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Back pain is a problem in adolescent athletes affecting postural control which is an important requirement for physical and daily activities whether under static or dynamic conditions. One leg stance and star excursion balance postural control tests are effective in measuring static and dynamic postural control respectively. These tests have been used in individuals with back pain, athletes and non-athletes without first establishing their reliabilities. In addition to this, there is no published literature investigating dynamic posture in adolescent athletes with back pain using the star excursion balance test. Therefore, the aim of the thesis was to assess deficit in postural control in adolescent athletes with and without back pain using static (one leg stance test) and dynamic postural (SEBT) control tests.
Adolescent athletes with and without back pain participated in the study. Static and dynamic postural control tests were performed using one leg stance and SEBT respectively. The reproducibility of both tests was established. Afterwards, it was determined whether there was an association between static and dynamic posture using the measure of displacement of the centre pressure and reach distance respectively. Finally, it was investigated whether there was a difference in postural control in adolescent athletes with and without back pain using the one leg stance test and the SEBT.
Fair to excellent reliabilities was recorded for the static (one leg stance) and dynamic (star excursion balance) postural control tests in the subjects of interest. No association was found between variables of the static and dynamic tests for the adolescent athletes with and without back pain. Also, no statistically significant difference was obtained between adolescent athletics with and without back pain using the static and dynamic postural control test.
One leg stance test and SEBT can be used as measures of postural control in adolescent athletes with and without back pain. Although static and dynamic postural control might be related, adolescent athletes with and without back pain might be using different mechanisms in controlling their static and dynamic posture. Consequently, static and dynamic postural control in adolescent athletes with back pain was not different from those without back pain. These outcome measures might not be challenging enough to detect deficit in postural control in our study group of interest.
The Star Excursion Balance Test (SEBT) is effective in measuring dynamic postural control (DPC). This research aimed to determine whether DPC measured by the SEBT in young athletes (YA) with back pain (BP) is different from those without BP (NBP). 53 BP YA and 53 NBP YA matched for age, height, weight, training years, training sessions/week and training minutes/session were studied. Participants performed 4 practice trials after which 3 measurements in the anterior, posteromedial and posterolateral SEBT reach directions were recorded. Normalized reach distance was analyzed using the mean of all 3 measurements. There was no statistical significant difference (p > 0.05) between the reach distance of BP (87.2 ± 5.3, 82.4 ± 8.2, 78.7 ± 8.1) and NBP (87.8 ± 5.6, 82.4 ± 8.0, 80.0 ± 8.8) in the anterior, posteromedial and posterolateral directions respectively. DPC in YA with BP, as assessed by the SEBT, was not different from NBP YA.
Obwohl der sozioökonomische Status (SES) eine in der Sozialepidemiologie häufig gebrauchte Variable darstellt, ist seine Verwendung mit methodischen Problemen verknüpft: Seine latente Struktur führt dazu, dass sich verschiedene Möglichkeiten der Operationalisierung eröffnen. Diese reichen von klassischen Ungleichheitsindikatoren wie Bildung, Einkommen oder Berufsposition, über multidimensionale oder über Nachbarschaftsmerkmale konstruierte Indizes, bis hin zu subjektiven Statuseinschätzungen. Problematisch ist dies insofern, als verschiedene Indikatoren auf unterschiedlichen theoretischen Konstrukten beruhen und unterschiedliche Schlussfolgerungen erlauben.
In dieser Arbeit wird deshalb in einem ersten Schritt anhand eines systematischen Reviews zum Zusammenhang von SES und Rückenschmerzen überprüft, welche Indikatoren in wissenschaftlichen Publikationen eingesetzt werden und wie die Auswahl begründet wird. Das Ergebnis zeigt eine klare Präferenz für klassische Indikatoren (Bildung, Einkommen und Berufsposition). Erläutert wurde die jeweilige Auswahl allerdings nur in einem geringen Prozentsatz der untersuchten Artikel, obwohl die unterschiedlichen Studienergebnisse nahelegen, dass der gewählte Indikator einen Einfluss auf den gefundenen Zusammenhang ausüben könnte.
Deshalb wurde in einem weiteren Schritt überprüft, wie unterschiedliche SES-Indikatoren mit der Verbesserung von Rückenschmerzen nach einer Rehabilitation (Studie 1) und der Neuentstehung von Rückenschmerzen (Studie 2) zusammenhängen. Außerdem wurde untersucht, ob ein einfaches Modell den Zusammenhang von SES und Gesundheit so darstellen kann, dass a priori abzuschätzen ist, wie hoch der Einfluss unterschiedlicher Indikatoren auf einen bestimmten Gesundheitsoutput sein könnte.
Es zeigt sich, dass sich der errechnete Zusammenhang zwischen den verschiedenen Indikatoren und chronischen Rückenschmerzen erheblich unterscheidet: Für Menschen, die bereits wegen Rückenschmerzen in Rehabilitation waren, erwiesen sich Bildung und Berufsposition als ähnlich einflussreiche Einflussfaktoren, während für das Einkommen kein bedeutender Zusammenhang festgestellt werden konnte. Für die Neuentstehung chronischer Rückenschmerzen zeigte sich die Berufsposition als wichtigster Indikator, gefolgt von Bildung, während für Einkommen kein signifikanter Zusammenhang gefunden werden konnte.
Folglich bestimmt die Wahl des Indikators die Höhe des festgestellten Zusammenhangs stark mit. Unterschiedliche Indikatoren dürfen deshalb nicht als austauschbar betrachtet werden und es muss bei jeder Forschungsfrage genau überlegt werden, welcher Indikator für die jeweilige Fragestellung am besten verwendet werden kann. Das vorgeschlagene theoretische Modell kann dabei als Unterstützung dienen.
Background:
Digital therapeutic care apps provide a new effective and scalable approach for people with nonspecific low back pain (LBP). Digital therapeutic care apps are also driven by personalized decision-support interventions that support the user in self-managing LBP, and may induce prolonged behavior change to reduce the frequency and intensity of pain episodes. However, these therapeutic apps are associated with high attrition rates, and the initial prescription cost is higher than that of face-to-face physiotherapy. In Germany, digital therapeutic care apps are now being reimbursed by statutory health insurance; however, price targets and cost-driving factors for the formation of the reimbursement rate remain unexplored.
Objective:
The aim of this study was to evaluate the cost-effectiveness of a digital therapeutic care app compared to treatment as usual (TAU) in Germany. We further aimed to explore under which circumstances the reimbursement rate could be modified to consider value-based pricing.
Methods:
We developed a state-transition Markov model based on a best-practice analysis of prior LBP-related decision-analytic models, and evaluated the cost utility of a digital therapeutic care app compared to TAU in Germany. Based on a 3-year time horizon, we simulated the incremental cost and quality-adjusted life years (QALYs) for people with nonacute LBP from the societal perspective. In the deterministic sensitivity and scenario analyses, we focused on diverging attrition rates and app cost to assess our model's robustness and conditions for changing the reimbursement rate. All costs are reported in Euro (euro1=US $1.12).
Results:
Our base case results indicated that the digital therapeutic care strategy led to an incremental cost of euro121.59, but also generated 0.0221 additional QALYs compared to the TAU strategy, with an estimated incremental cost-effectiveness ratio (ICER) of euro5486 per QALY. The sensitivity analysis revealed that the reimbursement rate and the capability of digital therapeutic care to prevent reoccurring LBP episodes have a significant impact on the ICER. At the same time, the other parameters remained unaffected and thus supported the robustness of our model. In the scenario analysis, the different model time horizons and attrition rates strongly influenced the economic outcome. Reducing the cost of the app to euro99 per 3 months or decreasing the app's attrition rate resulted in digital therapeutic care being significantly less costly with more generated QALYs, and is thus considered to be the dominant strategy over TAU.
Conclusions:
The current reimbursement rate for a digital therapeutic care app in the statutory health insurance can be considered a cost-effective measure compared to TAU. The app's attrition rate and effect on the patient's prolonged behavior change essentially influence the settlement of an appropriate reimbursement rate. Future value-based pricing targets should focus on additional outcome parameters besides pain intensity and functional disability by including attrition rates and the app's long-term effect on quality of life.
The research aimed to investigate back pain (BP) prevalence in a large cohort of young athletes with respect to age, gender, and sport discipline. BP (within the last 7days) was assessed with a face scale (face 1-2=no pain; face 3-5=pain) in 2116 athletes (m/f 61%/39%; 13.3 +/- 1.7years; 163.0 +/- 11.8cm; 52.6 +/- 13.9kg; 4.9 +/- 2.7 training years; 8.4 +/- 5.7 training h/week). Four different sports categories were devised (a: combat sports, b: game sports; c: explosive strength sport; d: endurance sport). Analysis was described descriptively, regarding age, gender, and sport. In addition, 95% confidence intervals (CI) were calculated. About 168 (8%) athletes were allocated into the BP group. About 9% of females and 7% of males reported BP. Athletes, 11-13years, showed a prevalence of 2-4%; while prevalence increased to 12-20% in 14- to 17-year olds. Considering sport discipline, prevalence ranged from 3% (soccer) to 14% (canoeing). Prevalences in weight lifting, judo, wrestling, rowing, and shooting were 10%; in boxing, soccer, handball, cycling, and horse riding, 6%. 95% CI ranged between 0.08-0.11. BP exists in adolescent athletes, but is uncommon and shows no gender differences. A prevalence increase after age 14 is obvious. Differentiated prevention programs in daily training routines might address sport discipline-specific BP prevalence.
In the context of back pain, great emphasis has been placed on the importance of trunk stability, especially in situations requiring compensation of repetitive, intense loading induced during high-performance activities, e.g., jumping or landing. This study aims to evaluate trunk muscle activity during drop jump in adolescent athletes with back pain (BP) compared to athletes without back pain (NBP). Eleven adolescent athletes suffering back pain (BP: m/f: n = 4/7; 15.9 ± 1.3 y; 176 ± 11 cm; 68 ± 11 kg; 12.4 ± 10.5 h/we training) and 11 matched athletes without back pain (NBP: m/f: n = 4/7; 15.5 ± 1.3 y; 174 ± 7 cm; 67 ± 8 kg; 14.9 ± 9.5 h/we training) were evaluated. Subjects conducted 3 drop jumps onto a force plate (ground reaction force). Bilateral 12-lead SEMG (surface Electromyography) was applied to assess trunk muscle activity. Ground contact time [ms], maximum vertical jump force [N], jump time [ms] and the jump performance index [m/s] were calculated for drop jumps. SEMG amplitudes (RMS: root mean square [%]) for all 12 single muscles were normalized to MIVC (maximum isometric voluntary contraction) and analyzed in 4 time windows (100 ms pre- and 200 ms post-initial ground contact, 100 ms pre- and 200 ms post-landing) as outcome variables. In addition, muscles were grouped and analyzed in ventral and dorsal muscles, as well as straight and transverse trunk muscles. Drop jump ground reaction force variables did not differ between NBP and BP (p > 0.05). Mm obliquus externus and internus abdominis presented higher SEMG amplitudes (1.3–1.9-fold) for BP (p < 0.05). Mm rectus abdominis, erector spinae thoracic/lumbar and latissimus dorsi did not differ (p > 0.05). The muscle group analysis over the whole jumping cycle showed statistically significantly higher SEMG amplitudes for BP in the ventral (p = 0.031) and transverse muscles (p = 0.020) compared to NBP. Higher activity of transverse, but not straight, trunk muscles might indicate a specific compensation strategy to support trunk stability in athletes with back pain during drop jumps. Therefore, exercises favoring the transverse trunk muscles could be recommended for back pain treatment.
In the context of back pain, great emphasis has been placed on the importance of trunk stability, especially in situations requiring compensation of repetitive, intense loading induced during high-performance activities, e.g., jumping or landing. This study aims to evaluate trunk muscle activity during drop jump in adolescent athletes with back pain (BP) compared to athletes without back pain (NBP). Eleven adolescent athletes suffering back pain (BP: m/f: n = 4/7; 15.9 ± 1.3 y; 176 ± 11 cm; 68 ± 11 kg; 12.4 ± 10.5 h/we training) and 11 matched athletes without back pain (NBP: m/f: n = 4/7; 15.5 ± 1.3 y; 174 ± 7 cm; 67 ± 8 kg; 14.9 ± 9.5 h/we training) were evaluated. Subjects conducted 3 drop jumps onto a force plate (ground reaction force). Bilateral 12-lead SEMG (surface Electromyography) was applied to assess trunk muscle activity. Ground contact time [ms], maximum vertical jump force [N], jump time [ms] and the jump performance index [m/s] were calculated for drop jumps. SEMG amplitudes (RMS: root mean square [%]) for all 12 single muscles were normalized to MIVC (maximum isometric voluntary contraction) and analyzed in 4 time windows (100 ms pre- and 200 ms post-initial ground contact, 100 ms pre- and 200 ms post-landing) as outcome variables. In addition, muscles were grouped and analyzed in ventral and dorsal muscles, as well as straight and transverse trunk muscles. Drop jump ground reaction force variables did not differ between NBP and BP (p > 0.05). Mm obliquus externus and internus abdominis presented higher SEMG amplitudes (1.3–1.9-fold) for BP (p < 0.05). Mm rectus abdominis, erector spinae thoracic/lumbar and latissimus dorsi did not differ (p > 0.05). The muscle group analysis over the whole jumping cycle showed statistically significantly higher SEMG amplitudes for BP in the ventral (p = 0.031) and transverse muscles (p = 0.020) compared to NBP. Higher activity of transverse, but not straight, trunk muscles might indicate a specific compensation strategy to support trunk stability in athletes with back pain during drop jumps. Therefore, exercises favoring the transverse trunk muscles could be recommended for back pain treatment.
In the context of back pain, great emphasis has been placed on the importance of trunk stability, especially in situations requiring compensation of repetitive, intense loading induced during high-performance activities, e.g., jumping or landing. This study aims to evaluate trunk muscle activity during drop jump in adolescent athletes with back pain (BP) compared to athletes without back pain (NBP). Eleven adolescent athletes suffering back pain (BP: m/f: n = 4/7; 15.9 +/- 1.3 y; 176 +/- 11 cm; 68 +/- 11 kg; 12.4 +/- 10.5 h/we training) and 11 matched athletes without back pain (NBP: m/f: n = 4/7; 15.5 +/- 1.3 y; 174 +/- 7 cm; 67 +/- 8 kg; 14.9 +/- 9.5 h/we training) were evaluated. Subjects conducted 3 drop jumps onto a force plate (ground reaction force). Bilateral 12-lead SEMG (surface Electromyography) was applied to assess trunk muscle activity. Ground contact time [ms], maximum vertical jump force [N], jump time [ms] and the jump performance index [m/s] were calculated for drop jumps. SEMG amplitudes (RMS: root mean square [%]) for all 12 single muscles were normalized toMIVC (maximum isometric voluntary contraction) and analyzed in 4 time windows (100 ms pre- and 200 ms post-initial ground contact, 100 ms pre- and 200 ms post-landing) as outcome variables. In addition, muscles were grouped and analyzed in ventral and dorsal muscles, as well as straight and transverse trunk muscles. Drop jump ground reaction force variables did not differ between NBP and BP (p > 0.05). Mm obliquus externus and internus abdominis presented higher SEMG amplitudes (1.3-1.9-fold) for BP (p < 0.05). Mm rectus abdominis, erector spinae thoracic/lumbar and latissimus dorsi did not differ (p > 0.05). The muscle group analysis over the whole jumping cycle showed statistically significantly higher SEMG amplitudes for BP in the ventral (p = 0.031) and transverse muscles (p = 0.020) compared to NBP. Higher activity of transverse, but not straight, trunk muscles might indicate a specific compensation strategy to support trunk stability in athletes with back pain during drop jumps. Therefore, exercises favoring the transverse trunk muscles could be recommended for back pain treatment.
The genesis of chronic pain is explained by a biopsychosocial model. It hypothesizes an interdependency between environmental and genetic factors provoking aberrant long-term changes in biological and psychological regulatory systems. Physiological effects of psychological and physical stressors may play a crucial role in these maladaptive processes. Specifically, long-term demands on the stress response system may moderate central pain processing and influence descending serotonergic and noradrenergic signals from the brainstem, regulating nociceptive processing at the spinal level. However, the underlying mechanisms of this pathophysiological interplay still remain unclear. This paper aims to shed light on possible pathways between physical (exercise) and psychological stress and the potential neurobiological consequences in the genesis and treatment of chronic pain, highlighting evolving concepts and promising research directions in the treatment of chronic pain. Two treatment forms (exercise and mindfulness-based stress reduction as exemplary therapies), their interaction, and the dose-response will be discussed in more detail, which might pave the way to a better understanding of alterations in the pain matrix and help to develop future prevention and therapeutic concepts
The genesis of chronic pain is explained by a biopsychosocial model. It hypothesizes an interdependency between environmental and genetic factors provoking aberrant long-term changes in biological and psychological regulatory systems. Physiological effects of psychological and physical stressors may play a crucial role in these maladaptive processes. Specifically, long-term demands on the stress response system may moderate central pain processing and influence descending serotonergic and noradrenergic signals from the brainstem, regulating nociceptive processing at the spinal level. However, the underlying mechanisms of this pathophysiological interplay still remain unclear. This paper aims to shed light on possible pathways between physical (exercise) and psychological stress and the potential neurobiological consequences in the genesis and treatment of chronic pain, highlighting evolving concepts and promising research directions in the treatment of chronic pain. Two treatment forms (exercise and mindfulness-based stress reduction as exemplary therapies), their interaction, and the dose-response will be discussed in more detail, which might pave the way to a better understanding of alterations in the pain matrix and help to develop future prevention and therapeutic concepts