MET-minutes/week ¼ 3.3 walking minutes walking days
◦ Moderate PA MET-minutes/week ¼ 4.0 moderate-intensity activity
minutes moderate-intensity activity days
◦ Vigorous PA MET-minutes/week ¼ 8.0 vigorous-intensity activity minutes
vigorous-intensity activity days
[1] Kim W, et al. PM R 2014;6:893-899; [2] Craig CL, et al. Med
Sci Sports Exerc. 2003.
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Ettinger and colleagues:
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van Baar et al.
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Bennell et al.
◦ dose–response relationship between adherence and
exercise effects in a large 18-month trial involving 439
people with knee OA. With increasing adherence,
improvements in pain, walking ability, and disability
significantly increased.
◦ that the beneficial effects of exercise last only as long as
the patient with OA continues to participate in exercise.
◦ 183 patients with hip/knee OA for 6 months after they had
completed a 12-week exercise program and found that the
beneficial effects of exercise on pain and disability were
lost 6 months after the exercise program had been
completed (Fig.)
Bennell KL, et al. Best Pract Res Clin Rheumatol. 2014 Feb;28(1):93-117.
Bennell KL, et al. Best Pract Res Clin Rheumatol. 2014 Feb;28(1):93117.
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Even though exercise itself might act as a
stressor, it has been demonstrated that it
reduces the harmful effects of other stressors
when performed at moderate intensities.
Neurotransmitter release, neurotrophic factor
and neurogenesis, and cerebral blood flow
alteration are some of the concepts involved.
Overwhelming evidence present in the literature
today suggests that exercise ensures successful
brain functioning
Deslandes A, et al. Neuropsychobiology. 2009;59(4):191-8.
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Report pain, difficulty performing activities of
daily living, sleep problems, and fatigue.
Present with range of physical impairments
including joint stiffness, muscle weakness,
altered proprioception, reduced balance, and
gait abnormalities.
Psychological impairments such as
depression and anxiety are common.
Bennell KL, et al. Best Pract Res Clin Rheumatol. 2014
Feb;28(1):93-117.
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Fluctuations in pain in patients with knee osteoarthritis (OA) are common, but risk factors for
pain fluctuation are poorly understood. To best identify the structural causes of fluctuations,
multiple assessments of pain status and structural lesions are needed.
OBJECTIVES: Determine whether pain resolution is accompanied by diminution of lesions in
patients with knee OA.
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METHODS:
570 Subjects queried about their knee pain by interview,
Knees assessed by MRI at the baseline and 15-month and 30-month clinic visits. For those
knees in which pain fluctuation was identified over 3 clinic visits, the relationship of bone
marrow lesions (BMLs), synovitis, and effusion to frequent knee pain and severity of knee pain
examined
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CONCLUSION:
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Changes in BMLs and synovitis are associated with fluctuations in
knee pain in patients with knee OA.
Pain resolution occurs more frequently when BMLs become smaller.
No significant association was found between the effusion score and frequent knee pain.
Zhang Y, et al. Arthritis Rheum. 2011 Mar;63(3):691-9.
[1] Bennell KL, et al. Best Pract Res Clin Rheumatol. 2014 Feb;28(1):93117. [2] Campbell et al. (2001)
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UNCERTAINTY among older adults with knee pain regarding the role of
exercise, including uncertainty around issues of exercise purpose,
safety, and effectiveness in managing knee pain
Factors such as laziness, forgetfulness, boredom, and lack of enjoyment
as barriers to exercise participation
Commonly held belief that knee pain is due to “wear and tear” within the
joint and that the problem will most probably worsen over the long
term.
Another common misconception is that participation in physical activity
and exercise, in the presence of OA, may cause damage within the
affected joint.
Holden et al: that many people also incorrectly believe that more severe
OA (X-ray damage) is less likely to benefit from exercise.
PRACTICAL IMPLICATION: These findings highlight how critical patient
education is in order to Bennell
maximize
patient
to exercise
in OA.
KL, et al.
Best Practadherence
Res Clin Rheumatol.
2014 Feb;28(1):93-117.
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In summary, for people with acute, subacute or
chronic low back pain, there is no evidence that
exercise increases the risk of additional back
pain episodes or work disability.
To the contrary, current medical literature
suggests that exercise has either a neutral effect
or has a slight potentially beneficial effect on that
risk.
It would appear that exercise is safe for people
with back pain, and exploration of the potential
benefits of exercise is warranted.
J. Rainville et al. Spine J. 4 (2004) 106–115.
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Objectives: To examine the association between the type and amount of physical activity (PA)
and low back pain (LBP) in people aged 50 years.
Participants: 1796 men and 2198 women aged 50 years included.
Methods:
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PA was categorized as vigorous, moderate, walking, strength exercises, or
flexibility exercises.
The total amount of PA was presented as quartiles of the total metabolic equivalent (MET)-minutes/week
based on the PA questionnaire.
Results:
After adjusting for age and body mass index, vigorous and moderate PA were associated with
an increased risk of LBP in both men and women, whereas strength exercises were associated
with a reduced risk of LBP.
Trends were most significantly demonstrated in women aged 65 years.
The PA quartiles for total MET-minutes/week for men showed a U-shaped association with
LBP, whereas only the fourth PA quartile for women showed an increased risk of LBP compared
with the second quartile.
Conclusions:
These results suggest that both the type and amount of PA affect the development of LBP in
people aged 50 years
thus activity modification might be helpful for prevention and management of LBP.
Kim W, et al. PM R. 2014;6:893-899
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Psychoneuroimmunology suggests that
activation of the proinflammatory cytokine
network (both at the periphery and the
central nervous system) can lead to a
constellation of “sickness behaviors,“
alterations in pain sensitivity such as
exaggerated pain response (hyperalgesia),
sleep disturbance, and fatigue.
[6] Irwin MR. Psychiatr Clin North Am. 2011 Sep;34(3):605-20.
[7] Fava M. J Clin Psychiatry. 2003;64 Suppl 13:26-9.
[8] Mease PJ. Am J Med. 2009 Dec;122(12 Suppl):S44-55
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The activation of proinflammatory cytokines,
possibly acting in concert with stress, might
lead to increased sensitization of the central
nervous system, which serves as a possible
neuronal substrate for amplification of
normal bodily sensations [6] and affects both
seratonin and norepinephrine
neurotransmitter systems that appear to
exert effects via spinal pathways,
subsequently playing a modulating role in
pain, sleep, and fatigue.
[6] Irwin MR. Psychiatr Clin North Am. 2011.
[7] Fava M. J Clin Psychiatry. 2003.
[8] Meese PJ. Am J Med. 2009 .
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Hyperexcitability of the central nervous system (CNS) has
been suggested to play an important role in the chronic
pain experienced by osteoarthritis (OA) patients.
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A systematic review
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The majority of these studies were case-control studies
and addressed OA of the knee joint.
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Overall results suggest that:
◦ peripheral mechanisms involved in OA pain, hypersensitivity of
the CNS a significant role in a subgroup
◦ Although the majority of the literature provides evidence for the
presence of CS in chronic OA pain, clinical identification and
treatment of CS in OA still in its infancy,
◦ future studies with good methodological quality necessary.
Lluch E, et al. Eur J Pain. 2014 Apr 3
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Severe pain has profound physiologic effects on the endocrine
system.
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Serum hormone abnormalities may result and these serve as
biomarkers for the presence of severe pain
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Initially severe pain causes a hyperarousal of the hypothalamicpituitary-adrenal system which results in elevated serum
hormone levels such as adrenocorticotropin, cortisol, and
pregnenolone.
If the severe pain does not abate, however, the system cannot
maintain its normal hormone production and serum levels of
some hormones may drop below normal range.
Some hormones are so critical to pain control that a deficiency
may enhance pain and retard healing.
Tennant F. Pain Ther. 2013 Dec;2(2):75-86.
Adapted from: Tennant F. Pain Ther. 2013 Dec;2(2):75-86.
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Energy drawn from high-energy phosphate bonds is needed for muscle activity. The cell stores
a small amount of ATP near the contractile proteins. The use of this ATP is not dependent on a
supply of oxygen, and, therefore, the energy is available as soon as the muscle requires it.
For exercise to continue beyond a few seconds, cells must synthesize ATP through 1 of 2
metabolic pathways: anaerobic (glycolytic) or aerobic (oxidative). All energy systems contribute
to meet the energy demands of different sporting events but 1 or 2 predominate according to
the sports-specific characteristics (predominantly aerobic or anaerobic).
Activities that depend primarily on the ATP-phosphocreatine (PC) system and anaerobic
glycolysis are classified as anaerobic activities I.e. events that require muscle activity for 2-3
minutes Examples of exercises in this category include golf or tennis swings, throwing events
in track and field,
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Activities of longer duration (2-3 minutes) that depend primarily on oxidative metabolism,
such as long-distance swimming, are classified as aerobic activities.
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Many sports activities require a blend of both anaerobic and aerobic metabolism.
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In “stop and go” sports such as tennis, approximately 60%-70% of the energy comes from ATPcreatine phosphate (CP) stores and anaerobic glycolysis and the remaining 30% from oxidative
processes [6].
Rivera-Brown AM, et al. PMR. 2012; 4:797-804
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Objective.
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Methods.
◦ to evaluate the relationships between fat mass, muscle mass, fat/muscle mass ratio,
metabolic syndrome, and musculoskeletal pain in community residents.
◦ 1530 participants completed pain questionnaires, underwent dual x-ray
absorptiometry to calculate body composition.
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Pain categorized according to the number of pain regions,
widespread pain, defined as pain above the waist, below the waist, on both sides of the
body, and in the axial region.
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Results.
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Conclusions.
◦ Total fat mass and fat/muscle ratio significantly and positively associated with
musculoskeletal pain only among females.
◦ Widespread pain more prevalent among those with metabolic syndrome in both
normal- and high-BMI subjects, especially among females.
◦ Increase in fat mass and fat/muscle mass ratio significantly associated with
musculoskeletal pain among females.
◦ Widespread pain significantly associated with a high fat/muscle ratio Understanding
the relation between fat mass and pain may provide insights into preventative
measures and therapeutic strategies for musculoskeletal pain.
Yoo JJ, et al. Arthritis Rheumatol. 2014 Sept 3.
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Exercise-induced muscle injury in humans frequently occurs after unaccustomed exercise, particularly if the
exercise involves a large amount of eccentric (muscle lengthening) contractions.
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Direct measures of exercise-induced muscle damage include cellular and subcellular disturbances, particularly
Z-line streaming.
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Indirectly assessed markers of muscle damage after exercise include
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Exact mechanisms to explain these changes not been delineated,
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the initial injury is ascribed to mechanical disruption of the fiber, and
subsequent damage is linked to inflammatory processes and to changes in excitation-contraction coupling within the muscle.
Performance of one bout of eccentric exercise induces an adaptation such that the muscle is less vulnerable to a subsequent bout of
eccentric exercise.
No general agreement as to its cause: several theories proposed to explain this "repeated bout effect," including
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increases in T2 signal intensity via magnetic resonance imaging techniques,
prolonged decreases in force production measured during both voluntary and electrically stimulated contractions (particularly at low
stimulation frequencies),
increases in inflammatory markers both within the injured muscle and in the blood,
increased appearance of muscle proteins in the blood, a
muscular soreness.
altered motor unit recruitment,
increase in sarcomeres in series,
blunted inflammatory response,
reduction in stress-susceptible fibers
research using human studies suggests that there is either no difference between men and women or that
women are more prone to exercise-induced muscle damage than are men.
Clarkson PM, et al. Am J Phys Med Rehabil. 2002
Nov;81(11 Suppl):S52-69.
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The three types of pain related to exercise are 1)
pain experienced during or immediately
following exercise, 2) delayed onset muscle
soreness, and 3) pain induced by muscle cramps.
Each is characterized by a different time course
and different etiology.
Thus, despite the common occurrence of pain
associated with exercise, the exact cause of these
pains remains a mystery
Miles MP, Clarkson PM. J Sports Med Phys Fitness. 1994 Sep;34(3):203-16.
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Pain perceived during exercise is considered
to result from a combination of factors
including acids, ions, proteins, and
hormones. Although it is commonly believed
that lactic acid is responsible for this pain,
evidence suggests that it is not the only
factor. However, no single factor has ever
been identified.
Miles MP, Clarkson PM. J Sports Med Phys Fitness. 1994 Sep;34(3):203-16.
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Delayed onset muscle soreness develops 24-48
hours after strenuous exercise biased toward
eccentric (muscle lengthening) muscle actions or
strenuous endurance events like a marathon.
Soreness is accompanied by a prolonged strength
loss, a reduced range of motion, and elevated
levels of creatine kinase in the blood. These are
taken as indirect indicators of muscle damage,
and biopsy analysis has documented damage to
the contractile elements. The exact cause of the
soreness response is not known but thought to
involve an inflammatory reaction to the damage.
Miles MP, Clarkson PM. J Sports Med Phys Fitness. 1994 Sep;34(3):203-16.
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Muscle cramps are sudden, intense, electrically
active contractions elicited by motor neuron
hyperexcitability. Although it is commonly
assumed that cramps during exercise are the
result of fluid electrolyte imbalance induced by
sweating, two studies have not supported this.
Moreover, participants in occupations that
require chronic use of a muscle but do not elicit
profuse sweating, such as musicians, often
experience cramps. Fluid electrolyte imbalance
may cause cramps if there is profuse prolonged
sweating such as that found in working in a hot
environment.
Miles MP, Clarkson PM. J Sports Med Phys Fitness. 1994 Sep;34(3):203-16.
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Muscle damage is caused by strenuous and unaccustomed exercise,
especially exercise involving eccentric muscle contractions, where
muscles lengthen as they exert force.
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Damage can be observed both directly at the cellular level and indirectly
from changes in various indices of muscle function.
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Several mechanisms offered to explain the etiology of the damage/repair
process, including
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mechanical factors such as tension and strain,
disturbances in calcium homeostasis,
inflammatory response
synthesis of stress proteins (heat shock proteins).
Changes in muscle function following eccentric exercise observed
◦ at the cellular level as an impairment in the amount and action of transport proteins
for glucose and lactate/H+,
◦ at the systems level as an increase in muscle stiffness and a prolonged loss in the
muscle's ability to generate force.
Clarkson PM, et al. Can J Appl Physiol. 1999 Jun;24(3):234-48.
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changes in the protein composition of human muscle
tissue after eccentric exercise.
subjects performed maximum eccentric, isokinetic
actions of the forearm flexors with one arm. Biopsy of
the biceps muscle of each arm taken 2 days after
exercise when muscles very sore, and muscle damage
documented by a mean decrease in the relaxed elbow
angle. Proteins from the biopsy tissue solubilized
These changes imply that the increased synthesis,
decreased degradation, or some combination thereof,
of these proteins may be necessary for the repair or
regeneration response to exercise-induced muscle
damage.
Reichsman F, et al. Eur J Appl Physiol Occup Physiol. 1991;62(4):245-50.
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time course of changes in muscle function and other correlates of muscle damage following
maximal effort eccentric actions of the forearm flexor muscles.
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Peak soreness: 2-3 d postexercise while peak swelling: 5 d postexercise.
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Maximal strength and the ability to fully flex the arm show the greatest decrements
immediately after exercise
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a linear restoration of these functions over the next 10 d.
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Blood creatine kinase (CK) levels increase precipitously at 2 d after exercise which is also the
time when spontaneous muscle shortening is most pronounced.
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Performance of one bout of eccentric exercise produces an adaptation such that the muscle is
more resistant to damage from a subsequent bout of exercise.
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The length of the adaptation differs among the measures such that when the exercise
regimens are separated by 6 wk, all measures show a reduction in response on the second,
compared with the first, bout.
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After 10 wk, only CK and muscle shortening show a reduction in response.
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After 6 months only the CK response is reduced.
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Conclusion: A combination of cellular factors and neurological factors may be involved in the
adaptation process.
Clarkson PM, et al. Med Sci Sports Exerc. 1992 May;24(5):512-20.
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This study examined the effects of exercise-induced muscle damage on
tremor and proprioception components of neuromuscular function.
volunteers (aged 18-30 yr) performed 50 maximal eccentric muscle
actions using the forearm flexors of the nondominant arm. Forearm
flexor tremor and perception of voluntary force and joint position were
monitored to assess changes in neuromuscular function.
Serum creatine kinase activity increased 5 d after exercise
This was accompanied by prolonged impaired joint range of motion and
reduced maximum strength.
Muscle soreness peaked 3 d postexercise.
Tremor amplitude was increase until 48 h after exercise, whereas the
power frequency spectrum was unaffected. Perception of joint position
at elbow angles and perception of force significantly impaired
The increase in tremor amplitude and loss of proprioceptive function in
the days after damage-inducing eccentric exercise suggest significant
impairment of neuromuscular function.
Saxton JM, Clarkson PM, et al. Med Sci Sports Exerc. 1995
Aug;27(8):1185-93.
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Lower-extremity muscle strength and afferent sensory
dysfunction, such as reduced proprioceptive acuity, are
potentially modifiable putative risk factors for knee osteoarthritis
(OA).
Findings from current studies suggest that muscle weakness is a
predictor of knee OA onset, while there is conflicting evidence
regarding the role of muscle weakness in OA progression.
In contrast, the literature suggests a role for afferent sensory
dysfunction in OA progression but not necessarily in OA onset.
The few pilot exercise studies performed in patients who are at
risk of incident OA indicate a possibility for achieving preventive
structure or load modifications. In contrast, large randomized
controlled trials of patients with established OA have failed to
demonstrate beneficial effects of strengthening exercises.
Subgroups of individuals who are at increased risk of knee OA
(such as those with previous knee injuries) are easily identified,
and may benefit from exercise interventions to prevent or delay
OA onset.
Roos EM, et al. Nat Rev Rheumatol. 2011.
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The effects of performing light eccentric
exercise (LB) during the period of recovery
from a heavy eccentric exercise bout (HB)
were studied.
The LB did not alter muscle soreness,
strength or elbow flexibility, but did reduce
or delay CK activity increase after HB.
The LB had no apparent effect on adaptation
to HB.
Donnelly AE, et al. Eur J Appl Physiol Occup Physiol. 1992;64(4):350-3.
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Being fit (biochemically speaking) means that
the individual has a well-developed
cardiovascular system that can efficiently
supply nutrients and oxygen to the muscles.
Have muscle cells that are well perfused with
capillaries (ie, they have a good muscle blood
supply).
muscle cells also have a large number of
mitochondria, and those mitochondria have a
high activity of Krebs cycle enzymes, electron
transport carriers, and oxidation enzymes.
Hochachka PW. Adv Exp Med Biol. 2000;475:311-35.
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Individuals who are unfit must endure the consequences of a
poorer blood supply, fewer mitochondria, less electron transport
units, a lower activity of the Krebs cycle, and poorer activity of
beta-oxidation enzymes.
To generate ATP in the mitochondria, a steady supply of fuel and
oxygen and decent activity of the oxidizing enzymes and carriers
are needed.
If any of these components are lacking, the rate at which ATP can
be produced by mitochondria is compromised. Under these
circumstances, the production of ATP by aerobic means is not
sufficient to provide the muscles with sufficient ATP to sustain
contractions. The result is anaerobic ATP generation using
glycolysis. Increasing the flux through glycolysis but not
increasing the oxidative consumption of the resulting pyruvate
increases the production of lactate.
Hochachka PW. Adv Exp Med Biol. 2000;475:311-35.
None completely explain the decline in force production capability because fatigue is
specific to the activity being performed.
the muscle contraction crossbridge cycle itself in order to explain a major contributor
to the fatigue process in exercise of any duration. The byproducts of adenosine
5'-triphosphate (ATP) hydrolysis, adenosine 5'-diphosphate (ADP) and inorganic
phosphate (Pi) are released during the crossbridge cycle and can be implicated in
the fatigue process due to the requirement of their release for proper crossbridge
activity. Pi release is coupled to the powerstroke of the crossbridge cycle.
The accumulation of Pi during exercise would lead to a reversal of its release step,
therefore causing a decrement in force production capability. Due to the release of
Pi with both the immediate (phosphagen) energy system and the hydrolysis of
ATP, Pi accumulation is probably the largest contributor to the fatigue process in
exercise of any duration.
ADP release occurs near the end of the crossbridge cycle and therefore controls the
velocity of crossbridge detachment. Therefore, ADP accumulation, which occurs
during exercise of extended duration (or in ischaemic conditions), causes a
slowing of the rate constants (and therefore a decrease in the maximal velocity of
shortening). in the crossbridge cycle and a reduced oscillatory power output.
The combined effects of these accumulated hydrolysis byproducts accounts for a
large amount of the fatigue process in exercise of any intensity or duration.
Mclester JR. Sports Med. 1997 May;23(5):287-305.
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Purpose: to determine if old individuals show a greater exerciseinduced decrement in motor performance and slower recovery
compared to young individuals.
College-age women and older women performed an exercise
consisting of 24 eccentric actions of the forearm flexors.
For both groups, strength reduced and soreness developed in the days following the exercise,
◦ generally indicating that muscle damage had occurred.
Older subjects - slower strength recovery such that by 5 days after exercise they had not
returned to their initial level of strength.
no significant difference in soreness development between groups.
Reaction time & movement time not adversely affected by the exercise.
Thus, the older subjects demonstrated a slower strength
recovery after damage-inducing exercise, and, with regard to
response speed, the older subjects could compensate for the
impaired muscle function as well as the younger subjects.
Dedrick ME, Clarkson PM. Eur J Appl Physiol Occup Physiol.
1990;60(3):183-6.
The best examples of light exercise are walking and light jogging.
The muscles that are recruited during this type of exercise are
those that contain a large amount of type I muscle cells, and,
because these cells have a good blood supply, it is easy for fuels
and oxygen to travel to the muscle. ATP consumption makes ADP
available for new ATP synthesis.
The presence of ADP (and the resulting synthesis of ATP) simulates
the movement of hydrogen (H+) into the mitochondria; this, in
turn, reduces the proton gradient and thus stimulates electron
transport. The hydrogen on the reduced form of nicotinamide
adenine dinucleotide (NADH) is used up, nicotinamide adenine
dinucleotide (NAD) becomes available, and fatty acids and
glucose are oxidized.
Both these exercise-induced responses augment the elevation in
fuel oxidation caused by the increase in ATP consumption.
Mclester JR. Sports Med. 1997 May;23(5):287-305.
An increase in the pace of running simply results
in an increased rate of fuel consumption, an
increased fatty acid release, and, therefore, an
increase in the rate of muscle fatty acid
oxidation.
However, if the intensity of the exercise increases
even further, a stage is reached in which the rate
of fatty acid oxidation becomes limited.
Therefore, the energy used during moderate
exercise is derived from a mixture of fatty acid
and glucose oxidation.
Mclester JR. Sports Med. 1997 May;23(5):287-305.
During muscular exercise, blood vessels in muscles dilate and blood flow is increased in order to
increase the available oxygen supply. Up to a point, the available oxygen is sufficient to meet
the energy needs of the body. However, when muscular exertion is very great, oxygen cannot
be supplied to muscle fibers fast enough, and the aerobic breakdown of pyruvic acid cannot
produce all the ATP required for further muscle contraction.
During such periods, additional ATP is generated by anaerobic glycolysis. In the process, most of
the pyruvic acid produced is converted to lactic acid. Although approximately 80% of the lactic
acid diffuses from the skeletal muscles and is transported to the liver for conversion back to
glucose or glycogen, some lactic acid accumulates in muscle tissue, making muscle contraction
painful and causing fatigue. Ultimately, once adequate oxygen is available, lactic acid must be
catabolized completely into carbon dioxide and water.
After exercise has stopped, extra oxygen is required to metabolize lactic acid; to replenish ATP,
phosphocreatine, and glycogen; and to replace (“pay back”) any oxygen that has been
borrowed from hemoglobin, myoglobin (an iron-containing substance similar to hemoglobin
that is found in muscle fibers), air in the lungs, and body fluids. The additional oxygen that
must be taken into the body after vigorous exercise to restore all systems to their normal
states is called oxygen debt. The debt is paid back by labored breathing that continues after
exercise has stopped.
Thus, the accumulation of lactic acid causes hard breathing and sufficient discomfort to stop
muscle activity until homeostasis is restored
Mclester JR. Sports Med. 1997 May;23(5):287-305.
Eventually, muscle glycogen must also be restored. Restoration of
muscle glycogen is accomplished through diet and may take
several days, depending on the intensity of exercise. The
maximum rate of oxygen consumption during the aerobic
catabolism of pyruvic acid is called maximal oxygen uptake.
Maximal oxygen uptake is determined by sex (higher in males), age
(highest at approximately age 20 y), and size (increases with
body size). Highly trained athletes can have maximal oxygen
uptakes that are twice that of average people, probably owing to
a combination of genetics and training.
As a result, highly trained athletes are capable of greater muscular
activity without increasing their lactic acid production and have
lower oxygen debts, which is why they do not become short of
breath as readily as untrained individuals.
Mclester JR. Sports Med. 1997 May;23(5):287-305.
In summary, the 3 different muscle metabolic systems that
supply the energy required for various activities are as
follows:
Phosphagen system (for 10- to 15-sec bursts of energy)
Glycogen lactic acid system (for another 30-40 sec of
energy)
Aerobic system (provides a great deal of energy that is
only limited by the body's ability to supply oxygen and
other important nutrients)
Many sports require the use of a combination of these
metabolic systems. By considering the vigor of a sports
activity and its duration, one can estimate very closely
which of the energy systems are used for each activity.
Mclester JR. Sports Med. 1997 May;23(5):287-305
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Cochrane review: to determine effects of stretching before or
after exercise on the development of delayed-onset muscle
soreness.
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showed that pre-exercise stretching reduced soreness at one day after
exercise by, on average, half a point on a 100-point scale.
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Post-exercise stretching reduced soreness at one day after exercise by, on
average, one point on a 100-point scale
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Similar effects were evident between half a day and three days after exercise.
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AUTHORS' CONCLUSIONS:
The evidence from randomised studies suggests that muscle
stretching, whether conducted before, after, or before and after
exercise, does not produce clinically important reductions in
delayed-onset muscle soreness in healthy adults.
Herbert RD, et al. Cochrane Database Syst Rev. 2011 Jul 6;(7):CD004577.
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Purpose: to examine the effects of acute exercise on pain perception in
healthy adults and adults with chronic pain using meta-analytic
techniques.
◦ Specifically, studies using a repeated measures design to examine the effect of acute
isometric, aerobic, or dynamic resistance exercise on pain threshold and pain
intensity measures were included in this meta-analysis
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Results: In chronic pain populations, the magnitude and direction of the
effect sizes were highly variable for aerobic and isometric exercise and
appeared to depend on the chronic pain condition being studied as well
as the intensity of the exercise.
While trends could be identified, the optimal dose of exercise that is
needed to produce hypoalgesia could not be systematically determined
with the amount of data available.
PERSPECTIVE:
both a hypoalgesic and hyperalgesic effect in adults with chronic pain.
Naugle KM, et al. J Pain. 2012 Dec;13(12):1139-50.
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The present qualitative analysis of the literature
aims to provide an overview of theoretical
models that are put forward to explain the
beneficial treatment effects of exercise in OA.
5 categories were formed:
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neuromuscular,
peri-articular,
intra-articular,
psychosocial components,
general fitness and health.
Beckwée D, et al. Ageing Res Rev. 2013 Jan;12(1):226-36.
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Centralization is a symptom response to repeated movements that can be used to classify patients into
sub-groups, determine appropriate management strategies, and prognosis.
Study aim: to systematically review the literature relating to centralization and directional preference,
and specifically report on prevalence, prognostic validity, reliability, loading strategies, and diagnostic
implications.
The prevalence of centralization was 44.4% (range 11%-89%) in 4745 patients with back and neck pain;
it was more prevalent in acute (74%) than sub-acute or chronic (42%) symptoms.
The prevalence of directional preference was 70% (range 60%-78%) in 2368 patients with back or neck
pain.
Twenty-one of 23 studies supported the prognostic validity of centralization, including 3 high quality
studies and 4 of moderate quality; whereas 2 moderate quality studies showed evidence that did not
support the prognostic validity of centralization.
Data on the prognostic validity of directional preference was limited to one study.
Centralization and directional preference appear to be useful treatment effect modifiers in 7 out of 8
studies. Levels of reliability were very variable (kappa 0.15-0.9) in 5 studies.
Findings of centralization or directional preference at baseline would appear to be useful indicators of
management strategies and prognosis, and therefore warrant further investigation.
May S, et al. Man Ther. 2012.
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Exercise therapy is widely used as an intervention in low-back
pain.
OBJECTIVES:
To evaluate the effectiveness of exercise therapy in adult nonspecific acute, subacute and chronic low-back pain versus no
treatment and other conservative treatments.
AUTHORS' CONCLUSIONS:
Exercise therapy appears to be slightly effective at decreasing
pain and improving function in adults with chronic low-back
pain, particularly in healthcare populations.
In subacute low-back pain there is some evidence that a graded
activity program improves absenteeism outcomes, though
evidence for other types of exercise is unclear.
In acute low-back pain, exercise therapy is as effective as either
no treatment or other conservative treatments.
Hayden JA, et al. Cochrane Database Syst Rev. 2005 Jul 20;(3):CD000335.
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AIM:
Progressive resistance exercises (PRE) are prescribed to reverse the deconditioning
associated with chronic back pain. The spine rehabilitation program has utilized 2
sets of progressive resistance exercises during each session, with increased
resistance between sets, and with successive sessions. Exercise literature has
challenged the need for multiple sets of resistance exercises, with a single set
producing similar functional benefits. The authors studied whether completing 1
versus 2 sets of resistance exercises would affect strength, pain and disability
outcomes in subjects with chronic low back pain (CLBP).
METHODS:
subjects with CLBP to perform either 1 set or 2 sets of progressive resistance
exercises during otherwise identical spine rehabilitation programs.. Primary
outcomes were back strength and progressive isoinertial lifting evaluation (PILE) at
discharge.
RESULTS:
At discharge, there was no significant difference in strength, disability or pain
measures between subjects completing 1 versus 2 sets of resistance exercises.
CONCLUSION:
These findings suggest that there were no added benefits for completing a second
set of resistance exercises during therapy sessions for patients with CLBP.
Limke JC, Rainville J, et al. Eur J Phys Rehabil Med. 2008 Dec;44(4):399-405.
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OBJECTIVES:
To observe if kinesiophobia was altered through an education- and quota-based exercise
physical therapy program, and to observe the relationship of kinesiophobia with other
measures related to chronic low back pain.
BACKGROUND:
The role of kinesiophobia in worsening the chronic low back pain predicament has been
documented in numerous studies. However, less is known of the effect of an exerciseonlybased physical therapy program's ability to alter kinesiophobia and improve functional abilities
in patients with chronic low back pain.
RESULTS:
Clinically and statistically significant improvement in flexibility, strength, and lifting ability
were observed. Statistically significant improvement in back pain, disability, and measures of
kinesiophobia were also noted at discharge and maintained at 12-month follow-up.
CONCLUSION:
In this study we observed that kinesiophobia decreased during an intensive physical therapy
program in which exercises were performed in a quota-based manner.
Following the successful performance of non-pain-contingent, quota-based exercise, patients'
fears of injury lessened, and this may have had a positive influence on disability.
Kernan T, Rainville J. J Orthop Sports Phys Ther. 2007 Nov;37(11):679-87.
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This focus resulted from research demonstrating that impairments of trunk strength, flexibility and
endurance are present in many people with chronic low back pain.
These impairments result in part from long-term inhibition of movements and physical inactivity that
results in neurological and physiological changes in the spine.
These changes include weakness of the paraspinal musculature, with selective loss of Type 2 muscle
fibers, alteration of the relaxation response of the paraspinal musculature associated with full spinal
flexibility and shortening of muscles nd connective tissues of the spinal region.
This limitation of movement and activity is largely voluntary, as people both consciously and
unconsciously limit activities that induce back pain, or avoid these altogether for fear of producing
injury or harm. Inhibition of movements and activities usually begins early in the course of back pain
and may be reinforced by health-care providers through their advice to patients to avoid activities and
movements that induce pain.
Reversal of these impairments in back function can be approached using established principles of
exercise.
J. Rainville et al. Spine J. 4 (2004) 106–115.
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Stretching exercises can be used to eliminate
impaired flexibility and restore normal trunk
range of motion. In order to be successful,
however, stretching must be performed at the
patient’s physiological end range and
therefore within the range of motion that may
induce back discomfort.
Stretching within the painful range is safe,
and acceptable to patients when their healthcare providers suggest it with confidence.
J. Rainville et al. Spine J. 4 (2004) 106–115.
Adapted from: J. Rainville et al. Spine J. 4 (2004) 106–115.
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Several methods for stretching are available.
Ballistic stretching is not generally recommended because this activates muscle
spindle reflexes that are counterproductive for improving muscle length.
Techniques using proprioceptive neuromuscular facilitation (PNF) have been
demonstrated to be effective but require a specially trained therapist or partner
and are impractical for independent home programs.
Static stretching is an effective means of improving flexibility, requires only
minimal training and can be done without a therapist. Static stretches must be
held for at least 30 seconds in order to induce changes in flexibility and can be
repeated in up to four sets with additional benefit.

Three sessions of stretching per week improve flexibility, but even greater gains in
flexibility are made when stretching is performed five times per week.

After flexibility had been increased through a training program, one session of
stretching per week is enough to maintain the increases.
J. Rainville et al. Spine J. 4 (2004) 106–115.
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Stretching exercises should address the six directions
of lumbar motion: flexion, extension, side bending to
the right and left, and rotation to the right and left.
Additionally, stretches aimed at improving the length
of hip flexors, extensors, rotators, adductors and
abductors, hamstrings, quadriceps and calves should
be emphasized.
Multiple studies have documented the efficacy of
stretching for improving trunk flexibility deficits in
patients with chronic back pain, with average
improvement of about 20% noted.
Long-term compliance with a therapeutic stretching
regimen has been documented and is generally high.
J. Rainville et al. Spine J. 4 (2004) 106–115.
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Because multiple studies have shown that the trunk muscles of patients with
chronic low back pain are weaker than those of healthy individuals, many
programs advocate strength training to correct this impairment.
Resistance training is the most studied form of exercise used for the development
of lumbar extension strength.
The effectiveness of a resistance-training program for stimulating adaptation of
trunk musculature is dependent on many factors. These include load, frequency,
volume and mode of training.
Different authors advocate various modes of resistance training. Some advocate
isoinertial resistive training on specifically developed equipment. These include
advocates for equipment that isolates the spinal musculature and eliminates pelvic
motion by firmly fixing the pelvis and others who allow more contribution of
pelvic motion during back extension.
One advantage of isoinertial exercise equipment for resistance training is that
performance level is constantly quantified, thereby giving continuous feedback
concerning progress toward treatment goals.
J. Rainville et al. Spine J. 4 (2004) 106–115.
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For optimum strength training of deconditioned individuals
using isoinertial exercises, the performance of sets of 8 to 12
repetition maximum (RM) is recommended.
Training at low loads (less than the RM) may be beneficial for
reducing fears and voluntary inhibitions during initial training
sessions but does not lead to improvement of strength and
therefore should be limited to a few sessions.
The frequency of strength training has been studied, and no
differences were noted in one versus three times per week or two
versus three times per week.
Currently, programs recommend once or twice per week for most
Individuals with higher frequencies of strength training
recommended for disabled workers and those with needs for
higher levels of strength, such as athletes.
J. Rainville et al. Spine J. 4 (2004) 106–115.

In general, improvements of 30% to 80% of volitional muscle strength are
observed during these programs.

Maintenance of lumbar extensor strength has been demonstrated with
training at one time per week and even as low as one time per month.

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Some advocate strength training using body weight as resistance.
Multiple methods are possible, including simple floor exercises, the use
of an exercise ball or methods in which the lower or upper part of the
body is fixed or supported on a platform or table, and the remaining
body is lifted or suspended from the edge of the platform using the
strength of the trunk muscles.
For most of these types of exercise, strength cannot be accurately
quantified (although improvements in quality of performance and in
number of repetitions is usually noted by the patient and therapist), and
potential benefits for improving strength have received limited
documentation
J. Rainville et al. Spine J. 4 (2004) 106–115.
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A compelling reason to use exercise for the treatment of chronic back pain is that it may
reduce back pain intensity.
Results from several randomized, controlled studies using a variety of types of exercise have
demonstrated a positive effect on pain.
Frost et al. noted that an active exercise program consisting of eight sessions over 4 weeks
was found to be superior to unsupervised home exercise instruction for pain reduction (38% in
the exercise versus 13% in the home exercise group).
Torstensen et al. compared an active graded exercise program consisting of three weekly
sessions for 12 weeks with conventional physical therapy and an unsupervised walking
program. They observed a 30% pain reduction in the active exercise group versus a 23% pain
reduction in the physical therapy group and a 9%pain reduction in the walking group at the end
of treatment.
Alaranta et al. randomized 378 patients with back pain for less than 6 months and substantial
work absences into a 3-week functional restoration program consisting of intensive exercise
with educational and behavioral support or a controlled group that received passive physical
therapy and low-intensity exercises. The intensive exercise group reported greater pain
reduction at follow-up compared with the controlled group (36% versus 20%).
Manniche et al. randomized patients into various intensities of back extension strengthening
(50 repetitions vs. 15 repetitions vs. controls). He found that the most intensively exercised
group had a significantly greater reduction in pain symptoms.
Kankaanpa¨a¨ randomized patients with chronic back pain into a 12-week active rehabilitation
program consisting of resistive training versus a control group receiving passive treatments
and noted a 54% reduction of pain in the active rehabilitation group versus no change in the
control group.
J. Rainville et al. Spine J. 4 (2004) 106–115.
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Not all studies have demonstrated pain reduction
with exercise.
Bendix et al. performed a study using functional
restoration versus community treatments but
noted no change in pain in the treatment or the
controlled group.
Additionally, low-intensity exercise may have
less effect on back pain as Hansen et al. noted no
posttreatment differences in pain in patients
randomized into treatment consisting of floor
exercises versus conventional physical therapy or
placebo traction.
J. Rainville et al. Spine J. 4 (2004) 106–115.

The mechanisms through which exercise may reduce pain
are not currently established.
◦ theorized that exercise may reduce back pain through a process
of neurological or physiologic desensitization of the painproducing tissue, through the repeated application of force or
stress to that tissue.

delayed onset muscle soreness is known to peak 1 to 2
days after exercise and may be experienced or interpreted
as an exacerbation of back pain by some patients.
◦ This muscle soreness occasionally aggravates patients’ fears
about reinjury and must be addressed effectively in order to avoid
undermining the exercise program.

Frequent reassurances that fluctuations in pain are
expected in response to exercise
◦ important for the successful use of exercise treatments.
J. Rainville et al. Spine J. 4 (2004) 106–115.

In summary, exercise can be viewed as being safe for individuals
with chronic back pain, because there is no evidence to suggest
that regular exercise increases the risk of future back pain or
degeneration.

There is modest evidence to suggest that the regular
performance of exercise may indeed decrease this risk.

Exercise can be perceived as useful for addressing three distinct
aspects of the chronic back pain syndrome.
First, exercise can be useful for improving impairments in function that
are frequently present in patients with chronic low back pain, including
reduced back flexibility, strength and cardiovascular endurance.
◦ Second, there is modest evidence to suggest that the regular performance
of exercise may directly reduce back pain intensity.
◦ Finally, exercise may be useful for reducing back pain– related disability
because it may be used as a tool to lessen excessive fear and concerns
about back pain and alter stifling pain attitudes and beliefs.
◦
J. Rainville et al. Spine J. 4 (2004) 106–115.
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To be discussed later.
It is recognized that psychosocial, behavioral,
cognitive and affective factors play crucial roles
in the development of chronic low back pain
syndromes and especially back pain–related
disability.
By understanding the mechanisms by which
these factors influence back pain, one can
envision ways that exercise may be used as a
therapeutic modality to address these issues.
J. Rainville et al. Spine J. 4 (2004) 106–115.
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
A complex array of factors influence a
person's decision to commence, and
maintain, participation in exercise and
physical activity.
Motivating factors include
◦ presence of social support,
◦ presentation of an organized exercise opportunity
conducted by professionals,
◦ having a partner exercise alongside them,
◦ being familiar with the exercise task,
◦ having positive outcome expectations of exercise.
Bennell KL, et al. Best Pract Res Clin Rheumatol. 2014 Feb;28(1):93-117.
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It appears that once people commence an exercise program, adherence is often
high in the early stages of participation, but can wane quite quickly as time
passes.
Campbell et al. interviewed patients with knee OA who participated in
physiotherapy, involving primarily home-based strengthening exercises. Patients
were most adherent with the physiotherapy regime in the initial period while still
seeing the physiotherapist regularly. However, the adherence dropped off once
contact with the physiotherapist ceased. The patients cited numerous reasons that
affected their motivation to adhere to the exercises, including:
◦
◦
attitude towards exercise

(e.g., willingness and ability to accommodate exercises into everyday life),

(those with more severe symptoms were most likely to adhere),

(those thinking arthritis was due to age or “wear and tear” were less adherent),

(high levels of continued compliance were related to perceptions that physiotherapy is effective
and improvement in symptoms).
perceived severity of knee symptoms
◦
ideas about the cause of arthritis
◦
perceived effectiveness of the intervention
Bennell KL, et al. Best Pract Res Clin Rheumatol. 2014 Feb;28(1):93-117.
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Factors influencing adherence to exercise can be
intrinsic and/or extrinsic to the patient with OA.
Internal factors include
◦ attributes of the individual
 (such as motivation levels, personality, self-image, health and
exercise attitudes, exercise history, and knowledge of OA) and
◦ personal experiences
 (such as effect of pain, stiffness and fatigue, finding suitable
exercise, perceived exercise benefits, and quality of sleep).

External factors include
◦ social environment
 (including family support, physical therapists' care, physicians'
encouragement, training partners, and socioeconomic status)
◦ physical environment
 (such as weather, availability and accessibility of exercise
facilities and classes, and transportation).
Bennell KL, et al. Best Pract Res Clin Rheumatol. 2014 Feb;28(1):93-117.
[1] Bennell KL, et al. Best Pract Res Clin Rheumatol. 2014 Feb;28(1):93-117.
[2] Petursdottir et al., 2010. [3] Bennell 2013
Adapted from Linton SJ, et al. Phys Ther. 2011.
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Firstly, intervention activity does not need to be time
consuming nor senior-led.
Secondly, patients need to be active participants in
decision making, helping to develop these plans and
strategies to overcome barriers and monitoring.
Thirdly, feedback was critical and had to be specific.
Finally, to ensure maintenance, intervention activity
should be integrated into community opportunities
wherever possible.
Estabrooks PA, et al. JAMA. 2003.
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The sequence of physical activity promotion was the five 'A's':

1. Assess the current level of physical activity, abilities, beliefs
and knowledge

2. Advise on health risks, benefits of change, appropriate
activity, its quantity and intensity

3. Agree a personal developmental plan with appropriate goals
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4. Assist in identifying barriers and strategies to address these.
Also to link in with community opportunities for activity and
social support
5. Arrange follow-ups by telephone calls or letter.
Estabrooks PA, et al. JAMA. 2003.
Quinn E. Motivation and goal setting for exercise. 2004.
http://sportsmedicine.about.com/od/sportspsychology/a/motivation.
htm (accessed 20 March 2011)
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Marks and Allegrante conducted a review of the literature
on factors associated with exercise adherence of patients
with chronic OA.
Unfortunately, almost all studies reviewed on the topic of
exercise adherence among people with OA were short
term and did not use validated measures of adherence.
Poor adherence was the most compelling reason for the
declining impact of the benefits of exercise over time.
The authors concluded that interventions to enhance selfefficacy, social support, and skills in long-term monitoring
of progress are necessary to foster exercise adherence
among patients with OA.
[1]Sisto SA, et al. Am J Phys Med Rehab. 2006;
[2] Marks R, Allegrante JP. J Aging Phys Act 2005;13:434–60
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1. International Physical Activity
Questionnaire (IPAQ)
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2. UCLA Activity Scale
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3. Lower Extremity Activity Scale
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Discussed definition of Physical Activity
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Exercise recommendations: that exercise is safe in
chronic pain
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Emphasize the role of patient education and professional
guidance to increase exercise adherence
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Applied patient-centered clinical approaches in identifying
these factors and with potential rehabilitative
interventions.
Asserted that physical activity prescription is a treatment
option and important component of a healthy lifestyle.

Contact Info:
Armando Miciano, M.D.
Nevada Rehabilitation Institute, Las Vegas NV
www.springmountainrehab.com
702-869-4401
[email protected]