Presenters: Armando Miciano MD, Shruti Mutalik MD, Devi Nampiaparampil MD 2014 AAPMR Annual Assembly Course, November 16, 2014 San Diego, CA

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

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

TOPICS/SPEAKER:

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.

Learning Objectives

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.

Course Description

Exercise, Work Activity, & Participation Levels of

Individuals with Chronic Pain:

their role in Care Planning.

Section Presenter:Armando Miciano, MD

Nevada Rehabilitation Institute, Las Vegas, NV

2014 AAPMR Annual Assembly, San Diego CA November 2014

Medical Director Spring Mountain Rehab, Las Vegas NV

Practitioner – Nevada Rehabilitation Institute, Las Vegas NV

Disclosures

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

Course section –LEARNING OBJECTIVES:

Physical Activity◦ Exercise activity

Activities of daily living (ADL)

Instrumental Activities of daily living (IADL)

Work Activity

TERMINOLOGY

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: ◦ Measure levels of physical activity in adults with knee OA and report the prevalence of

meeting public health physical activity guidelines. METHODS:

◦ 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)

RESULTS:◦ 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.

CONCLUSION:◦ 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.

Objective physical activity measurement in the osteoarthritis initiative: Are guidelines being met?

Dunlop DD, et al. Arthritis Rheum. 2011 Nov;63(11):3372-82.

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.

Physical Activity Guidelines for Americans. 2008

Crandall S, et al. Phys Ther. 2013 Jan;93(1):17-21.

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 moderate-intensity 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.

Assessment of Physical Activity [1]

[1] Kim W, et al. PM R 2014;6:893-899; [2] Craig CL, et al. Med Sci Sports Exerc. 2003.

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.

These values were used to define 4 continuous 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

Total PA MET-minutes/week ¼ sum of walking, moderate PA, vigorous PA MET-minutes/week scores

Assessment of Physical Activity [1]

[1] Kim W, et al. PM R 2014;6:893-899; [2] Craig CL, et al. Med Sci Sports Exerc. 2003.

Ettinger and colleagues:◦ 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.

van Baar et al. ◦ that the beneficial effects of exercise last only as long as the

patient with OA continues to participate in exercise. Bennell et al.

◦ 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.)

Exercise Adherence & Optimal Outcomes

Bennell KL, et al. Best Pract Res Clin Rheumatol. 2014 Feb;28(1):93-117.

Exercise Adherence & Optimal Outcomes


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

Exercise as a stressor relief

Deslandes A, et al. Neuropsychobiology. 2009;59(4):191-8.

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.

Symptoms reported: OA disease model


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.

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

CONCLUSION:

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.

Fluctuation of knee pain and changes in bone marrow lesions, effusions, and synovitis on MRI.

Zhang Y, et al. Arthritis Rheum. 2011 Mar;63(3):691-9.

Why don’t patients adhere to exercise rec? [1]Model depicting factors that influence ongoing adherence to exercise in patients with knee OA. [2]

[1] Bennell KL, et al. Best Pract Res Clin Rheumatol. 2014 Feb;28(1):93-117. [2] Campbell et al. (2001)

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 maximize patient adherence to exercise in OA.

Attitudes and beliefs of older people with OA about the role of exercise


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.

Exercise and the risk on low back pain

J. Rainville et al. Spine J. 4 (2004) 106–115.

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:

◦ 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.

Relationship Between the Type and Amount of Physical Activity and Low Back Pain

Kim W, et al. PM R. 2014;6:893-899

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.

Pathophysiology

[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

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.

Psychoneuroimmunology

[6] Irwin MR. Psychiatr Clin North Am. 2011.[7] Fava M. J Clin Psychiatry. 2003. [8] Meese PJ. Am J Med. 2009 .

Hyperexcitability of the central nervous system (CNS) has been suggested to play an important role in the chronic pain experienced by osteoarthritis (OA) patients.

A systematic review

The majority of these studies were case-control studies and addressed OA of the knee joint.

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.

Evidence for central sensitization (CS) in patients with osteoarthritis pain: A systematic literature review.

Lluch E, et al. Eur J Pain. 2014 Apr 3

Severe pain has profound physiologic effects on the endocrine system.

Serum hormone abnormalities may result and these serve as biomarkers for the presence of severe pain

Initially severe pain causes a hyperarousal of the hypothalamic-pituitary-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.

Physiologic effects of pain on the endocrine system.

Tennant F. Pain Ther. 2013 Dec;2(2):75-86.

Physiologic effects of pain on the endocrine system.

Adapted from: Tennant F. Pain Ther. 2013 Dec;2(2):75-86.

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,

Activities of longer duration (2-3 minutes) that depend primarily on oxidative metabolism, such as long-distance swimming, are classified as aerobic activities.

Many sports activities require a blend of both anaerobic and aerobic metabolism.

In “stop and go” sports such as tennis, approximately 60%-70% of the energy comes from ATP-creatine phosphate (CP) stores and anaerobic glycolysis and the remaining 30% from oxidative processes [6].

Principles of Exercise Physiology: Responses to Acute Exercise

Rivera-Brown AM, et al. PMR. 2012; 4:797-804

Objective. ◦ to evaluate the relationships between fat mass, muscle mass, fat/muscle mass

ratio, metabolic syndrome, and musculoskeletal pain in community residents. Methods.

◦ 1530 participants completed pain questionnaires, underwent dual x-ray absorptiometry to calculate body composition. 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. Results.

◦ 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.

Conclusions. ◦ 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.

Relationships between body mass index, fat mass, muscle mass, and musculoskeletal pain in community residents

Yoo JJ, et al. Arthritis Rheumatol. 2014 Sept 3.

Exercise-induced muscle injury in humans frequently occurs after unaccustomed exercise, particularly if the exercise involves a large amount of eccentric (muscle lengthening) contractions.

Direct measures of exercise-induced muscle damage include cellular and subcellular disturbances, particularly Z-line streaming.

Indirectly assessed markers of muscle damage after exercise include

◦ 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.

Exact mechanisms to explain these changes not been delineated, ◦ 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◦ 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.

Exercise-induced muscle damage in humans.

Clarkson PM, et al. Am J Phys Med Rehabil. 2002 Nov;81(11 Suppl):S52-69.

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

Exercise-induced muscle pain, soreness, and cramps.

Miles MP, Clarkson PM. J Sports Med Phys Fitness. 1994 Sep;34(3):203-16.

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.



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.



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.



Muscle damage is caused by strenuous and unaccustomed exercise, especially exercise involving eccentric muscle contractions, where muscles lengthen as they exert force.

Damage can be observed both directly at the cellular level and indirectly from changes in various indices of muscle function.

Several mechanisms offered to explain the etiology of the damage/repair process, including ◦ 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.

Exercise-induced muscle damage

Clarkson PM, et al. Can J Appl Physiol. 1999 Jun;24(3):234-48.

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.

Muscle protein changes following eccentric exercise in humans.

Reichsman F, et al. Eur J Appl Physiol Occup Physiol. 1991;62(4):245-50.

time course of changes in muscle function and other correlates of muscle damage following maximal effort eccentric actions of the forearm flexor muscles.

Peak soreness: 2-3 d postexercise while peak swelling: 5 d postexercise.

Maximal strength and the ability to fully flex the arm show the greatest decrements immediately after exercise ◦ a linear restoration of these functions over the next 10 d.

Blood creatine kinase (CK) levels increase precipitously at 2 d after exercise which is also the time when spontaneous muscle shortening is most pronounced.

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.

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.

After 10 wk, only CK and muscle shortening show a reduction in response.

After 6 months only the CK response is reduced.

Conclusion: A combination of cellular factors and neurological factors may be involved in the adaptation process.

Muscle function after exercise-induced muscle damage and rapid adaptation.

Clarkson PM, et al. Med Sci Sports Exerc. 1992 May;24(5):512-20.

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.

Neuromuscular dysfunction following eccentric exercise.

Saxton JM, Clarkson PM, et al. Med Sci Sports Exerc. 1995 Aug;27(8):1185-93.

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.

Muscle weakness, afferent sensory dysfunction and exercise in knee osteoarthritis.

Roos EM, et al. Nat Rev Rheumatol. 2011.

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.

Exercise-induced muscle damage: effects of light exercise on damaged muscle.

Donnelly AE, et al. Eur J Appl Physiol Occup Physiol. 1992;64(4):350-3.

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.

Fuel usage in individuals who are unfit

Hochachka PW. Adv Exp Med Biol. 2000;475:311-35.

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.

Fuel usage in individuals who are unfit

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.

Muscle contraction and fatigue. The role of adenosine 5'-diphosphate and inorganic phosphate.

Mclester JR. Sports Med. 1997 May;23(5):287-305.

Purpose: to determine if old individuals show a greater exercise-induced 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.

Young vs. Old: The effects of eccentric exercise on motor performance in young and older women.

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.

Fuel usage (light exercise)


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.

Fuel usage (moderate exercise)


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

Postexercise Recovery: Oxygen debt


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.

Postexercise Recovery: Recovery of muscle glycogen postexercise


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.

Muscle Metabolic Systems During Exercise

Mclester JR. Sports Med. 1997 May;23(5):287-305

Cochrane review: to determine effects of stretching before or after exercise on the development of delayed-onset muscle soreness.

showed that pre-exercise stretching reduced soreness at one day after exercise by, on average, half a point on a 100-point scale.

Post-exercise stretching reduced soreness at one day after exercise by, on average,

one point on a 100-point scale

Similar effects were evident between half a day and three days after exercise.

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.

Stretching to prevent or reduce muscle soreness after exercise.

Herbert RD, et al. Cochrane Database Syst Rev. 2011 Jul 6;(7):CD004577.

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

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.

A meta-analytic review of the hypoalgesic effects of exercise

Naugle KM, et al. J Pain. 2012 Dec;13(12):1139-50.

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: ◦ neuromuscular, ◦ peri-articular, ◦ intra-articular, ◦ psychosocial components, ◦ general fitness and health.

Osteoarthritis of the knee: why does exercise work? A qualitative study of the literature.

Beckwée D, et al. Ageing Res Rev. 2013 Jan;12(1):226-36.

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.

Centralization and directional preference: a systematic review

May S, et al. Man Ther. 2012.

Exercise therapy is widely used as an intervention in low-back pain.

OBJECTIVES: To evaluate the effectiveness of exercise therapy in adult non-specific

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.

Exercise therapy for treatment of non-specific low back pain.

Hayden JA, et al. Cochrane Database Syst Rev. 2005 Jul 20;(3):CD000335.

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.

1-set Resistance ex. for CLBP

Limke JC, Rainville J, et al. Eur J Phys Rehabil Med. 2008 Dec;44(4):399-405.

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 exerciseonly-based 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.

Quota-based vs. graded activity

Kernan T, Rainville J. J Orthop Sports Phys Ther. 2007 Nov;37(11):679-87.

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.

Exercise as a tool to improve back function


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 health-care providers suggest it with confidence.

Exercise for the goal of improving impaired flexibility


Frequently observed pattern of trunk flexion for patients with chroniclow back pain.

Adapted from: J. Rainville et al. Spine J. 4 (2004) 106–115.

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.



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.



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.

Exercise with the goal of improving impairedback strength


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.



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.

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



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.

Exercise as a modality to reduce chronic lowback pain symptoms


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.



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 pain-producing 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.



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.

Exercise as treatment for LBP: conclusions


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.

Exercise as treatment for behavioral, cognitive, affective and disability components of chronic back pain


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.

Motivating Factors to exercise: knee OA


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), ◦ perceived severity of knee symptoms

(those with more severe symptoms were most likely to adhere), ◦ ideas about the cause of arthritis

(those thinking arthritis was due to age or “wear and tear” were less adherent), ◦ perceived effectiveness of the intervention

(high levels of continued compliance were related to perceptions that physiotherapy is effective and improvement in symptoms).

Motivating Factors to exercise: knee OA


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).

Why don’t patients adhere to exercise rec?


Why don’t patients adhere to exercise rec? [1]Model depicting the internal and external barriers and facilitators to exercising in people with osteoarthritis [2,3]

[1] Bennell KL, et al. Best Pract Res Clin Rheumatol. 2014 Feb;28(1):93-117. [2] Petursdottir et al., 2010. [3] Bennell 2013

Guiding Principles – as insight into providing a patient-centered approach

Adapted from Linton SJ, et al. Phys Ther. 2011.

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.

Practical Recommendations: Physical Activity Promotion [1]

Estabrooks PA, et al. JAMA. 2003.

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

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.

Practical Recommendations: Physical Activity Promotion [1]

Estabrooks PA, et al. JAMA. 2003.

Goal-setting

Quinn E. Motivation and goal setting for exercise. 2004. http://sportsmedicine.about.com/od/sportspsychology/a/motivation.htm (accessed 20 March 2011)

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 self-

efficacy, social support, and skills in long-term monitoring of progress are necessary to foster exercise adherence among patients with OA.

Exercise adherence and 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

1. International Physical Activity Questionnaire (IPAQ)

2. UCLA Activity Scale

3. Lower Extremity Activity Scale

Suggested: Physical Activity Patient-Reported Outcomes

Discussed definition of Physical Activity

Exercise recommendations: that exercise is safe in chronic pain

Emphasize the role of patient education and professional guidance to increase exercise adherence

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.

Conclusion

Contact Info:

Armando Miciano, M.D. Nevada Rehabilitation Institute, Las Vegas NV

www.springmountainrehab.com 702-869-4401

[email protected]

Thank You.

Documents

Presenters: Armando Miciano MD, Shruti Mutalik MD, Devi Nampiaparampil MD 2014 AAPMR Annual Assembly Course, November 16, 2014 San Diego, CA