Chronic pain, commonly defined as daily or recurrent pain that persists for at least 6 months, is an overlooked public health problem that affects an estimated 100 million Americans (10). The prevalence of chronic pain is greater than the combination of heart disease, diabetes, and cancer, resulting in an economic burden of up to $635 billion each year in medical treatment (10). Chronic pain is a health condition that affects not only adults but also is a surprisingly common problem affecting 20–30% of children and adolescents (19). At times, the etiology of pediatric chronic pain is clearly identifiable when it is related to a disease, such as cancer, sickle cell anemia, or juvenile arthritis (2,3,29).
However, many common chronic pain conditions in childhood and adolescence, such as headaches, abdominal pain, and musculoskeletal pain, can occur without a clear medical explanation and result in considerable diagnostic and treatment challenges for medical providers and significant frustration for the patients and families. These chronic nonmalignant pain syndromes are often very disabling and can impact multiple areas of function within daily activities. For example, children and adolescents with chronic pain typically experience significant declines in their quality of life and increased impairment in physical and social activities, as well as frequent school absences (13). In addition, they report increased levels of depression, anxiety, and emotional distress (26). One specific chronic pain condition, juvenile fibromyalgia, is characterized by widespread musculoskeletal pain, multiple painful tender points on touch, fatigue, sleep difficulty, and several other associated symptoms. Youth with juvenile fibromyalgia often have even greater impairments in functioning compared to those with other chronic pain conditions, such as higher levels of functional disability, emotional distress, and more school absences (12,16). Without appropriate treatment, these youth are at risk for continuing pain and disability into adulthood (11). As such, early implementation of effective pain management treatment strategies during childhood and adolescence is critical to ease both the economic burden and social impact of chronic pain in adulthood.
Several pain management treatments, such as medications, psychological and behavioral interventions, exercise, and other nonpharmacological therapies are commonly used to help youth cope with and manage their chronic pain symptoms. Psychological and behavioral interventions in the form of cognitive-behavioral therapy (CBT) for pediatric chronic pain, including juvenile fibromyalgia, has gained strong evidence-based support to effectively decrease pain intensity and improve daily physical and emotional function (15,27). CBT focuses on teaching a variety of skills, such as muscle relaxation, activity pacing, distraction, problem solving, using calming statements and others to cope with and reduce pain. Although these strategies have been found to be useful, it has been suggested that integrating more than one nonpharmacological approach for pain may have combinatorial benefits for children with chronic pain (Figure) (14).
Specifically, preliminary data in adults with fibromyalgia indicates that the addition of exercise to behavioral treatment can further alleviate debilitating musculoskeletal pain symptoms. For example, the American Pain Society recommends moderately intense aerobic exercise and muscle strengthening exercise at least twice per week in addition to self-management interventions (1). Although increased physical activity and exercise have been found to reduce pain (7), patients with fibromyalgia and other chronic pain conditions often struggle to meet recommended guidelines for regular exercise for a variety of reasons including fatigue, fear that movement will increase the intensity of their pain, or long-standing patterns of physical inactivity. As such, we aimed to develop an integrative neuromuscular training protocol designed specifically for youth with juvenile fibromyalgia to prepare them for increased engagement in physical activity.
ACTIVITY IN PATIENTS WITH CHRONIC PAIN
Just as sufficient preparative training before sports participation should be considered to prevent injury and to support the continued participation of healthy adolescents, proper training should also be considered before integrating increased physical activity into the lives of adolescents who live with a chronic pain disorder. Fibromyalgia is one of the most debilitating chronic pain conditions and, often, exercise is strongly recommended to help patients resume normal daily activities (1); however, the fear of activity resulting in potential pain flare-ups and increased muscle soreness may ultimately lead to cessation of any physical activity involvement. Therefore, sufficient preparation for prescribed amounts of activity may be necessary to prevent increased pain. Beginning physical activity without possessing the necessary strength to perform these activities can even put a chronic pain patient at risk of suffering a traumatic injury; much like inadequate preparation for sport participation can put an athlete at risk. Although activity in general is important to integrate into the everyday life of chronic pain patients, it is also imperative that the type of activity is appropriate for this population and the method of implementation is conducive for their condition and stage of development. It has long been understood that children and adolescents have different learning techniques than adults, and they require developmentally appropriate preparation for sport participation and activity (9,20,21,23,24). Therefore, a program involving integrative neuromuscular training may be a fitting option for youth who are seeking to treat their chronic pain condition with exercise.
Integrative neuromuscular training can be defined as a program or plan that incorporates general and specific strength and conditioning activities, which enhance fundamental skill-related components of physical fitness. Furthermore, integrative neuromuscular training consists of a series of exercises, particularly designed to improve children and adolescents' balance, posture, strength, and mechanics, to enable them to safely participate in higher levels of activity while minimizing risk for injury (21,22). Specifically, we emphasize the importance of establishing fundamental motor skills (locomotor skills such as running, jumping, hopping, and strength determined functional postures) that will serve as a foundation for sustained physical activity throughout life.
NEUROMUSCULAR TRAINING IN ADOLESCENT PATIENTS WITH FIBROMYALGIA
Preliminary data from our laboratory indicate that children and adolescents with musculoskeletal pain have a propensity for altered gait (reduced stride length) and biomechanical (reduced lower extremity strength and postural control) deficits relative to norms that may make them more prone to injury or exacerbated pain with exercise. For example, patients with juvenile idiopathic arthritis have demonstrated altered landing mechanics during a drop vertical jump task when compared with control subjects, and these biomechanical deficits were also found to be predictive of higher disability (6). In addition, results from our laboratory indicate that adolescents with fibromyalgia exhibit decreased knee extension, knee flexion, and hip abduction strength and dynamic stability when compared with their active peers (30). Designing an appropriate intervention for fibromyalgia patients with chronic pain should, therefore, involve specialized instruction in fundamental movements and strength building while minimizing the likelihood of pain flare-ups. A specifically designed program, including resistance, dynamic stability, and core focused strength exercises, which target motor control deficits, should be implemented while taking into account patients' baseline level of fitness. The minimization of the potential for delayed onset muscle soreness that can arise after resistive exercise would also be an important consideration for patients who already suffer from pain and may have difficulty tolerating the increased soreness or distinguishing it from their pain symptoms. Traditional exercise programs typically involve prolonged periods of aerobic exercise or high volume resistance training, which may not be desirable for youth with juvenile fibromyalgia. Therefore, implementing a neuromuscular training program where intermittent-type activities are used may be more beneficial in reducing the exercise-induced symptoms and soreness.
Each exercise in this training program for adolescents with juvenile fibromyalgia was selected based on the concept of fundamental skill development and modified from well-established neuromuscular training programs used for healthy active adolescents. These training programs have previously been shown to be effective in significantly reducing risk of injury in young adolescent female athletes by improving landing mechanics, dynamic stability, and lower extremity neuromuscular control (5,8,20). This program has been developed in four levels of progression, with each stage focusing on a different muscle action, therefore requiring each participant to adequately and consistently perform each action before progressing to the next level (Table 1). Each level of this protocol contains exercises focused on the following movement concepts: squat; hip hinge; posterior chain development; anterior, posterior, and rotational core development; pushing movements; and pulling movements (Tables 2–5).
GUIDELINES FOR IMPLEMENTING NEUROMUSCULAR TRAINING WITH PATIENTS WITH CHRONIC PAIN
When implementing training programs with adolescents who suffer from chronic musculoskeletal pain, trainers should be cautious of hypermobile joints, previous injury or surgery history, and common body parts that are typically the most bothersome for these patients. They should also be aware of ranges of motion throughout these exercises, joint alignment, and equal distribution of resistance between the limbs involved in the exercise. For example, often patients with chronic pain are protective of certain body parts that have been previously injured or where they have frequent pain and tend to compensate by guarding that part of their body through unequal weight distribution on their lower extremities or favoring their affected limb. This is often driven by underlying anxiety or fear that pain will be worsened with use. The trainer should also take caution in using the word “pain” or “hurt” when asking about the patient's perception of each exercise, as that can be a trigger for these patients to associate pain with exercise (28,32). Also, many patients are using their muscles in a new way during the exercises and any new feeling in their body that is different or uncomfortable may automatically be perceived as pain. Therefore, an important lesson for patients to learn while doing these exercises is differentiating between “pain” and muscle “soreness.” The training staff should explain to the patients that normal active youth often experience a burning or soreness with the exercise program. Through communication with the instructor, patients with chronic pain may find that the exercise induced soreness is a temporary result and may not be the same pain “flare-ups” that they experience with their condition. As patients adapt to training and gain an appreciation of this difference in muscle soreness and pain, the patient's adherence to the program will likely improve. This education also helps normalize their experience and gain more confidence in the way their body moves while lessening any anxiety that being active will worsen their pain. Additionally, the training staff should be ready to build in appropriate breaks and rest periods to help prevent patients' from overexerting themselves, which can lead to pain flare ups considering their previous sedentary lifestyle. It is therefore important to teach the patients how to control the pace of exercises during the training and while practicing at home, as it is common for patients to try to hurry through the exercises to complete their program for that day quickly. Giving the patients specific instructions on how to pace each exercise will keep them focused on the exercise at hand and also teach them how to control their body and perform the movements safely and effectively (For specific exercise instructions, see Tables 2–5). As noted previously, adolescents with fibromyalgia demonstrate significant deficits in lower extremity strength and dynamic postural control relative to their unaffected peers. The present protocol has been successfully used with adolescents in our laboratory, and preliminary results indicate improved knee extensor and hip abduction strength in adolescent patients with fibromyalgia after 8 weeks of neuromuscular training (31). In addition, patients with fibromyalgia showed improvements on the Star Excursion Balance Test, which is a functional screening tool that can assess lower extremity dynamic stability (17), as well as deficits after an injury (25).
The provided protocol (Tables 2–5) outlines guidelines and suggestions on training volume and specific exercise instructions; however, the prescribed exercises, sets, and repetitions for a juvenile chronic pain condition exercise program should be individualized and attainable for each patient and also modifiable as needed. Initial volume selection should be low to allow the patients with chronic pain to learn how to perform each exercise with proper technique. With data lacking in adolescents with fibromyalgia, we have based our initial progression models (volume and intensity) on those used in healthy children and adolescents (4,18,20). Our preliminary empirical evidence indicates that exercise progression in patients with fibromyalgia should only occur after the patient can properly perform the exercise at the prescribed volume and intensity. The exercise professionals who supervise the training should be skilled in recognizing proper technique and should provide constructive feedback during the learning and development process, especially when improper technique increases risk of pain. Therefore, those involved in treating chronic pain populations may find this protocol useful when working with patients with conditions such as fibromyalgia. Educating the patients about the practical applications of these exercises for their daily life activities also helps strengthen their “buy in” for why exercise and activity should be implemented and how it supports management of their symptoms and, ultimately, improves their daily function. By incorporating these exercises into the lives of adolescents who suffer with chronic pain conditions, such as fibromyalgia, we aim to improve their strength, posture, balance, and biomechanics, so that they gain the ability and confidence to engage in a more active lifestyle.
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