Do age, gender, and education modify the effectiveness of app-delivered and tailored self-management support among adults with low back pain?-Secondary analysis of the selfBACK randomised controlled trial.

selfBACK is an artificial intelligence based self-management app for low back pain (LBP) recently reported to reduce LBP-related disability. The aim of this study was to examine if age, gender, or education modify the effectiveness of the selfBACK intervention using secondary analysis of the selfBACK randomized controlled trial. Persons seeking care for LBP were recruited from primary care in Denmark and Norway and an outpatient clinic (Denmark). The intervention group (n = 232) received the selfBACK app adjunct to usual care. The control group (n = 229) received usual care only. Analyses were stratified by age (18-34, 35-64, ≥65 years), gender (male, female), and education (≤12, >12 years) to investigate differences in effect at three and nine months follow-up on LBP-related disability (Roland-Morris Disability Questionnaire [RMDQ]), LBP intensity and pain self-efficacy. Overall, there was no effect modification for any of the sociodemographic factors. However, data on LBP-related disability suggest that the effect of the intervention was somewhat more beneficial in older than in younger participants. The difference between the intervention and control group due to interaction was 2.6 (95% CI: 0.4 to 4.9) RMDQ points for those aged ≥65 years as compared to those aged 35-64 years. In conclusion, age, gender, or education did not influence the effect of the selfBACK intervention on LBP-related disability. However, older participants may have an additional long-term positive effect compared to younger participants. Trial registration: ClinicalTrials.gov Identifier: NCT03798288.

Effect of an Artificial Intelligence-Based Self-Management App on Musculoskeletal Health in Patients With Neck and/or Low Back Pain Referred to Specialist Care: A Randomized Clinical Trial.

Importance: Self-management is a key element in the care of persistent neck and low back pain. Individually tailored self-management support delivered via a smartphone app in a specialist care setting has not been tested. Objective: To determine the effect of individually tailored self-management support delivered via an artificial intelligence-based app (SELFBACK) adjunct to usual care vs usual care alone or nontailored web-based self-management support (e-Help) on musculoskeletal health. Design, Setting, and Participants: This randomized clinical trial recruited adults 18 years or older with neck and/or low back pain who had been referred to and accepted on a waiting list for specialist care at a multidisciplinary hospital outpatient clinic for back, neck, and shoulder rehabilitation. Participants were enrolled from July 9, 2020, to April 29, 2021. Of 377 patients assessed for eligibility, 76 did not complete the baseline questionnaire, and 7 did not meet the eligibility criteria (ie, did not own a smartphone, were unable to take part in exercise, or had language barriers); the remaining 294 patients were included in the study and randomized to 3 parallel groups, with follow-up of 6 months. Interventions: Participants were randomly assigned to receive app-based individually tailored self-management support in addition to usual care (app group), web-based nontailored self-management support in addition to usual care (e-Help group), or usual care alone (usual care group). Main Outcomes and Measures: The primary outcome was change in musculoskeletal health measured by the Musculoskeletal Health Questionnaire (MSK-HQ) at 3 months. Secondary outcomes included change in musculoskeletal health measured by the MSK-HQ at 6 weeks and 6 months and pain-related disability, pain intensity, pain-related cognition, and health-related quality of life at 6 weeks, 3 months, and 6 months. Results: Among 294 participants (mean [SD] age, 50.6 [14.9] years; 173 women [58.8%]), 99 were randomized to the app group, 98 to the e-Help group, and 97 to the usual care group. At 3 months, 243 participants (82.7%) had complete data on the primary outcome. In the intention-to-treat analysis at 3 months, the adjusted mean difference in MSK-HQ score between the app and usual care groups was 0.62 points (95% CI, -1.66 to 2.90 points; P = .60). The adjusted mean difference between the app and e-Help groups was 1.08 points (95% CI, -1.24 to 3.41 points; P = .36). Conclusions and Relevance: In this randomized clinical trial, individually tailored self-management support delivered via an artificial intelligence-based app adjunct to usual care was not significantly more effective in improving musculoskeletal health than usual care alone or web-based nontailored self-management support in patients with neck and/or low back pain referred to specialist care. Further research is needed to investigate the utility of implementing digitally supported self-management interventions in the specialist care setting and to identify instruments that capture changes in self-management behavior. Trial Registration: ClinicalTrials.gov Identifier: NCT04463043.

Exergaming in older adults: the effects of game characteristics on brain activity and physical activity.

Introduction: Exergames are increasingly used in rehabilitation settings for older adults to train physical and cognitive abilities. To meet the potential that exergames hold, they need to be adapted to the individual abilities of the player and their training objectives. Therefore, it is important to know whether and how game characteristics affect their playing. The aim of this study is to investigate the effect of two different kinds of exergame (step game and balance game) played at two difficulty levels on brain activity and physical activity. Methods: Twenty-eight older independently living adults played two different exergames at two difficulty levels each. In addition, the same movements as during gaming (leaning sideways with feet in place and stepping sideways) were performed as reference movements. Brain activity was recorded using a 64-channel EEG system to assess brain activity, while physical activity was recorded using an accelerometer at the lower back and a heart rate sensor. Source-space analysis was applied to analyze the power spectral density in theta (4 Hz-7 Hz) and alpha-2 (10 Hz-12 Hz) frequency bands. Vector magnitude was applied to the acceleration data. Results: Friedman ANOVA revealed significantly higher theta power for the exergaming conditions compared to the reference movement for both games. Alpha-2 power showed a more diverse pattern which might be attributed to task-specific conditions. Acceleration decreased significantly from the reference movement to the easy condition to the hard condition for both games. Discussion: The results indicate that exergaming increases frontal theta activity irrespective of type of game or difficulty level, while physical activity decreases with increasing difficulty level. Heart rate was found to be an inappropriate measure in this population older adults. These findings contribute to understanding of how game characteristics affect physical and cognitive activity and consequently need to be taken into account when choosing appropriate games and game settings for exergame interventions.

Energy cost of gait in children and the effect of speed, age, and body size.

BACKGROUND: Energy cost (EC) of comfortable walking is often used in clinical evaluation of children with altered gait function. EC is presented as energy expenditure per kg bodyweight per meter, either in total (grossEC) or in addition to resting energy expenditure (netEC). GrossEC is considered more reliable and netEC less affected by between-subject variations in speed, age, and body size. However, the effect of the individual child's speed on EC is rarely considered, while altered gait function may affect both speed and EC. RESEARCH QUESTION: To what extent are grossEC and netEC affected by within-subject variation in speed and between-subject variations in speed, age, and body size? METHODS: Forty-two typically developing children (7-15 y) were included in this cross-sectional study. Age, height, and bodyweight were obtained. Breath-to-breath gas-exchange measures of VO2 and VCO2 were conducted during rest and five over-ground gait conditions: walking at slow, comfortable, and fast speed, jogging and running. All conditions lasted 3-5 min. Body surface area, non-dimensional speed, grossEC, and netEC were calculated. Regression analyses and mixed model analyses were conducted to explain the effect of speed, age, and body size on variations in EC. RESULTS: GrossEC showed a non-significant, concave up relation to within-subject variation in speed, with a minimum around comfortable/fast walking speed. NetEC had a strong positive linear relation to within-subject variation in speed. For each gait condition, grossEC was more affected by between-subject variations in speed, age, and body size compared to netEC. However, the effect of age and body size was not eliminated for netEC but was quadratic. SIGNIFICANCE: Although normalised to speed and bodyweight, grossEC and netEC are still affected by those factors. However, they are affected differently for within- and between-subject variations. This must be considered when interpreting EC in children in relation to gait function.

Effects of Ankle-Foot Orthoses on acceleration and energy cost of walking in children and adolescents with cerebral palsy.

BACKGROUND: Impaired postural control is a key feature of cerebral palsy that affects daily living. Measures of trunk movement and acceleration have been used to assess dynamic postural control previously. In many children with cerebral palsy, ankle-foot orthoses are used to provide a stable base of support, but their effect on postural control is not yet understood. OBJECTIVES: The objectives of the current study were to investigate the effects of ankle-foot orthoses on postural control and energy cost of walking in children with cerebral palsy. STUDY DESIGN: Clinical study with controls. METHODS: Trunk accelerometry (amplitude and structure) and energy cost of walking (J/kg/m) were recorded from five-minute walking trials with and without ankle-foot orthoses for children with cerebral palsy and without orthoses for the reference group. RESULTS: Nineteen children with unilateral spastic cerebral palsy and fourteen typically developed children participated. The use of ankle-foot orthoses increased structure complexity of trunk acceleration in mediolateral and anterior-posterior directions. The use of ankle-foot orthoses changed mediolateral-structure toward values found in typically developed children. This change was not associated with a change in energy cost during walking. CONCLUSIONS: The use of ankle-foot orthoses does affect trunk acceleration that may indicate a beneficial effect on postural control. Using measures of trunk acceleration may contribute to clinical understanding on how the use of orthoses affect postural control.

Individually tailored self-management app-based intervention (selfBACK) versus a self-management web-based intervention (e-Help) or usual care in people with low back and neck pain referred to secondary care: protocol for a multiarm randomised clinical trial.

INTRODUCTION: Low back pain (LBP) and neck pain (NP) are common and costly conditions. Self-management is a key element in the care of persistent LBP and NP. Artificial intelligence can be used to support and tailor self-management interventions, but their effectiveness needs to be ascertained. The aims of this trial are (1) to evaluate the effectiveness of an individually tailored app-based self-management intervention (selfBACK) adjunct to usual care in people with LBP and/or NP in secondary care compared with usual care only, and (2) to compare the effectiveness of selfBACK with a web-based self-management intervention without individual tailoring (e-Help). METHODS AND ANALYSIS: This is a randomised, assessor-blind clinical trial with three parallel arms: (1) selfBACK app adjunct to usual care; (2) e-Help website adjunct to usual care and (3) usual care only. Patients referred to St Olavs Hospital, Trondheim (Norway) with LBP and/or NP and accepted for assessment/treatment at the multidisciplinary outpatient clinic for back or neck rehabilitation are invited to the study. Eligible and consenting participants are randomised to one of the three arms with equal allocation ratio. We aim to include 279 participants (93 in each arm). Outcome variables are assessed at baseline (before randomisation) and at 6-week, 3-month and 6-month follow-up. The primary outcome is musculoskeletal health measured by the Musculoskeletal Health Questionnaire at 3 months. A mixed-methods process evaluation will document patients' and clinicians' experiences with the interventions. A health economic evaluation will estimate the cost-effectiveness of both interventions' adjunct to usual care. ETHICS AND DISSEMINATION: The trial is approved by the Regional Committee for Medical and Health Research Ethics in Central Norway (Ref. 2019/64084). The results of the trial will be published in peer-review journals and presentations at national and international conferences relevant to this topic. TRIAL REGISTRATION NUMBER: NCT04463043.

Effectiveness of App-Delivered, Tailored Self-management Support for Adults With Lower Back Pain-Related Disability: A selfBACK Randomized Clinical Trial.

Importance: Lower back pain (LBP) is a prevalent and challenging condition in primary care. The effectiveness of an individually tailored self-management support tool delivered via a smartphone app has not been rigorously tested. Objective: To investigate the effectiveness of selfBACK, an evidence-based, individually tailored self-management support system delivered through an app as an adjunct to usual care for adults with LBP-related disability. Design, Setting, and Participants: This randomized clinical trial with an intention-to-treat data analysis enrolled eligible individuals who sought care for LBP in a primary care or an outpatient spine clinic in Denmark and Norway from March 8 to December 14, 2019. Participants were 18 years or older, had nonspecific LBP, scored 6 points or higher on the Roland-Morris Disability Questionnaire (RMDQ), and had a smartphone and access to email. Interventions: The selfBACK app provided weekly recommendations for physical activity, strength and flexibility exercises, and daily educational messages. Self-management recommendations were tailored to participant characteristics and symptoms. Usual care included advice or treatment offered to participants by their clinician. Main Outcomes and Measures: Primary outcome was the mean difference in RMDQ scores between the intervention group and control group at 3 months. Secondary outcomes included average and worst LBP intensity levels in the preceding week as measured on the numerical rating scale, ability to cope as assessed with the Pain Self-Efficacy Questionnaire, fear-avoidance belief as assessed by the Fear-Avoidance Beliefs Questionnaire, cognitive and emotional representations of illness as assessed by the Brief Illness Perception Questionnaire, health-related quality of life as assessed by the EuroQol-5 Dimension questionnaire, physical activity level as assessed by the Saltin-Grimby Physical Activity Level Scale, and overall improvement as assessed by the Global Perceived Effect scale. Outcomes were measured at baseline, 6 weeks, 3 months, 6 months, and 9 months. Results: A total of 461 participants were included in the analysis; the population had a mean [SD] age of 47.5 [14.7] years and included 255 women (55%). Of these participants, 232 were randomized to the intervention group and 229 to the control group. By the 3-month follow-up, 399 participants (87%) had completed the trial. The adjusted mean difference in RMDQ score between the 2 groups at 3 months was 0.79 (95% CI, 0.06-1.51; P = .03), favoring the selfBACK intervention. The percentage of participants who reported a score improvement of at least 4 points on the RMDQ was 52% in the intervention group vs 39% in the control group (adjusted odds ratio, 1.76; 95% CI, 1.15-2.70; P = .01). Conclusions and Relevance: Among adults who sought care for LBP in a primary care or an outpatient spine clinic, those who used the selfBACK system as an adjunct to usual care had reduced pain-related disability at 3 months. The improvement in pain-related disability was small and of uncertain clinical significance. Process evaluation may provide insights into refining the selfBACK app to increase its effectiveness. Trial Registration: ClinicalTrials.gov Identifier: NCT03798288.

Metabolic rate and muscle activation level when wearing state-of-the-art cold-weather protective clothing during level and inclined walking.

Use of cold-weather personal protective clothing (PPC) in cold climates is essential but can add metabolic cost to the wearer. This study measured the effect of wearing state-of-the-art PPC and personal protective equipment (PPE), with the possible effect of clothing layers and fit, on physiological responses including metabolic rate (MR) and muscle activation level. 19 male participants (80.2 ±â€¯5.9 kg, 181.5 ±â€¯5.1 cm) wore five different clothing ensembles during level (0°) and inclined (6°) walking. Compared to a base layer ensemble (388.7 ±â€¯42.7 W/737.8 ±â€¯57.9 W), wearing a 3-layer PPC ensemble (421.5 ±â€¯44.7 W/811.7 ±â€¯69.2 W) significantly increased MR, and adding PPE (458.3 ±â€¯59.8 W/864.5 ±â€¯71.2 W) further increased MR during level/inclined walking. Independent of the extra weight, adding a middle layer between base layer and outer clothing significantly increased MR during inclined walking only, and no effect of oversized outer clothing was measured.

Lower limb muscle fatigue during walking in children with cerebral palsy.

AIM: To investigate whether more prominent signs of muscle fatigue occur during self-paced walking in children with cerebral palsy (CP) compared to typically developing peers. METHOD: In this case-control study, 13 children with CP (four males, nine females; mean age [SD] 11y 4mo [3y 8mo]; nine in Gross Motor Function Classification System [GMFCS] level I, three in GMFCS level II, and one in GMFCS level III) and 14 typically developing peers (nine males, five females; mean age [SD] 9y 10mo [1y 10mo]) walked 5 minutes overground at a self-selected walking speed. Electromyography (EMG) median frequency and root mean square (RMS) were identified per gait cycle from EMG recordings of the tibialis anterior, gastrocnemius medialis, soleus, rectus femoris, and semitendinosus. Rate of change in those variables was analysed using mixed linear model analyses. RESULTS: The decrease in EMG median frequency of gastrocnemius medialis and soleus and increase in EMG-RMS of tibialis anterior, gastrocnemius medialis, and soleus were significantly larger in the most affected leg of children with CP compared with typically developing peers. INTERPRETATION: Increased selective muscle fatigue of the lower leg muscles was observed during self-paced walking in children with mild-to-moderate severe CP. This could contribute to and account for limited walking capacity. WHAT THIS PAPER ADDS: Children with cerebral palsy (CP) show more signs of lower leg muscle fatigue than typically developing peers. No signs of muscle fatigue were observed in upper leg muscles of children with CP.

Micro movements of the upper limb in fibromyalgia: The relation to proprioceptive accuracy and visual feedback.

The purpose of this study was to explore the role of visual and proprioceptive feedback in upper limb posture control in fibromyalgia (FM) and to assess the coherence between acceleration measurements of upper limb micro movements and surface electromyography (sEMG) of shoulder muscle activity (upper trapezius and deltoid). Twenty-five female FM patients and 25 age- and sex-matched healthy controls (HCs) performed three precision motor tasks: (1) maintain a steady shoulder abduction angle of 45° while receiving visual feedback about upper arm position and supporting external loads (0.5, 1, or 2kg), (2) maintain the same shoulder abduction angle without visual feedback (eyes closed) and no external loading, and (3) a joint position sense test (i.e., assessment of proprioceptive accuracy). Patients had more extensive increase in movement variance than HCs when visual feedback was removed (P<0.03). Proprioceptive accuracy was related to movement variance in HCs (R⩾0.59, P⩽0.002), but not in patients (R⩽0.25, P⩾0.24). There was no difference between patients and HCs in coherence between sEMG and acceleration data. These results may indicate that FM patients are more dependent on visual feedback and less reliant on proprioceptive information for upper limb posture control compared to HCs.

Aerobic and cardiovascular autonomic adaptations to moderate intensity endurance exercise in patients with fibromyalgia.

OBJECTIVE: To investigate whether moderate intensity endurance exercise has similar effects on cardiovascular fitness and autonomic function in patients with fibromyalgia and healthy controls. DESIGN: Case-control intervention study. SUBJECTS: Twenty-five female patients with fibromyalgia and 25 age- and sex-matched healthy controls (age range 40-64 years) were recruited to the study. Fifteen patients and 19 controls participated at both pre- and post-test. METHODS: Supervised spinning workouts of moderate intensity (~75% of age-predicted maximum heart rate) were performed twice a week for 12 weeks. Cardiovascular fitness was evaluated by an incremental ergometer cycling test to anaerobic threshold. Autonomic function was assessed by heart rate recovery after exercise, resting blood pressure, and resting heart rate variability. Pain was scored on a visual analogue scale, while overall symptom level was assessed by the Fibromyalgia Impact Questionnaire. RESULTS: Linear regression analysis with adjustments for baseline level and attendance rate showed a similar dose-dependent increase in patients and controls in oxygen uptake and workload after the 12-week intervention. Indices of autonomic function remained unchanged in both groups. Neck/shoulder pain decreased in patients, while overall symptom level remained unchanged. CONCLUSIONS: Female patients with fibromyalgia have similar cardiovascular adaptations to moderate intensity endurance exercise as healthy controls.

Sleep problems, exercise and obesity and risk of chronic musculoskeletal pain: the Norwegian HUNT study.

BACKGROUND: The objective was to investigate the association between self-reported sleep problems and risk of chronic pain in the low back and neck/shoulders, and whether physical exercise and body mass index (BMI) alter this association. METHODS: The study comprised data on 26 896 women and men in the Nord-Trøndelag Health Study (Norway) without chronic pain or physical impairment at baseline in 1984-86. Occurrence of chronic pain was assessed at follow-up in 1995-97. A generalized linear model was used to calculate adjusted risk ratios. RESULTS: Sleep problems were dose-dependently associated with risk of pain in the low back and neck/shoulders in both women and men (P < 0.001 both genders). Women and men who reported sleep problems 'sometimes' and 'often/always' had a higher risk of chronic pain of 23-32% and 51-66%, respectively, than those who reported sleep problems 'never'. Combined analyses showed that persons with sleep problems 'sometimes' and who exercised ≥1 hour per week had lower risk of chronic pain in the low back (P < 0.04) and neck/shoulders (P < 0.001) than inactive persons with a similar level of sleep problems (P < 0.04). Likewise, persons with BMI <25 kg/cm(2) and sleep problems 'sometimes' had lower risk of chronic pain in the low back (P < 0.001) and neck/shoulders (P < 0.001) than persons with BMI ≥25 kg/cm(2) and a similar level of sleep problems. CONCLUSION: Sleep problems are associated with an increased risk of chronic pain in the low back and neck/shoulders. Regular exercise and maintenance of normal body weight may reduce the adverse effect of mild sleep problems on risk of chronic pain.

Upper limb position control in fibromyalgia.

BACKGROUND: Motor problems are reported by patients with fibromyalgia (FM). However, the mechanisms leading to alterations in motor performance are not well understood. In this study, upper limb position control during sustained isometric contractions was investigated in patients with FM and in healthy controls (HCs). METHODS: Fifteen female FM patients and 13 HCs were asked to keep a constant upper limb position during sustained elbow flexion and shoulder abduction, respectively. Subjects received real-time visual feedback on limb position and both tasks were performed unloaded and while supporting loads (1, 2, and 3 kg). Accelerations of the dominant upper limb were recorded, with variance (SD of mean position) and power spectrum analysis used to characterize limb position control. Normalized power of the acceleration signal was extracted for three frequency bands: 1-3 Hz, 4-7 Hz, and 8-12 Hz. RESULTS: Variance increased with load in both tasks (P < 0.001) but did not differ significantly between patients and HCs (P > 0.17). Power spectrum analysis showed that the FM patients had a higher proportion of normalized power in the 1-3 Hz band, and a lower proportion of normalized power in the 8-12 Hz band compared to HCs (P < 0.05). The results were consistent for all load conditions and for both elbow flexion and shoulder abduction. CONCLUSION: FM patients exhibit an altered neuromuscular strategy for upper limb position control compared to HCs. The predominance of low-frequency limb oscillations among FM patients may indicate a sensory deficit.