Joseph G. Wasser

Chronic pain management in the obese patient: a focused review of key challenges and potential exercise solutions

In obese persons, general and specific musculoskeletal pain is common. Emerging evidence suggests that obesity modulates pain via several mechanisms such as mechanical loading, inflammation, and psychological status. Pain in obesity contributes to deterioration of physical ability, health-related quality of life, and functional dependence. We present the accumulating evidence showing the interrelationships of mechanical stress, inflammation, and psychological characteristics on pain. While acute exercise may transiently exacerbate pain symptoms, regular participation in exercise can lower pain severity or prevalence. Aerobic exercise, resistance exercise, or multimodal exercise programs (combination of the two types) can reduce joint pain in young and older obese adults in the range of 14%–71.4% depending on the study design and intervention used. While published attrition rates with regular exercise are high (∼50%), adherence to exercise may be enhanced with modification to exercise including the accumulation of several exercise bouts rather than one long session, reducing joint range of motion, and replacing impact with nonimpact activity. This field would benefit from rigorous comparative efficacy studies of exercise intensity, frequency, and mode on specific and general musculoskeletal pain in young and older obese persons.

Prevalence and proposed mechanisms of chronic low back pain in baseball: part i.

ABSTRACT The prevalence of low back pain (LBP) among active baseball players ranges between 3 and 15%. The execution of baseball-specific manoeuvres, such as pitching or batting, may be related to the onset of LBP. These baseball motions are complex and require appropriate activation of the core musculature to produce a well-timed motion with forces minimized at the extremities. The spine, core and back musculature are involved with acceleration and deceleration of rotational motions. This narrative review synopsizes the available evidence of the prevalence of and mechanical factors underlying LBP in the baseball population. Possible mechanical mechanisms linking baseball play to LBP include aberrant motion, improper timing, high lumbar stress due to mechanical loading and lumbopelvic strength deficits. Potential clinical implications relating to these possible mechanical mechanisms will also be highlighted. The state of the evidence suggests that there are deficits in understanding the role of baseball motion and playing history in the development of spine conditions.

Exercise Benefits for Chronic Low Back Pain in Overweight and Obese Individuals.

Overweight and obese individuals with chronic low back pain (LBP) struggle with the combined physical challenges of physical activity and pain interference during daily life; perceived disability increases, pain symptoms worsen, and performance of functional tasks and quality of life (QOL) decline. Consistent participation in exercise programs positively affects several factors including musculoskeletal pain, perceptions of disability due to pain, functional ability, QOL, and body composition. It is not yet clear, however, what differential effects occur among different easily accessible exercise modalities in the overweight‐obese population with chronic LBP. This narrative review synopsizes available randomized and controlled, or controlled and comparative, studies of easily accessible exercise programs on pain severity, QOL, and other outcomes, such as physical function or body composition change, in overweight‐obese persons with chronic LBP. We identified 16 studies (N = 1,351) of various exercise programs (aerobic exercise [AX], resistance exercise [RX], aquatic exercise [AQU], and yoga‐Pilates) that measured efficacy on LBP symptoms, and at least one other outcome such as perceived disability, QOL, physical function, and body composition. RX, AQU, and Pilates exercise programs demonstrated the greatest effects on pain reduction, perceived disability, QOL, and other health components. The highest adherence rate occurred with RX and AQU exercise programs, indicating that these types of programs may provide a greater overall impact on relevant outcomes for overweight‐obese LBP patients.

Functional Screening for Atraumatic Low Back Pain in Baseball Players.

When evaluating a baseball player with atraumatic, insidious low back pain (LBP), consider lumbar truncal muscle dynamic strength deficits as a mechanism underlying the problem. A simple functional screen can be used to determine specific dynamic strength and control weaknesses along the kinematic chain. Muscle weaknesses contribute to poor mechanics and resultant high forces at the lumbar spine (1,7). Abdominal, gluteal, hip girdle, paraspinal, and other muscles work together to provide spinal stability. Four potential screening tests include single-legged squats (A), in-line lunges (B), hip drops (C) and alternating quadruped tests (D) (Fig.) (5,7). Failure to control single-legged motion, dynamic stability and rotational stability may transfer high,

Assessment and rehabilitation of chronic low back pain in baseball: part II

ABSTRACT Repetitive throwing and hitting motions in baseball place mechanical stresses to the lumbar spine which may cause low back pain (LBP). Pain may be due to vertebral stress reactions or insufficiency fractures, intervertebral disc degeneration or intervertebral disc herniation. Untreated chronic conditions have high potential to lead to a more significant injury such as spondylolysis. Chronic LBP increases the risk for missed playing time, early career termination and lower quality of life after retirement. Proper clinical assessment and prevention/rehabilitation of LBP in this population is thus important for performance, play time and overall long-term quality of life. This narrative review synopsizes the available evidence for assessment and rehabilitation of baseball players with LBP, including the structured rehabilitative techniques and programmes which should be administered to affected players. The state of the evidence suggests that there are deficits in identifying the optimal prevention and rehabilitation prescription components for the variety of LBP-inducing injuries in this athletic population.

Mechanisms and Treatments for Shoulder Injuries in Overhead Throwing Athletes.

Shoulder injuries in overhead throwing athletes are very common. Throwing volume and mechanical forces that are placed on the glenohumeral joint and associated soft tissue structures are contributors. Poor biomechanics and weak links in the kinetic chain place this athletic population at increased risk for shoulder injuries. Common biomechanical deficiencies in overhead throwing athletes typically involve poor sequential timing of muscle activity and insufficient coordination also presented in shoulder elevation and other functional tasks. Kinetic chain deficits will lead to injury due to poor transference of energy from the lower extremities to the dominant upper extremity. Correction of these deficits involves effective treatment and prevention strategies. These include core and hip strengthening, balance training, optimize timing of biomechanical phases and events for each throwing movement, and following recommended rest guidelines. This article will synopsize current evidence of sport-specific injury mechanisms, injury treatment, and prevention of the shoulder in overhead throwing athletes.

Exercise intervention for unilateral amputees with low back pain: study protocol for a randomised, controlled trial

BackgroundAtraumatic lower limb amputation is a life-changing event for approximately 185,000 persons in the United States each year. A unilateral amputation is associated with rapid changes to the musculoskeletal system including leg and back muscle atrophy, strength loss, gait asymmetries, differential mechanical joint loading and leg length discrepancies. Even with high-quality medical care and prostheses, amputees still develop secondary musculoskeletal conditions such as chronic low back pain (LBP). Resistance training interventions that focus on core stabilization, lumbar strength and dynamic stability during loading have strong potential to reduce LBP and address amputation-related changes to the musculoskeletal system. Home-based resistance exercise programs may be attractive to patients to minimize travel and financial burdens.Methods/designThis study will be a single-assessor-blinded, pre-post-test randomised controlled trial involving 40 men and women aged 18–60 years with traumatic, unilateral transtibial amputation. Participants will be randomised to a home-based, resistance exercise group (HBRX) or a wait-list control group (CON). The HBRX will consist of 12 weeks of elastic resistance band and bodyweight training to improve core and lumbopelvic strength. Participants will be monitored via Skype or Facetime on a weekly basis. The primary outcome will be pain severity (11-point Numerical Pain Rating Scale; NRSpain). Secondary outcomes will include pain impact on quality of life (Medical Outcomes Short Form 36, Oswestry Disability Index and Roland Morris Disability Questionnaire), kinematics and kinetics of walking gait on an instrumented treadmill, muscle morphology (muscle thickness of multifidus, transversus abdominis, internal oblique), maximal muscle strength of key lumbar and core muscles, and daily step count.DiscussionThe study findings will determine whether a HBRX program can decrease pain severity and positively impact several physiological and mechanical factors that contribute to back pain in unilateral transtibial amputees with chronic LBP. We will determine the relative contribution of the exercise-induced changes in these factors on pain responsiveness in this population.Trial registrationClinicalTrials.gov, ID: NCT03300375. Registered on 2 October 2017.

Poster 36: Motion Features Related to Shoulder Pain in Lacrosse Athletes: Implications for Prehabilitation

Disclosures: Nhung Quach, MD: I Have No Relevant Financial Relationships To Disclose Objective: Elucidate outcomes of individuals with extremely severe post-traumatic amnesia (EsPTA) after Traumatic Brain Injury (TBI) and determine correlating measures. Design: Retrospective cohort study. Setting: Academic Medical Center. Participants: Individuals (N 1⁄4 565) with moderate-severe TBI from the Northern California TBI Model System of Care admitted between 1988 and 2011; followed through 2016. Interventions: Not applicable. Main Outcome Measures: PTA duration, Intracranial Pressure (ICP), Glasgow Coma Scale (GCS), Disability Rating Scale, Functional Independence Measures, and productivity. Results: EsPTA (greater than 28 days) group had higher disability levels, lower functional independence status, and reduced productivity vs. nonEsPTA (less than or equal to 28 days) group. Individuals with GCS less than or equal 8werenearly four timesmore likely to developEsPTA (P<.0001), and were almost at three times higher risk to have intracranial hypertension (ICH) compared with GCS 9-15 group (P < .01). The risk of developing EsPTA increased more than four times for individuals with ICH (ICP greater thanorequal to20mmHg)versus ICPless than20mmHg(P<.0001). Conclusions: GCS correlates with ICH, a factor that may be treated to shorten PTA duration and improve clinical outcomes in persons with moderate to severe TBI. Level of Evidence: Level III

Poster 178 Motion Alterations in High School and Collegiate Male Lacrosse Players with Chronic Mild Low Back Pain: Implications for Rehabilitation

He declined the recommendation. He reported the pain was worse after running or playing sports, specifically with flexion-based maneuvers accompanied by an audible “snap.” Upon assessment, the multiple differential diagnoses that might cause lateral knee pain were excluded. On physical examination, the patient had a prominence of the tibial tuberosity and fibular head, a visible/ audible snapping of the biceps femoris tendon subluxed from the protruding fibular head and correlated to the pain, laxity with varus and valgus stress tests and patellar mobilization test bilaterally, greater on the right. He was unable to perform a full squat. Setting: Outpatient Musculoskeletal clinic. Results: After 2 months PT and continuing HEP, the patient reported his symptoms were improved. He returned to his regular duty as an auto mechanic that requires frequent squatting, and resumed playing sports. Discussion: Bilateral symptomatic snapping in lateral knees is rare throughout the literature. A coexisting of Osgood Schlatter, significant fibular head prominence with biceps femoris tendon subluxation and ligamentous laxity in the same person may be even more rare. The concomitant abnormalities render difficulty pinpointing the exact cause of his symptoms. We theorized and concluded that his pain was most likely caused by a combination of congenital structural malformation, acquired improper movement patterns, and biopsychosocial factors. The rehabilitation treatment played a role and achieved good results. Conclusions: Although rare, symptomatic snapping knee should be considered in patients with lateral knee pain. By increasing awareness of this case, a conservative rehab course with a reasonable length should be implemented prior to considering a surgical intervention. Level of Evidence: Level V

Poster 152 Psychological Status of Recovering Injured Runners: Implications for Rehabilitation Program Content

Disclosures: Wonkee Chang: I Have No Relevant Financial Relationships To Disclose Objective: To investigate the relationships between biomechanical properties of the glenohumeral joint capsule and clinical factors in adhesive capsulitis (AC) patients with diabetes mellitus (DM), and to compare the biomechanical properties between diabetic (DM group) and non-diabetic patients (non-DM group). Design: A retrospective study. Setting: A tertiary university hospital outpatient clinic dedicated to intra-articular hydraulic distension (IHD). Participants: A total of 154 patients (DM group 30, non-DM group 124) with AC who underwent IHD. Interventions: IHD was performed using a hydraulic distension system designed for constantevolumeespeed fluid infusion with simultaneous intraarticular pressure monitoring. Stiffness of capsule (K_cap) was defined as the slope of elastic phase in Pressure-Volume curve. Capsular capacity (V_max), defined as the total infused volume and the pressure at the maximal volume (P_max) were also recorded. Main Outcome Measures: Correlation coefficients between K_cap and demographic and clinical parameters (including glycemic profile such as HbA1c and DM duration) in DM group. Comparison of K_cap, V_max and P_max between DM group and non-DM group. Results: Duration of DM showed positive correlation with K_cap (r1⁄40.468, P1⁄4.028). HbA1c did not show significant correlation with stiffness of capsule, nor did the type of DM medication (Insulin vs OHA only) show any significant difference in K_cap. Mean age was significantly higher in DM group (n1⁄430) than non-DM group (n1⁄4123) (62.60 9.6 vs 57.33 9.7 P1⁄4.008), otherwise there were no significant differences in demographic data, shoulder ROM and biomechanical properties of glenohumeral joint capsule (K_cap, C_max and P_max). Conclusions: The stiffness of glenohumeral joint capsule had positive correlation with DM duration, suggesting that patients with longer duration of DM had stiffer joint capsule. Other clinical factors including HbA1c had no meaningful relationship with capsular stiffness in DM patients. These findings implicate that the duration of DM may be one of the key factors in the pathogenesis of adhesive capsulitis in DM patients. Level of Evidence: Level IV