Laura Ann Zdziarski

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.

Review of lacrosse-related musculoskeletal injuries in high school and collegiate players

Context: Participation in lacrosse has dramatically increased since 2001. Changes in the game rules, sport equipment, and athlete characteristics have all contributed to the injury patterns in lacrosse over time. Objective: A summary of lacrosse-related musculoskeletal injuries. Data Sources: Medline, CINAHL, Scopus, and Web of Science were searched for articles relating to the epidemiology and mechanisms of lacrosse injuries in high school and collegiate lacrosse players. Study Selection: The search strategy used the following keywords: lacrosse, injury, musculoskeletal, high school, intercollegiate, knee, shoulder, fracture, ankle, foot, concussion, and surveillance. Studies were included if they reported injury risk, injury type, or injury mechanism in high school or collegiate lacrosse players. Study Design: Systematic review. Level of Evidence: Level 4. Data extraction: Injury type, frequency, and mechanism as well as population were extracted. Results: Thirteen cohort studies and an additional 15 case series and reports were included. For all lacrosse players, ankle, knee, and hand/wrist were key sites for acute injury. Among collegiate players, preseasonal play elicits more injuries than seasonal play. Female players incur more noncontact and overuse injuries than male players. Boys have 3 to 5 times the risk for sustaining a fracture compared with girls in competition and practice. Women experienced fewer concussions but more facial fractures than men. Injuries to the foot/ankle, head, face, and wrist/hand more often required surgery in girls than in boys. Conclusion: Male players incur more injuries than female players. However, because of the collisional nature of play, more shoulder, arm, and upper leg injuries occur in male players. Fractures to the head and hand occur relatively more frequently in female players. Injury risk can be modified with appropriate training regimens and by respecting the game rules.

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.

Kinematic, Cardiopulmonary, and Metabolic Responses of Overweight Runners While Running at Self-Selected and Standardized Speeds

To determine the differences in kinematic, cardiopulmonary, and metabolic responses between overweight and healthy weight runners at a self‐selected and standard running speed.

Comparison of the Vacuum Mattress versus the Spine Board Alone for Immobilization of the Cervical Spine Injured Patient: A Biomechanical Cadaveric Study

Study Design. A biomechanical cadaveric study. Objective. We sought to determine the amount of motion generated in an unstable cervical spine fracture with use of the vacuum mattress versus the spine board alone. Our hypothesis is that the vacuum mattress will better immobilize an unstable cervical fracture. Summary of Background Data. Trauma patients in the United States are immobilized on a rigid spine board, whereas in many other places, vacuum mattresses are used with the proposed advantages of improved comfort and better immobilization of the spine. Methods. Unstable subaxial cervical injuries were surgically created in five fresh whole human cadavers. The amount of motion at the injured motion segment during testing was measured using a Fastrak, three-dimensional, electromagnetic motion analysis device (Polhemus Inc.). The measurements recorded in this investigation included maximum displacements during application and removal of the device, while tilting to 90°, during a bed transfer, and a lift onto a gurney. Linear and angular displacements were compared using the Generalized Linear Model analysis of variance for repeated measures for each of the six dependent variables (three planes of angulations and three axes of displacement). Results. There was more motion in all six planes of motion during the application process with use of the spine board alone, and this was statistically significant for axial rotation (P = 0.011), axial distraction (P = 0.035), medial-lateral translation (P = 0.027), and anteroposterior translation (P = 0.026). During tilting, there was more motion with just the spine board, but this was only statistically significant for anteroposterior translation (P = 0.033). With lifting onto the gurney, there was more motion with the spine board in all planes with statistical significance, except lateral bending. During the removal process, there was more motion with the spine board alone, and this was statistically significant for axial rotation (P = 0.035), lateral bending (P = 0.044), and axial distraction (P = 0.023). Conclusion. There was more motion when using a spine board alone during typical maneuvers performed during early management of the spine injured patient than the vacuum mattress. There may be benefit of use of the vacuum mattress versus the spine board alone in preventing motion at an unstable, subaxial cervical spine injury. Level of Evidence: 2

Biomechanical, metabolic and cardiopulmonary responses of masters recreational runners during running at different speeds

ABSTRACT This study tested interactions between age and running speed on biomechanics, metabolic responses and cardiopulmonary responses. Three-hundred participants ran at preferred and standardized speeds. Age group (younger, masters [≥40 years]) by speed (self-selected 8.8 km/h, 11.2 km/h and 13.6 km/h) interactions were tested on main outcomes of sagittal kinematic, temporal spatial, metabolic and cardiopulmonary parameters. At all speeds, angular displacements of the ankle, pelvis and knee were less in masters than younger runners (Hedges g effect size range = 0.30–1.04; all p < 0.05). A significant age group by speed interaction existed for hip angular displacement (Wald χ2 = 10.753; p = 0.013). Masters runners ran at higher relative heart rates (p < 0.05) but at similar rates of oxygen use and energy expenditure. Masters runners used hip-dominant motion and step lengthening as running speed increased, but did not change centre of mass vertical displacement. This may increase mechanical stresses on tissues of the lower extremity in masters runners, especially hamstrings, hip joint and Achilles.

Shooting motion in high school, collegiate, and professional men’s lacrosse players

Abstract The purposes of this research were to quantify the kinematics of the lacrosse shot, based on arm dominance and player experience level. Male players (N = 39; 14–30 years; high school [n = 24], collegiate [n = 9], professional [n = 6]), performed overhead shots using dominant and non-dominant sides. Motion was captured using a high-speed, 12-camera optical system and high-speed filming. Body segment rotational velocities and joint angles were determined at key points in the shot cycle from foot contact (0% of shot) to ball release (100% of shot). All players shot with less anterior trunk lean, less transverse shoulder rotation, and slower trunk-shoulder rotational velocities with the non-dominant side than the dominant side (all p < 0.05). Professional players produced crosse angular velocities 21% faster than high school or collegiate players (p < 0.05). Transverse shoulder rotation range of motion on both dominant and non-dominant and trunk rotation sides was highest in the professional players (p < 0.05). These kinematic features enable professional players to produce faster ball speeds than younger players (138 ± 7 km/h vs. 112 ± 15 km/h, respectively; p < 0.05). Less anterior lean or suboptimal rotation sequence could increase proximal shoulder forces that could contribute to injury as in other throwing sports.

Poster 15: Patient and Clinical Outcomes with a Transformational Coaching Intervention After Orthopedic Trauma

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 29: Psychosocial Intervention and the Use of Pain Medication in Orthopaedic Trauma Patients

Disclosures: Alexandra Dluzniewski: I Have No Relevant Financial Relationships To Disclose Objective: To identify factors that influence pain medication use (PMU) post-operatively among orthopaedic trauma patients who received either an integrative care 10-step psychosocial intervention (Icare) or standard trauma care (UScare). Design: An ongoing single-blinded, randomized, controlled trial. Setting: Level I trauma center at an academic institution. Participants: Patients admitted to the orthopaedic trauma service (N1⁄489; 40.4% female, 29.7 7.9 kg/m, 42.9 16.6 yrs). Interventions: Investigators implemented Icare during the hospital stay and at follow-up visits. The program provided coping strategies and supportive material that were tailored to each patient’s needs; goal setting, physical movement, reducing psychological stressors, and others. Follow-up visits occurred at weeks 2, 6 and 12. Main Outcome Measures: Hospital length of stay (LOS), and 12-week values for post-traumatic stress disorder (PTSD), number of pain medications and patient-reported average pain severity. Results: Of the 89 patients, 50 were using pain medication at 12 weeks (20 females, 30 males). There were no significant differences in PMU at 12 weeks between Icare and UScare. Despite similar pain severity as males, females were twice as likely to be using pain medication at 12 weeks if their LOS was greater than seven days. Regression analysis was used to determine which factors contributed to the variance of PMU at week 12. The model was adjusted for age, sex, LOS and study group (model R21⁄40.244). The addition of patient-reported pain and PTSD scores contributed an additional 15.7% and 23.1% to the variance of the model, respectively (model R21⁄40.673; p<.05). Conclusions: While both Icare and UScare decreased PMU over time, women used pain medicines for longer during recovery especially if the hospital LOS was longer than a week. A possibility exists that PTSD may be disproportionately impacting women after orthopaedic trauma. The findings suggest PTSD coping strategies could be useful in reducing medication use during follow-up. Level of Evidence: Level III

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