Influence of a proprioceptive training on functional ankle stability in young speed skaters - a prospective randomised study.

The influence of a 12-week-proprioceptive training on functional ankle stability was investigated in young speed skaters. Twenty-eight speed skaters were randomly divided into an intervention (n = 14) and into a control group (n = 14). A 15-min circle training was performed 5 times per week over a 12-week period. Measurements were taken prior to the training, after 6 and 12 weeks of training. Kinaesthesia was evaluated with the Isomed2000 in all movements of the ankle joint. Dynamic balance was tested with the Biodex Stability System at the stable level 8 and at the unstable level 2, measuring the overall stability index, the anterior/posterior and the medial/lateral scores. Static single-leg stance was evaluated using the Kistler force platform. Kinaesthesia of the intervention group improved significantly for plantarflexion of the right foot (P = 0.001) after 12 weeks. Dynamic balance showed significant differences in the intervention group after 12 weeks in comparison with the first measurement for each foot in the overall stability index, the anterior/posterior and the medial/lateral scores (P ≤ 0.017, respectively) at the unstable level 2. Functional ankle stability improved in terms of dynamic balance after 12 weeks of proprioceptive training. Therefore, inclusion of proprioceptive exercises in the daily training programme is recommended for young speed skaters.

An epidemiological investigation of training and injury patterns in triathletes.

Associated with the trend towards increased health consciousness and fitness, triathlon has established itself as a sport for masses. The goals of this study were to evaluate injury risk factors of non-professional triathletes and to compare prospective and retrospective evaluation methods. Using an online survey, 212 triathletes retrospectively answered a questionnaire about their training habits and injuries during the past 12 months. Forty-nine of these triathletes participated in a 12-month prospective trial. Injuries were classified with regard to the anatomical location, type of injury, incidence and associated risk factors. Most injuries occurred during running (50%) followed by cycling (43%) and swimming (7%). Fifty-four per cent (retrospective) and 22% (prospective) of the injuries were contusions and abrasions, 38% (retrospective) and 46% (prospective) were ligament and capsular injuries, 7% (retrospective) and 32% (prospective) were muscle and tendon injuries and 1% (retrospective) and 0% (prospective) were fractures. The incidence of an injury per 1000 training hours was 0.69 (retrospective) and 1.39 (prospective) during training and 9.24 (retrospective) and 18.45 (prospective) during competition. The main risk factor for injury in non-professional triathlon is participation in a competitive triathlon event. A retrospective design may underestimate the rate of overuse injuries.

Prehabilitative high-intensity interval training and resistance exercise in patients prior allogeneic stem cell transplantation.

Physical capacity prior allogeneic stem cell transplantation (allo-HCT) has been shown as a relevant prognostic factor for survival after transplant. Therefore, we evaluated feasibility and preliminary efficacy of a high-intensity interval training (HIIT) and moderate to high-intensity resistance exercise (RE) to increase physical capacity in patient's prior allo-HCT. In this multicentre single arm pilot study, a supervised exercise program was performed twice weekly for 4-12 weeks prior allo-HCT, depending on the individual time remaining. Outcomes were feasibility (recruitment, adherence, safety), physical capacity (cardiorespiratory fitness [VO2peak], muscle strength) and patient reported outcomes (physical functioning, fatigue). Thirty patients were intended, 16 could be included, and 14 completed post intervention assessment (75% male, 55 ± 11 years). The study was stopped early due to a low recruitment rate. Nine patients (64%) reached the initial minimum planned number of eight exercise sessions. Individual adherence was high with 92% for HIIT and 85% for RE. 87% of all performed exercise sessions were completed without complaints and VO2peak increased significantly from 20.4 to 23.4 ml/kg/min. The low recruitment rate suggests that initiation of the intervention concept immediately before allo-HCT is feasible only in a small number of patients. In particular, the timeframe directly prior allo-HCT seems too short for exercise interventions, although the exercise program was designed to improve outcomes in a very short time frame. HIIT and RE were feasible, effective and well accepted by the included patients.

Dose-response relationship and effect modifier of stabilisation exercises in nonspecific low back pain: a project-wide individual patient data re-analysis on 1483 intervention participants.

ABSTRACT: This planned MiSpEx-Network reanalysis was designed to derive a dose-response relationship under consideration of further effect modifiers in exercises on low back pain. One thousand four hundred eighty three intervention participants with low back pain (mean age, 40.9 years [SD 14 years]) performed stabilisation exercises (3 weeks supervised, 9 weeks self-administered). Patients reported pain intensity, disability, and disability days at baseline, 3 weeks, 12 weeks, and 6 months post randomisation. Exercise characteristics and effect modifiers were prospectively monitored. Beyond the comparison to the results of the control group, linear mixed models were calculated to determine a dose-response relationship. The interventions led to small but significantly larger symptom reductions than in the control group at each measurement. Longer durations of the intervention led to larger symptom reductions. Higher exercise frequencies were associated with a decrease in pain intensity: to train once more per week led to a mean decrease of 0.93 points in pain intensity [95% CI = -1.54 to -0.32]. Disability days were also impacted (estimate = -0.07 [-0.14 to 0.00]), but disability was not (-0.09 [-0.67 to 0.48]). Adding perturbation was superior to adding stretching or a behavioural module. The relationships were robust when additional effect modifiers were considered and against the control group' effects. The odds ratio for a clinically important effect with higher exercise frequencies decreased at 3 weeks (OR = 0.71 [0.618-0.813] for >2.5*week -1 ) and increased at 12 weeks (1.13 [1.006-1.270], >1.5*week -1 ). Using longer intervention durations, adding a perturbation component to the stabilisation trainings and using higher frequencies (up to a certain point) may lead to an even more beneficial response on exercise in patients with low back pain. Developing strategies to maintain a training frequency of at least 2 times per week may be relevant in stabilisation exercises to treat low back pain.

Effectiveness of digital primary prevention interventions targeting physical activity, motor skills and nutrition in children aged 3-10 years in the setting of day care and primary school: protocol for a systematic review.

INTRODUCTION: Available evidence points to an association of increased screen time and the availability of digital tools during childhood with negative health outcomes in later life. For many years, public discourse focused on restricting access and use of digital technologies below certain ages. However, little is known about the specific benefit of a responsible use of digital primary prevention in the setting of (early) childhood education. The objective of this evidence synthesis is to investigate the effectiveness of digital primary prevention interventions targeting physical activity, motor skills and/or nutrition in children aged 3-10 years in day-care facilities and (pre-) schools. METHODS AND ANALYSIS: We present the rationale and methodological steps of a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses procedures. Automated searches will be conducted by applying a pretested search strategy to the databases MEDLINE/PubMed, EMBASE and PsycInfo to identify relevant interventional (randomised controlled trials, controlled trials, crossover trials and pilot and feasibility) and observational (case-control, cohort) studies in English or German, with no date restrictions. The overall search will be complemented by backward, forward and additional hand searches. Two researchers will independently screen titles/abstracts and assess full texts by applying predefined eligibility criteria. Data extraction will be conducted by using a pretested data extraction sheet. The assessment of methodological quality will be performed independently by two review authors using the Critical Appraisals Skills Programme relevant to the study design applied in the given study. Additionally, qualitative content analysis will be conducted to analyse priorities for future research extracted from the discussion sections and conclusions of included studies. PROSPERO REGISTRATION NUMBER: CRD42020207682.

Psychosocial Moderators and Mediators of Sensorimotor Exercise in Low Back Pain: A Randomized Multicenter Controlled Trial.

The effects of exercise interventions on unspecific chronic low back pain (CLBP) have been investigated in many studies, but the results are inconclusive regarding exercise types, efficiency, and sustainability. This may be because the influence of psychosocial factors on exercise induced adaptation regarding CLBP is neglected. Therefore, this study assessed psychosocial characteristics, which moderate and mediate the effects of sensorimotor exercise on LBP. A single-blind 3-arm multicenter randomized controlled trial was conducted for 12-weeks. Three exercise groups, sensorimotor exercise (SMT), sensorimotor and behavioral training (SMT-BT), and regular routines (CG) were randomly assigned to 662 volunteers. Primary outcomes (pain intensity and disability) and psychosocial characteristics were assessed at baseline (M1) and follow-up (3/6/12/24 weeks, M2-M5). Multiple regression models were used to analyze whether psychosocial characteristics are moderators of the relationship between exercise and pain, meaning that psychosocial factors and exercise interact. Causal mediation analysis were conducted to analyze, whether psychosocial characteristics mediate the exercise effect on pain. A total of 453 participants with intermittent pain (mean age = 39.5 ± 12.2 years, f = 62%) completed the training. It was shown, that depressive symptomatology (at M4, M5), vital exhaustion (at M4), and perceived social support (at M5) are significant moderators of the relationship between exercise and the reduction of pain intensity. Further depressive mood (at M4), social-satisfaction (at M4), and anxiety (at M5 SMT) significantly moderate the exercise effect on pain disability. The amount of moderation was of clinical relevance. In contrast, there were no psychosocial variables which mediated exercise effects on pain. In conclusion it was shown, that psychosocial variables can be moderators in the relationship between sensorimotor exercise induced adaptation on CLBP which may explain conflicting results in the past regarding the merit of exercise interventions in CLBP. Results suggest further an early identification of psychosocial risk factors by diagnostic tools, which may essential support the planning of personalized exercise therapy. Level of Evidence: Level I. Clinical Trial Registration: DRKS00004977, LOE: I, MiSpEx: grant-number: 080102A/11-14. https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00004977.

Which Functional Outcomes Can be Measured in Low Back Pain Trials and Therapies?: A Prospective 2-Year Factor-, Cluster-, and Reliability-Multicenter Analysis on 42 Variables in 1049 Individuals.

STUDY DESIGN: Prospective 2-year factor-, cluster-, and reliability-multicenter analysis. OBJECTIVE: To provide evidence on the uniqueness and usefulness of a set of potential relevant functional outcomes. SUMMARY OF BACKGROUND DATA: A very high number of functional outcomes that can be utilized as variables in low back pain (LBP) trials exists. METHODS: Participants (n = 1049) with and without current LBP were included. At 7 visits (baseline, 4 wk, 3 mo, 6 mo, 9 mo, 1 yr, and 2 yr), 42 different functional outcomes were assessed. Two exploratory factor analyses (for baseline-values and for changes scores to 3 mo post-baseline) were calculated (maximum likelihood extraction, varimax factor rotation). The strongest factor-loading outcomes were selected for the following hierarchical cluster analyses (average linkage, Euclidean distance measure). For each cluster, time point, and outcome, reliability analyses were subsequently calculated using intraclass correlation coefficients, standard error of measurements and coefficients of variation. RESULTS: The factor analysis for the cross-sectional values revealed 9 factors with a cumulative variance explanation of 61.7% and 13 unique ones. The change-score factor analysis revealed nine factors with a total variance explanation of 61.8%, seven outcomes were unique. Ten outcomes were important for both cross-sectional and change-score analyses, 11 were most valuable for cross-sectional and four for the change scores. Patients with pain grades 1 to 3 show comparable patterns (cluster 2). Grade 0 (cluster 1) and grade 4 (cluster 3) are unique and cannot be cumulated with other grades. Most biomechanical outcomes were highly reliable and display low measurement errors. CONCLUSION: We found 25 potentially meaningful functional outcomes in the context of objective functional measurements (such as trunk range of motion, dynamic and static balance, strength, and muscle fatigue resistance) and body characteristics. The present framework may help to select appropriate functional outcomes and rate effects beyond the known core set of outcomes.Level of Evidence: 1.

RENaBack: low back pain patients in rehabilitation-study protocol for a multicenter, randomized controlled trial.

BACKGROUND: Millions of people in Germany suffer from chronic pain, in which course and intensity are multifactorial. Besides physical injuries, certain psychosocial risk factors are involved in the disease process. The national health care guidelines for the diagnosis and treatment of non-specific low back pain recommend the screening of psychosocial risk factors as early as possible, to be able to adapt the therapy to patient needs (e.g., unimodal or multimodal). However, such a procedure has been difficult to implement in practice and has not yet been integrated into the rehabilitation care structures across the country. METHODS: The aim of this study is to implement an individualized therapy and aftercare program within the rehabilitation offer of the German Pension Insurance in the area of orthopedics and to examine its success and sustainability in comparison to the previous standard aftercare program. The study is a multicenter randomized controlled trial including 1204 patients from six orthopedic rehabilitation clinics. A 2:1 allocation ratio to intervention (individualized and home-based rehabilitation aftercare) versus the control group (regular outpatient rehabilitation aftercare) is set. Upon admission to the rehabilitation clinic, participants in the intervention group will be screened according to their psychosocial risk profile. They could then receive either unimodal or multimodal, together with an individualized training program. The program is instructed in the clinic (approximately 3 weeks) and will continue independently at home afterwards for 3 months. The success of the program is examined by means of a total of four surveys. The co-primary outcomes are the Characteristic Pain Intensity and Disability Score assessed by the German version of the Chronic Pain Grade questionnaire (CPG). DISCUSSION: An improvement in terms of pain, work ability, patient compliance, and acceptance in our intervention program compared to the standard aftercare is expected. The study contributes to provide individualized care also to patients living far away from clinical centers. TRIAL REGISTRATION: DRKS, DRKS00020373 . Registered on 15 April 2020.

Stress and Self-Efficacy as Long-Term Predictors for Chronic Low Back Pain: A Prospective Longitudinal Study.

PURPOSE: Psychosocial variables are known risk factors for the development and chronification of low back pain (LBP). Psychosocial stress is one of these risk factors. Therefore, this study aims to identify the most important types of stress predicting LBP. Self-efficacy was included as a potential protective factor related to both, stress and pain. PARTICIPANTS AND METHODS: This prospective observational study assessed n = 1071 subjects with low back pain over 2 years. Psychosocial stress was evaluated in a broad manner using instruments assessing perceived stress, stress experiences in work and social contexts, vital exhaustion and life-event stress. Further, self-efficacy and pain (characteristic pain intensity and disability) were assessed. Using least absolute shrinkage selection operator regression, important predictors of characteristic pain intensity and pain-related disability at 1-year and 2-years follow-up were analyzed. RESULTS: The final sample for the statistic procedure consisted of 588 subjects (age: 39.2 (±13.4) years; baseline pain intensity: 27.8 (±18.4); disability: 14.3 (±17.9)). In the 1-year follow-up, the stress types "tendency to worry", "social isolation", "work discontent" as well as vital exhaustion and negative life events were identified as risk factors for both pain intensity and pain-related disability. Within the 2-years follow-up, Lasso models identified the stress types "tendency to worry", "social isolation", "social conflicts", and "perceived long-term stress" as potential risk factors for both pain intensity and disability. Furthermore, "self-efficacy" ("internality", "self-concept") and "social externality" play a role in reducing pain-related disability. CONCLUSION: Stress experiences in social and work-related contexts were identified as important risk factors for LBP 1 or 2 years in the future, even in subjects with low initial pain levels. Self-efficacy turned out to be a protective factor for pain development, especially in the long-term follow-up. Results suggest a differentiation of stress types in addressing psychosocial factors in research, prevention and therapy approaches.

Personalized Treatment Suggestions: The Validity and Applicability of the Risk-Prevention-Index Social in Low Back Pain Exercise Treatments.

Background: The back pain screening tool Risk-Prevention-Index Social (RPI-S) identifies the individual psychosocial risk for low back pain chronification and supports the allocation of patients at risk in additional multidisciplinary treatments. The study objectives were to evaluate (1) the prognostic validity of the RPI-S for a 6-month time frame and (2) the clinical benefit of the RPI-S. Methods: In a multicenter single-blind 3-armed randomized controlled trial, n = 660 persons (age 18-65 years) were randomly assigned to a twelve-week uni- or multidisciplinary exercise intervention or control group. Psychosocial risk was assessed by the RPI-S domain social environment (RPI-SSE) and the outcome pain by the Chronic Pain Grade Questionnaire (baseline M1, 12-weeks M4, 24-weeks M5). Prognostic validity was quantified by the root mean squared error (RMSE) within the control group. The clinical benefit of RPI-SSE was calculated by repeated measures ANOVA in intervention groups. Results: A subsample of n = 274 participants (mean = 38.0 years, SD 13.1) was analyzed, of which 30% were classified at risk in their psychosocial profile. The half-year prognostic validity was good (RMSE for disability of 9.04 at M4 and of 9.73 at M5; RMSE for pain intensity of 12.45 at M4 and of 14.49 at M5). People at risk showed significantly stronger reduction in pain disability and intensity at M4/M5, if participating in a multidisciplinary exercise treatment. Subjects at no risk showed a smaller reduction in pain disability in both interventions and no group differences for pain intensity. Regarding disability due to pain, around 41% of the sample would gain an unfitted treatment without the back pain screening. Conclusion: The RPI-SSE prognostic validity demonstrated good applicability and a clinical benefit confirmed by a clear advantage of an individualized treatment possibility.

Motor Control Stabilisation Exercise for Patients with Non-Specific Low Back Pain: A Prospective Meta-Analysis with Multilevel Meta-Regressions on Intervention Effects.

Low-to-moderate quality meta-analytic evidence shows that motor control stabilisation exercise (MCE) is an effective treatment of non-specific low back pain. A possible approach to overcome the weaknesses of traditional meta-analyses would be that of a prospective meta-analyses. The aim of the present analysis was to generate high-quality evidence to support the view that motor control stabilisation exercises (MCE) lead to a reduction in pain intensity and disability in non-specific low back pain patients when compared to a control group. In this prospective meta-analysis and sensitivity multilevel meta-regression within the MiSpEx-Network, 18 randomized controlled study arms were included. Participants with non-specific low back pain were allocated to an intervention (individualized MCE, 12 weeks) or a control group (no additive exercise intervention). From each study site/arm, outcomes at baseline, 3 weeks, 12 weeks, and 6 months were pooled. The outcomes were current pain (NRS or VAS, 11 points scale), characteristic pain intensity, and subjective disability. A random effects meta-analysis model for continuous outcomes to display standardized mean differences between intervention and control was performed, followed by sensitivity multilevel meta-regressions. Overall, 2391 patients were randomized; 1976 (3 weeks, short-term), 1740 (12 weeks, intermediate), and 1560 (6 months, sustainability) participants were included in the meta-analyses. In the short-term, intermediate and sustainability, moderate-to-high quality evidence indicated that MCE has a larger effect on current pain (SMD = -0.15, -0.15, -0.19), pain intensity (SMD = -0.19, -0.26, -0.26) and disability (SMD = -0.15, -0.27, -0.25) compared with no exercise intervention. Low-quality evidence suggested that those patients with comparably intermediate current pain and older patients may profit the most from MCE. Motor control stabilisation exercise is an effective treatment for non-specific low back pain. Sub-clinical intermediate pain and middle-aged patients may profit the most from this intervention.

Sports Therapy Interventions Following Total Hip Replacement.

BACKGROUND: Sport rehabilitation is a reimbursable intervention assisting reintegration and self-help. In this study, we measured the effects of sport rehabilitation on muscle strength around the hip joint at 1 year after surgery, as well as cardiopulmonary endurance performance and stability of stance, in patients who had undergone a first implantation of a total hip endoprosthesis (total hip replacement, THR) as a treatment for osteoarthritis of the hip. METHODS: 160 patients were randomly allotted either to an intervention group with intensive sport rehabilitation for the first year or to a control group. At three time points (baseline, six and twelve months after surgery), measurements were made of muscular strength around the hip joint (with isokinetic dynamometry), stability of stance, and endurance performance. The primary endpoint was the change in strength of the hip extensors, abductors, flexors, and adductors at twelve months after surgery. RESULTS: With respect to the primary endpoint, the results were not significantly better in patients who had received sport rehabilitation than in those who had not. At one year, the patients in the intervention group had less pain as measured by the WOMAC pain score (p = 0.023), though the size of this effect was small (r = 0.27). Health-related quality of life was higher in the intervention group at six months, albeit with a small effect size (p = 0.036, r = 0.25); this was no longer demonstrable at one year. The other parameters studied displayed no significant changes. CONCLUSION: This trial did not demonstrate any significant benefit of sports rehabilitation on functional outcomes in patients who had undergone total hip replacement. Nonetheless, positive trends after the intervention were seen in some parameters. The unexpectedly high dropout rate had been underestimated in the planning phase of the trial; further trials with larger numbers of patients should be performed.

The Feasibility and Effectiveness of a New Practical Multidisciplinary Treatment for Low-Back Pain: A Randomized Controlled Trial.

Low-back pain is a major health problem exacerbated by the fact that most treatments are not suitable for self-management in everyday life. Particularly, interdisciplinary programs consist of intensive therapy lasting several weeks. Additionally, therapy components are rarely coordinated regarding reinforcing effects, which would improve complaints in persons with higher pain. This study assesses the effectiveness of a self-management program, firstly for persons suffering from higher pain and secondly compared to regular routines. Study objectives were treated in a single-blind multicenter controlled trial. A total of n = 439 volunteers (age 18-65 years) were randomly assigned to a twelve-week multidisciplinary sensorimotor training (3-weeks-center- and 9-weeks-homebased) or control group. The primary outcome pain (Chronic-Pain-Grade) as well as mental health were assessed by questionnaires at baseline and follow-up (3/6/12/24 weeks, M2-M5). For statistical analysis, multiple linear regression models were used. N = 291 (age 39.7 ± 12.7 years, female = 61.1%, 77% CPG = 1) completed training (M1/M4/M5), showing a significantly stronger reduction of mental health complaints (anxiety, vital exhaustion) in people with higher than those with lower pain in multidisciplinary treatment. Compared to regular routines, the self-management-multidisciplinary treatment led to a clinically relevant reduction of pain-disability and significant mental health improvements. Low-cost exercise programs may provide enormous relief for therapeutic processes, rehabilitation aftercare, and thus, cost savings for the health system.

Development of a risk stratification and prevention index for stratified care in chronic low back pain. Focus: yellow flags (MiSpEx network).

INTRODUCTION: Chronic low back pain (LBP) is a major cause of disability; early diagnosis and stratification of care remain challenges. OBJECTIVES: This article describes the development of a screening tool for the 1-year prognosis of patients with high chronic LBP risk (risk stratification index) and for treatment allocation according to treatment-modifiable yellow flag indicators (risk prevention indices, RPI-S). METHODS: Screening tools were derived from a multicentre longitudinal study (n = 1071, age >18, intermittent LBP). The greatest prognostic predictors of 4 flag domains ("pain," "distress," "social-environment," "medical care-environment") were determined using least absolute shrinkage and selection operator regression analysis. Internal validity and prognosis error were evaluated after 1-year follow-up. Receiver operating characteristic curves for discrimination (area under the curve) and cutoff values were determined. RESULTS: The risk stratification index identified persons with increased risk of chronic LBP and accurately estimated expected pain intensity and disability on the Pain Grade Questionnaire (0-100 points) up to 1 year later with an average prognosis error of 15 points. In addition, 3-risk classes were discerned with an accuracy of area under the curve = 0.74 (95% confidence interval 0.63-0.85). The RPI-S also distinguished persons with potentially modifiable prognostic indicators from 4 flag domains and stratified allocation to biopsychosocial treatments accordingly. CONCLUSION: The screening tools, developed in compliance with the PROGRESS and TRIPOD statements, revealed good validation and prognostic strength. These tools improve on existing screening tools because of their utility for secondary preventions, incorporation of exercise effect modifiers, exact pain estimations, and personalized allocation to multimodal treatments.