Theory and rationale for surface EMG-assisted stretching as an adjunct to chronic musculoskeletal pain rehabilitation

A clinical protocol is reviewed, which utilizes supportive intervention, education, and surface EMG biofeedback to facilitate movement and to maximize effective stretching with chronic musculoskeletal pain patients. Support for this clinical protocol is provided with an overview of the physiological basis of stretching, surface EMG patterns associated with stretching, and the effects of pain and emotional factors on stretching and movement inhibition.     

Effects of twelve-month strength training subsequent to twelve-month stretching exercise in treatment of chronic neck pain

Previously, in a randomized study, we showed that women with chronic neck pain were able to perform intensive training for neck and shoulder muscles and that the increase in strength was accompanied by a reduction in pain and disability. The changes were significantly greater in the training groups compared with controls. The aim of the present study was to evaluate whether the controls would achieve similar results. Thus, 59 women in the control group initiated high-intensity strength training. Maximal isometric neck strength increased by 44% in both flexion and rotation and 27% in extension at the 2-year follow-up. Statistically and also clinically significant decreases in neck pain and disability indices occurred. Stretching and aerobic exercising during the first follow-up year produced only minor changes in both subjective and functional measures. Adding progressive strength training for the second year led to a significant improvement in neck strength and also to a considerable decrease in the pain and disability scores. Thus, to achieve effective rehabilitation in cases of chronic neck pain, a combination of strength training and stretching exercises are recommended.     

Influence of water exercise and land stretching on salivary cortisol concentrations and anxiety in chronic low back pain patients

Land stretching exercises are common exercise therapy for low back pain (LBP) patients. However, recently, water exercise became a popular rehabilitation for LBP patients, and many studies have reported the physical benefits of water exercise. This study compared the psychological and endocrinological effects of water exercise and land stretching by measuring salivary cortisol concentration and anxiety in chronic LBP patients. Seven volunteers (4 female and 3 male, mean age: 61.9 +/- 11.8 yrs) who suffered from chronic LBP (pain duration: 4.5 +/- 1.3 yrs) participated in the sessions of water exercise and land stretching programs (90 minutes) on different days. The land stretching program consisted mainly of stretching, and the water exercise program contained not only stretching, but also walking, jogging, muscle strengthening, swimming and relaxation. After both exercise programs, the subjective pain scores of the patients showed a significant decrease. Salivary cortisol concentrations were also significantly decreased during pre- to post-90 minute water exercise. (P < 0.05). With land stretching, salivary cortisol concentrations also decreased significantly (P < 0.05). State anxiety decreased significantly (P < 0.05) after both water exercise and land stretching compared with pre-exercise scores (P < 0.05), though no significant changes were found in the patients' trait anxiety scores. No significant correlation was found between salivary cortisol concentrations and state anxiety with water exercise and land stretching. The findings of the present study suggested both exercises showed similar tendencies, and had decreased salivary cortisol level and state anxiety.     

Low-Educated Women with Chronic Pain Were Less Often Selected to Multidisciplinary Rehabilitation Programs

Background

There is a lack of research about a potential education-related bias in assessment of patients with chronic pain. The aim of this study was to analyze whether low-educated men and women with chronic pain were less often selected to multidisciplinary rehabilitation than those with high education.

Methods

The population consisted of consecutive patients (n = 595 women, 266 men) referred during a three-year period from mainly primary health care centers for a multidisciplinary team assessment at a pain rehabilitation clinic at a university hospital in Northern Sweden. Patient data were collected from the Swedish Quality Registry for Pain Rehabilitation National Pain Register. The outcome variable was being selected by the multidisciplinary team assessment to a multidisciplinary rehabilitation program. The independent variables were: sex, age, born outside Sweden, education, pain severity as well as the hospital, anxiety and depression scale (HADS).

Results

Low-educated women were less often selected to multidisciplinary rehabilitation programs than high-educated women (OR 0.55, CI 0.30–0.98), even after control for age, being born outside Sweden, pain intensity and HADS. No significant findings were found when comparing the results between high- and low-educated men.

Conclusion

Our findings can be interpreted as possible discrimination against low-educated women with chronic pain in hospital referrals to pain rehabilitation. There is a need for more gender-theoretical research emphasizing the importance of taking several power dimensions into account when analyzing possible bias in health care.     

慢性疼痛治疗的研究进展

慢性疼痛是临床常见的病症,给患者和社会都带来极大的负担。其发病机制受生理、心理和社会等多种因素的影响较为复杂,因此,慢性疼痛的治疗一直是临床上的一大难题。单一的治疗手段往往不能取得令人满意的效果,目前常采用多手段联合的方式来治疗慢性疼痛,常见的包括药物治疗、心理治疗、介入治疗以及自我管理等。针对不同类型的慢性疼痛甚至同一类型的不同病人其治疗方案也不尽相同,近年来兴起的跨学科康复计划为慢性疼痛的治疗指明了方向。本文就慢性疼痛治疗的研究进展进行了综述,以期为临床实践提供更多参考和理论依据。     

Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilisation trial

Objectives To assess the clinical effectiveness of surgical stabilisation (spinal fusion) compared with intensive rehabilitation for patients with chronic low back pain.Design Multicentre randomised controlled trial.Setting 15 secondary care orthopaedic and rehabilitation centres across the United Kingdom.Participants 349 participants aged 18-55 with chronic low back pain of at least one year''s duration who were considered candidates for spinal fusion.Intervention Lumbar spine fusion or an intensive rehabilitation programme based on principles of cognitive behaviour therapy.Main outcome measure The primary outcomes were the Oswestry disability index and the shuttle walking test measured at baseline and two years after randomisation. The SF-36 instrument was used as a secondary outcome measure.Results 176 participants were assigned to surgery and 173 to rehabilitation. 284 (81%) provided follow-up data at 24 months. The mean Oswestry disability index changed favourably from 46.5 (SD 14.6) to 34.0 (SD 21.1) in the surgery group and from 44.8 (SD14.8) to 36.1 (SD 20.6) in the rehabilitation group. The estimated mean difference between the groups was –4.1 (95% confidence interval –8.1 to –0.1, P = 0.045) in favour of surgery. No significant differences between the treatment groups were observed in the shuttle walking test or any of the other outcome measures.Conclusions Both groups reported reductions in disability during two years of follow-up, possibly unrelated to the interventions. The statistical difference between treatment groups in one of the two primary outcome measures was marginal and only just reached the predefined minimal clinical difference, and the potential risk and additional cost of surgery also need to be considered. No clear evidence emerged that primary spinal fusion surgery was any more beneficial than intensive rehabilitation.     

End-to-end military pain management

The last three years have seen significant changes in the Defence Medical Services approach to trauma pain management. This article seeks to outline these changes that have occurred at every level of the casualty's journey along the chain of evacuation, from the point of injury to rehabilitation and either continued employment in the Services or to medical discharge. Particular attention is paid to the evidence for the interventions used for both acute pain and chronic pain management. Also highlighted are possible differences in pain management techniques between civilian and military casualties.     

Model-based prediction of the individual training intensity for the lower back muscles with application to physical rehabilitation

The individual adjustment of the training intensity during physical training of the lower back muscles plays a crucial role in strength rehabilitation of chronic low back pain patients. Since an one-repetition maximum test may increase injury risk and a common N-repetition maximum test with several trials is stressful for the patient and in many cases inaccurate, in this paper a model-based approach is proposed for predicting the N-repetition maximum. The individual training intensity represented by the N-repetition maximum is predicted by means of a biomechanical model together with fatigue parameters obtained from an isometric muscle contraction measurement.     

Spinal deformities rehabilitation - state of the art review

Background

Medical rehabilitation aims at an improvement in function, capacity and participation. For the rehabilitation of spinal deformities, the goal is to maintain function and prevent secondary symptoms in the short- and long-term. In patients with scoliosis, predictable signs and symptoms include pain and reduced pulmonary function.

Materials and methods

A Pub Med review was completed in order to reveal substantial evidence for inpatient rehabilitation as performed in Germany. No evidence has been found in general to support claims for actual inpatient rehabilitation programmes as used today. Nevertheless, as there is some evidence that inpatient rehabilitation may be beneficial to patients with spinal deformities complicated by certain additional conditions, the body of evidence there is for conservative treatment of spinal deformities has been reviewed in order to allow suggestions for outpatient conservative treatment and inpatient rehabilitation.

Discussion

Today, for both children and adolescents, we are able to offer intensive rehabilitation programmes lasting three to five days, which enable the patients to acquire the skills necessary to prevent postures fostering scoliosis in everyday life without missing too much of school teaching subjects at home. The secondary functional impairments adult scoliosis patients might have, as in the opinion of the author, still today require the time of 3-4 weeks in the clinical in-patient setting. Time to address psychosocial as well as somatic limitations, namely chronic pains and cardiorespiratory malfunction is needed to preserve the patients working capability in the long-term.

Conclusion

Outpatient treatment/rehabilitation is sufficient for adolescents with spinal deformities. Inpatient rehabilitation is recommended for patients with spinal deformities and pain or severe restrictive ventilation disorder.     

Pain centers--organization and outcome.

Pain treatment centers have evolved at a rapid rate, but they differ in their complexity and services provided. Patients, as well as primary care physicians, have difficulty in identifying the appropriate center for a specific problem. Guidelines for pain centers have recently been proposed by the International Association for the Study of Pain, along with an attempt at their accreditation. Outcome studies from pain centers have proliferated, with a wide range of treatment programs being reported. Comprehensive multidisciplinary pain centers using the rehabilitation medicine approach are effective in decreasing disability and increasing the productivity of patients with chronic, disabling pain.     

Effects of ankle position during static stretching for the hamstrings on the decrease in passive stiffness

Static stretching is frequently performed to improve flexibility of the hamstrings, although the ankle position during hamstring stretching has not been fully investigated. We investigated the effects of ankle position during hamstring stretching on the decrease in passive stiffness. Fourteen healthy men performed static stretching for the hamstrings with the ankle dorsiflexed and plantar-flexed in a randomized order on different days. The hip was passively flexed to the maximum angle which could be tolerated without stretch pain with the knee fully extended; this was maintained for 5 min, with 1-min stretching performed in 5 sessions. Final angles and passive stiffness were measured before and after stretching. The final angle was defined as that formed by the tibia and horizontal plane when the knee was passively extended from hip and knee angles at 90° flexion to the maximum extension angle which could be tolerated without stretch pain. Passive stiffness was determined by the slope of torque–angle curve during the measurement of the final angle. The final angle significantly increased after stretching with the ankle dorsiflexed and plantar-flexed, whereas passive stiffness significantly decreased only after stretching with the ankle planter-flexed. The results suggest that passive stiffness decreases after stretching with the ankle planter-flexed but not after stretching with the ankle dorsiflexed, although the range of joint motion increases regardless of the ankle position during 5-min stretching for the hamstrings. These results indicate that static stretching should be performed with the ankle plantar-flexed when aiming to decrease passive stiffness of the hamstrings.     

Illness behavior and dysfunction: review of concepts and application to chronic pain

The purpose of this presentation is to review the elements that comprise the concept of illness behavior including elaboration of a more formal theoretical and operational model for illness behavior and then discuss the application of the illness behavior model to chronic pain, especially chronic orofacial pain. The model of illness behavior presented emphasizes four critical areas of conceptual interest, namely, (1) monitoring of somatic signals; (2) cognitive processes whereby bodily symptoms are interpreted; (3) attaching meaning to symptoms in the context of emotional state and concurrent environmental events; and (4) the ethnocultural influences that pervade meaning and shape coping responses. Our model of illness behavior was generalized from a closely related model developed to guide research when the specific illness behavior of interest was dysfunctional chronic pain behavior. We also include a time dimension in our chronic pain model. Dysfunctional chronic pain is understood to be the most important undesirable consequence associated with suffering a persistent pain condition. Dysfunctional chronic pain is a subset of illness behaviors inconsistent with medically documented findings, while the complaints of pain are prominent. Changes occur in emotional status, most typically reported as mood and behavioral changes associated with depression, such as demoralization, helplessness, and social isolation. Excesses in medical care, hospitalizations for surgery, and abuse of medications are further characteristics of dysfunctional chronic pain.     

Worker rehabilitation programs. Separating fact from fiction.

A few worker rehabilitation programs have had outstanding success in improving ability to function for persons with occupational back pain. Local programs must show that they have similar success. Because the definitions of terms such as "back school," "work hardening," and "functional restoration" are blurred at a local level, the choice of a program for an individual patient must depend primarily on the program''s demonstrated success rate with similar patients. The chances of returning to work decrease as a function of time after injury. Therefore, referring physicians, insurers, and employers must be provided with information regarding results in terms of acute (0 to 6 weeks), subacute (7 to 12 weeks), and chronic (more than 12 weeks) back pain. Other important variables include selection criteria, program cost, and dropout rate. We advocate standardized reporting of such data for all worker rehabilitation programs. A model "report to consumers," described here, is a minimal obligation. The validity of a number of important internal quality assurance issues is uncertain. Ethical and legal pressures must be recognized.     

Rehabilitation in paraneoplastic stiff-person syndrome – Case Report

We aimed to share our rehabilitation experience in a patient diagnosed with paraneoplastic Stiff-person syndrome(SPS). A 45-year-old female patient was admitted to neurology with the complaint of widespread painful contractions. EMG was evaluated in favor of SPS. Amphiphysin-antibody was +++ in CSF. Patients’ treatment was arranged and transferred to rehabilitation inpatient-clinic.The patient was included in the rehabilitation program of range of motion,stretching,strengthening, posture&walking exercises, balance&coordination exercises, 5 days/week for 3 months. The patient was screened for breast cancer, diagnosed with invasive breast carcinoma and underwent mastectomy. With the rehabilitation, the patient was mobilized first in the parallel-bar then with tripod-cane in the following months. Significant improvements were found in functional status and quality of life with control of spasticity and mobilization. Although the primary treatment of paraneoplastic SPS is cancer treatment, significant gains have been achieved with rehabilitation. It is necessary to raise awareness of the importance of rehabilitation to physicians who diagnose the disease.     

Do weather changes influence pain levels in women with fibromyalgia,and can psychosocial variables moderate these influences?

The aim of this study was to examine the association between fibromyalgia pain and weather, and to investigate whether psychosocial factors influence this relationship. Women with chronic widespread pain/fibromyalgia (N?=?50) enrolled in a larger study, were recruited from a 4-week inpatient rehabilitation program in Norway ( 2009–2010), and reported their pain and psychological factors up to three times per day (morning, afternoon, evening) for 5 weeks. These ratings were then related to the official local weather parameters. Barometric pressure recorded simultaneously impacted pain significantly while temperature, relative humidity, and solar flux did not. No psychological variables influenced the weather–pain interaction. No weather parameter predicted change in the subsequent pain measures. The magnitude of the inverse association between pain and barometric pressure was very small, and none of the psychological variables studied influenced the association between pain and barometric pressure. All in all, the evidence for a strong weather–pain association in fibromyalgia seems limited at best.     

Static mechanical allodynia (SMA) is a paradoxical painful hypo-aesthesia: observations derived from neuropathic pain patients treated with somatosensory rehabilitation

The present study aimed at investigating the time span it takes to remove a static mechanical allodynia (SMA) in humans suffering from chronic peripheral neuropathic pain. Forty-three subjects were included in the study and, during somatosensory rehabilitation, their SMA territory was precisely mapped. They then underwent distant vibrotactile counter stimulation (DVCS) treatment. It was observed that, with DVCS, SMA disappeared in all cases, and was transformed into an underlying hypoaesthesia. It was found that the "tenderness to touch" symptom (which is SMA) was located in the same territory as the underlying hypoaesthesia, which was located on a part of the cutaneous territory of a partially damaged nerve. These results demonstrate that treating patients suffering from neuropathic pain with DVCS revealed a skin territory of denervation that was previously masked by SMA. Thus, SMA can be considered as a paradoxical painful hypoaesthesia. Furthermore, mapping SMA is a valuable source of information for our understanding of abnormal sensory processing in neuropathic pain patients. We conclude that the mapping of the zone of hypersensitivity on the skin in humans suffering from chronic peripheral neuropathic pain improves diagnosis. The mapping of the zone of hypersensitivity is a tool to presume which branch of the peripheral nerve is damaged. The location of the axonal lesions is at the periphery, while the mechanism of pain sensitization is probably central and referred peripherally to the skin by a painful hypoaesthesia.     

Dogs as an Adjunct to Therapy: Effects of Animal-Assisted Therapy on Rehabilitation Following Spinal Cord Injury

ABSTRACT

Approximately 17,000 new cases of spinal cord injury (SCI) are reported annually in the United States. Rehabilitation from SCI involves substantial mental, emotional, and physical challenges. Using a randomized controlled trial design, we assessed the efficacy of animal-assisted therapy (AAT) as an aid in rehabilitation following a SCI. We hypothesized that patients with SCI undergoing rehabilitation occupational therapy with AAT would demonstrate greater positive shifts in mood and outlook, reduced pain, and reduced stress compared with patients exposed to the same rehabilitation therapy but without AAT. Over four sessions of occupational therapy, 31 patients completed standard rehabilitation activities (control group) or rehabilitation activities integrating an animal therapy team (treatment group). Patients completed the Positive and Negative Affect Schedule (PANAS) and Numerical Rating Scale (NRS) at each session, had salivary cortisol sampled at the second session, and completed the Brief Pain Inventory at study baseline and exit. Data were analyzed using repeated measures ANOVAs and t-tests. The results revealed a small but significant effect of animal-assisted therapy on self-reported negative affect. Findings for group differences on positive affect, stress, and pain unpleasantness were null, although non-significant findings were in the hypothesized direction for several variables and yielded small effect sizes. Continued research is needed on the influence of AAT on mood improvement, stress reduction, and ultimately improved physical health outcomes during rehabilitation after SCI.     

The sports medicine approach to occupational low back pain.

Absenteeism caused by low back pain costs industry millions of dollars per year. Innovative approaches for the prevention and treatment of low back pain in workers are mandatory. The sports medicine approach for aggressive rehabilitation offers a possible solution.     

Th1-Th17 Cells Contribute to the Development of Uropathogenic Escherichia coli-Induced Chronic Pelvic Pain

The etiology of chronic prostatitis/chronic pelvic pain syndrome in men is unknown but may involve microbes and autoimmune mechanisms. We developed an infection model of chronic pelvic pain in NOD/ShiLtJ (NOD) mice with a clinical Escherichia coli isolate (CP-1) from a patient with chronic pelvic pain. We investigated pain mechanisms in NOD mice and compared it to C57BL/6 (B6) mice, a strain resistant to CP-1-induced pain. Adoptive transfer of CD4+ T cells, but not serum, from CP-1-infected NOD mice was sufficient to induce chronic pelvic pain. CD4+ T cells in CP-1-infected NOD mice expressed IFN-γ and IL-17A but not IL-4, consistent with a Th1/Th17 immune signature. Adoptive transfer of ex-vivo expanded IFN-γ or IL-17A-expressing cells was sufficient to induce pelvic pain in naïve NOD recipients. Pelvic pain was not abolished in NOD-IFN-γ-KO mice but was associated with an enhanced IL-17A immune response to CP1 infection. These findings demonstrate a novel role for Th1 and Th17-mediated adaptive immune mechanisms in chronic pelvic pain.     

Impaired orofacial motor functions on chronic temporomandibular disorders

Because temporomandibular disorders (TMDs) rehabilitation continues to be a challenge, a more comprehensive picture of the orofacial functions in patients with chronic pain is required. This study assessed the orofacial functions, including surface electromyography (EMG) of dynamic rhythmic activities, in patients with moderate-severe signs and symptoms of chronic TMD. It was hypothesized that orofacial motor control differs between patients with moderate-severe chronic TMD and healthy subjects. Seventy-six subjects (46 with TMD and 30 control) answered questionnaires of severity of TMD and chewing difficulties. Orofacial functions and EMG during chewing were assessed.Standardized EMG indices were obtained by quantitative analysis of the differential EMG signals of the paired masseter and temporal muscles, and used to describe muscular action during chewing.TMD patients showed significant greater difficulty in chewing; worse orofacial scores; longer time for free mastication; a less accurate recruitment of the muscles on the working and balancing sides, reduced symmetrical mastication index (SMI) and increased standardized activity during EMG test than healthy subjects. SMI, TMD severity and orofacial myofunctional scores were correlated (P < 0.01). Impaired orofacial functions and increased activity of the muscles of balancing sides during unilateral chewing characterized the altered orofacial motor control in patients with moderate-severe chronic TMD. Implications for rehabilitation are discussed.