Can Modified Neuromuscular Training Support the

Can ModifiedNeuromuscular TrainingSupport the Treatment ofChronic Pain inAdolescents?Staci M. Thomas, MS,1 Soumitri Sil, PhD,2 Susmita Kashikar-Zuck, PhD,2 and Gregory D. Myer, PhD,1,3–61Cincinnati Children’s Hospital Medical Center, Division of Sports Medicine, Sports Medicine Biodynamics Center andHuman Performance Laboratory, Cincinnati, Ohio; 2Cincinnati Children’s Hospital Medical Center, Division ofBehavioral Medicine and Clinical Psychology, Cincinnati, Ohio; 3Departments of Pediatrics and 4Orthopaedic Surgery,College of Medicine, University of Cincinnati, Cincinnati, Ohio; 5Athletic Training Division, School of Allied MedicalProfessions, The Ohio State University, Columbus, Ohio; and 6Departments of Athletic Training, Rocky MountainUniversity of Health Professions, Provo, Utah

A B S T R A C T

MANY ADOLESCENT PATIENTS

WHO SUFFER FROM CHRONIC

MUSCULOSKELETAL PAIN LIVE

SEDENTARY LIVES BECAUSE OF

DISCOMFORT AND FEAROF FLARE-

UPS WITH ACTIVITY. THEREFORE,

BEFORE INITIATING PHYSICAL

ACTIVITY, PATIENTS WITH

CHRONIC PAINWHO ARE INACTIVE

SHOULD UNDERGO ADEQUATE

TRAINING TO REDUCE THE RISK OF

PAIN FLARE-UPS AND EVEN INJURY.

IMPLEMENTING A NEUROMUSCU-

LAR TRAINING PROGRAM, WHICH

FOCUSES ON GENERAL AND SPE-

CIFIC STRENGTH EXERCISES THAT

TEACH PROPER TECHNIQUE AND

JOINT MECHANICS, MAY PROVIDE

AN OPPORTUNITY TO PREPARE

FOR THE DEMANDS OF INCREAS-

ING PHYSICAL ACTIVITY. THIS

ARTICLE PRESENTS THE DEVEL-

OPMENT OF A NEUROMUSCULAR

TRAINING PROTOCOL SPECIFI-

CALLY DESIGNED FOR USE IN THIS

CLINICAL POPULATION.

INTRODUCTION

Chronic pain, commonly definedas daily or recurrent pain thatpersists for at least 6 months, is

an overlooked public health problemthat affects an estimated 100 millionAmericans (10). The prevalence ofchronic pain is greater than the combi-nation of heart disease, diabetes, andcancer, resulting in an economic burdenof up to $635 billion each year in med-ical treatment (10). Chronic pain isa health condition that affects not onlyadults but also is a surprisingly commonproblem affecting 20–30% of childrenand adolescents (19). At times, the etiol-ogy of pediatric chronic pain is clearlyidentifiable when it is related to a disease,such as cancer, sickle cell anemia, orjuvenile arthritis (2,3,29).

However, many common chronic painconditions in childhood and adoles-cence, such as headaches, abdominalpain, and musculoskeletal pain, canoccur without a clear medical explana-tion and result in considerable diagnosticand treatment challenges for medicalproviders and significant frustration for

the patients and families. These chronicnonmalignant pain syndromes are oftenvery disabling and can impact multipleareas of function within daily activities.For example, children and adolescentswith chronic pain typically experiencesignificant declines in their quality of lifeand increased impairment in physicaland social activities, as well as frequentschool absences (13). In addition, theyreport increased levels of depression,anxiety, and emotional distress (26).One specific chronic pain condition,juvenile fibromyalgia, is characterizedby widespread musculoskeletal pain,multiple painful tender points on touch,fatigue, sleep difficulty, and several otherassociated symptoms. Youth with juve-nile fibromyalgia often have evengreater impairments in functioningcompared to those with other chronicpain conditions, such as higher levels offunctional disability, emotional distress,and more school absences (12,16).

KEY WORDS :

pain; neuromuscular; training; adoles-cents; musculoskeletal

VOLUME 35 | NUMBER 3 | JUNE 2013 Copyright � National Strength and Conditioning Association12

Without appropriate treatment, theseyouth are at risk for continuing painand disability into adulthood (11). Assuch, early implementation of effectivepain management treatment strategiesduring childhood and adolescence iscritical to ease both the economic bur-den and social impact of chronic pain inadulthood.

Several pain management treatments,such as medications, psychological andbehavioral interventions, exercise, andother nonpharmacological therapies arecommonly used to help youth cope withand manage their chronic pain symp-toms. Psychological and behavioralinterventions in the form of cognitive-behavioral therapy (CBT) for pediatricchronic pain, including juvenile fibro-myalgia, has gained strong evidence-based support to effectively decrease painintensity and improve daily physical andemotional function (15,27). CBT focuseson teaching a variety of skills, such asmuscle relaxation, activity pacing, distrac-tion, problem solving, using calmingstatements and others to cope with andreduce pain. Although these strategieshave been found to be useful, it has beensuggested that integrating more than onenonpharmacological approach for pain

may have combinatorial benefits for chil-dren with chronic pain (Figure) (14).

Specifically, preliminary data in adultswith fibromyalgia indicates that theaddition of exercise to behavioral treat-ment can further alleviate debilitatingmusculoskeletal pain symptoms. Forexample, the American Pain Societyrecommends moderately intense aero-bic exercise and muscle strengtheningexercise at least twice per week in addi-tion to self-management interventions(1). Although increased physical activityand exercise have been found to reducepain (7), patients with fibromyalgia andother chronic pain conditions oftenstruggle to meet recommended guide-lines for regular exercise for a variety ofreasons including fatigue, fear thatmovement will increase the intensityof their pain, or long-standing patternsof physical inactivity. As such, we aimedto develop an integrative neuromusculartraining protocol designed specificallyfor youth with juvenile fibromyalgia toprepare them for increased engagementin physical activity.

ACTIVITY IN PATIENTS WITHCHRONIC PAIN

Just as sufficient preparative trainingbefore sports participation should be

considered to prevent injury and tosupport the continued participation ofhealthy adolescents, proper trainingshould also be considered before inte-grating increased physical activity intothe lives of adolescents who live witha chronic pain disorder. Fibromyalgia isone of the most debilitating chronicpain conditions and, often, exercise isstrongly recommended to help patientsresume normal daily activities (1); how-ever, the fear of activity resulting inpotential pain flare-ups and increasedmuscle soreness may ultimately lead tocessation of any physical activityinvolvement. Therefore, sufficient prep-aration for prescribed amounts of activ-ity may be necessary to preventincreased pain. Beginning physical activ-ity without possessing the necessarystrength to perform these activities caneven put a chronic pain patient at risk ofsuffering a traumatic injury; much likeinadequate preparation for sport partic-ipation can put an athlete at risk.Although activity in general is importantto integrate into the everyday life ofchronic pain patients, it is also impera-tive that the type of activity is appropri-ate for this population and the methodof implementation is conducive for theircondition and stage of development. It

Figure. This figure represents an example of a treatment program which integrates more than one approach for treatingadolescents with a chronic pain condition, such as fibromyalgia. Coping skills training and neuromuscular trainingcombined may lead to decreased disability, distress, and pain.

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has long been understood that childrenand adolescents have different learningtechniques than adults, and they requiredevelopmentally appropriate prepara-tion for sport participation and activity(9,20,21,23,24). Therefore, a programinvolving integrative neuromusculartrainingmay be a fitting option for youthwho are seeking to treat their chronicpain condition with exercise.

Integrative neuromuscular trainingcan be defined as a program or planthat incorporates general and specificstrength and conditioning activities,which enhance fundamental skill-related components of physical fitness.Furthermore, integrative neuromuscu-lar training consists of a series of exer-cises, particularly designed to improvechildren and adolescents’ balance, pos-ture, strength, and mechanics, to enablethem to safely participate in higher lev-els of activity while minimizing risk forinjury (21,22). Specifically, we empha-size the importance of establishing fun-damental motor skills (locomotor skillssuch as running, jumping, hopping, andstrength determined functional pos-tures) that will serve as a foundationfor sustained physical activity through-out life.

NEUROMUSCULAR TRAINING INADOLESCENT PATIENTS WITHFIBROMYALGIA

Preliminary data from our laboratoryindicate that children and adolescentswith musculoskeletal pain have a pro-pensity for altered gait (reduced stridelength) and biomechanical (reducedlower extremity strength and posturalcontrol) deficits relative to norms thatmay make them more prone to injuryor exacerbated pain with exercise. Forexample, patients with juvenile idio-pathic arthritis have demonstratedaltered landing mechanics duringa drop vertical jump task when com-pared with control subjects, and thesebiomechanical deficits were also foundto be predictive of higher disability (6).In addition, results from our laboratoryindicate that adolescents with fibromyal-gia exhibit decreased knee extension,knee flexion, and hip abduction strengthand dynamic stability when compared

with their active peers (30). Designingan appropriate intervention for fibro-myalgia patients with chronic painshould, therefore, involve specializedinstruction in fundamental movementsand strength building while minimizingthe likelihood of pain flare-ups. A spe-cifically designed program, includingresistance, dynamic stability, and corefocused strength exercises, which targetmotor control deficits, should be imple-mented while taking into accountpatients’ baseline level of fitness.The minimization of the potential fordelayed onset muscle soreness that canarise after resistive exercise would alsobe an important consideration forpatients who already suffer from painand may have difficulty tolerating theincreased soreness or distinguishing itfrom their pain symptoms. Traditionalexercise programs typically involve pro-longed periods of aerobic exercise orhigh volume resistance training, whichmay not be desirable for youthwith juvenile fibromyalgia. Therefore,implementing a neuromuscular trainingprogram where intermittent-type activ-ities are used may be more beneficial inreducing the exercise-induced symp-toms and soreness.

Each exercise in this training program foradolescents with juvenile fibromyalgiawas selected based on the concept offundamental skill development and mod-ified from well-established neuromuscu-lar training programs used for healthyactive adolescents. These training pro-grams have previously been shown tobe effective in significantly reducing riskof injury in young adolescent female ath-letes by improving landing mechanics,dynamic stability, and lower extremityneuromuscular control (5,8,20). Thisprogram has been developed in fourlevels of progression, with each stagefocusing on a different muscle action,therefore requiring each participant toadequately and consistently performeach action before progressing to thenext level (Table 1). Each level of thisprotocol contains exercises focused onthe following movement concepts:squat; hip hinge; posterior chain devel-opment; anterior, posterior, and

rotational core development; pushingmovements; and pulling movements(Tables 2–5).

GUIDELINES FOR IMPLEMENTINGNEUROMUSCULAR TRAININGWITH PATIENTS WITH CHRONICPAIN

When implementing training pro-grams with adolescents who sufferfrom chronic musculoskeletal pain,trainers should be cautious of hyper-mobile joints, previous injury or sur-gery history, and common body partsthat are typically the most bothersomefor these patients. They should alsobe aware of ranges of motion through-out these exercises, joint alignment,and equal distribution of resistancebetween the limbs involved in theexercise. For example, often patientswith chronic pain are protective of cer-tain body parts that have been previ-ously injured or where they havefrequent pain and tend to compensateby guarding that part of their bodythrough unequal weight distributionon their lower extremities or favoringtheir affected limb. This is often drivenby underlying anxiety or fear that painwill be worsened with use. The trainershould also take caution in using theword “pain” or “hurt” when askingabout the patient’s perception of eachexercise, as that can be a trigger forthese patients to associate pain withexercise (28,32). Also, many patientsare using their muscles in a new wayduring the exercises and any new feel-ing in their body that is different oruncomfortable may automatically beperceived as pain. Therefore, an impor-tant lesson for patients to learn whiledoing these exercises is differentiatingbetween “pain” and muscle “soreness.”The training staff should explain to thepatients that normal active youth oftenexperience a burning or soreness withthe exercise program. Through com-munication with the instructor, pa-tients with chronic pain may find thatthe exercise induced soreness is a tem-porary result and may not be the samepain “flare-ups” that they experiencewith their condition. As patients adaptto training and gain an appreciation of

Development of a Neuromuscular Training Protocol

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this difference in muscle soreness andpain, the patient’s adherence to theprogram will likely improve. This edu-cation also helps normalize their expe-rience and gain more confidence in theway their body moves while lesseningany anxiety that being active willworsen their pain. Additionally, thetraining staff should be ready to buildin appropriate breaks and rest periodsto help prevent patients’ from overex-erting themselves, which can lead topain flare ups considering their previ-ous sedentary lifestyle. It is thereforeimportant to teach the patients howto control the pace of exercises duringthe training and while practicing athome, as it is common for patients totry to hurry through the exercises tocomplete their program for that dayquickly. Giving the patients specificinstructions on how to pace eachexercise will keep them focused onthe exercise at hand and also teachthem how to control their body andperform the movements safely andeffectively (For specific exercise in-structions, see Tables 2–5). As notedpreviously, adolescents with fibromyal-gia demonstrate significant deficits inlower extremity strength and dynamicpostural control relative to their

unaffected peers. The present protocolhas been successfully used with adoles-cents in our laboratory, and prelimi-nary results indicate improved kneeextensor and hip abduction strengthin adolescent patients with fibromyal-gia after 8 weeks of neuromusculartraining (31). In addition, patientswith fibromyalgia showed improve-ments on the Star Excursion BalanceTest, which is a functional screeningtool that can assess lower extremitydynamic stability (17), as well as deficitsafter an injury (25).

The provided protocol (Tables 2–5)outlines guidelines and suggestions ontraining volume and specific exerciseinstructions; however, the prescribedexercises, sets, and repetitions for ajuvenile chronic pain condition exer-cise program should be individualizedand attainable for each patient and alsomodifiable as needed. Initial volumeselection should be low to allow thepatients with chronic pain to learnhow to perform each exercise withproper technique. With data lackingin adolescents with fibromyalgia, wehave based our initial progressionmodels (volume and intensity) onthose used in healthy children and

adolescents (4,18,20). Our preliminaryempirical evidence indicates that exer-cise progression in patients with fibro-myalgia should only occur after thepatient can properly perform the exer-cise at the prescribed volume andintensity. The exercise professionalswho supervise the training should beskilled in recognizing proper techniqueand should provide constructive feedbackduring the learning and developmentprocess, especially when improper tech-nique increases risk of pain. Therefore,those involved in treating chronic painpopulations may find this protocol usefulwhen working with patients with condi-tions such as fibromyalgia. Educating thepatients about the practical applicationsof these exercises for their daily life activ-ities also helps strengthen their “buy in”for why exercise and activity should beimplemented and how it supports man-agement of their symptoms and, ulti-mately, improves their daily function.By incorporating these exercises intothe lives of adolescents who suffer withchronic pain conditions, such as fibro-myalgia, we aim to improve theirstrength, posture, balance, and biome-chanics, so that they gain the abilityand confidence to engage in a moreactive lifestyle.

Table 1A description of each level of progression

Level 1—Isometric focused exercises (Table 2)

The exercises for level 1 are focused on obtaining and then sustaining proper joint position and technique. Before progressing toLevel 2, each participant should be able to position himself or herself in the proper alignment and maintain that correct form forthe prescribed time.

Level 2—Concentric focused exercises (Table 3)

The exercises for Level 2 are focused on each participant properly, creating the movement for each exercise, thus performingprimarily concentric muscle contractions. The use of the TRX Suspension Trainer (Fitness Anywhere LLC, San Francisco, CA) aidsin providing assistance to the participants during the eccentric movement phase of the appropriate exercises. Once eachparticipant can correctly and confidently produce the movement for each exercise, he or she may progress to Level 3.

Level 3—Eccentric focused exercises (Table 4)

The exercises for Level 3 are focused on resisting movement for each exercise, therefore resulting in each participant primarilyperforming eccentric muscle actions. The use of the TRX Suspension Trainer allows the participants to gain assistance inperforming the concentric movement phase of the appropriate exercises. Once each participant can correctly and confidentlyperform the eccentric muscle contractions necessary for each exercise, he or she may progress to Level 4.

Level 4—Functional movement exercises (Table 5)

The exercises in Level 4 are focused on each participant performing both concentric and eccentric muscle actions, thereforeresulting in functional movements, which will aid in preparing patients with chronic pain for increasing their physical activity.


Table 2Level 1 isometric exercises for an integrative neuromuscular training program for adolescents with fibromyalgia

Level 1—Hold exercises Time/reps Sets

Level 1—BOSU� Balance Trainer (BOSU, Ashland, OH) double leg deephold with TRX upper body assistance

The patient starts by standing on the BOSU with the round sideup and holding onto the TRX handles. Then, the patient bends hisor her hips and knees until the knees are bent to approximately908, using the TRX handles as support. The patient holds thisposition for the prescribed time.

10 s 2

Level 1—Double leg pelvic bridge hold

The patient starts by laying on the mat with the knees bent andfeet on the floor. Then, the patient pushes through the heels ofthe feet, raising the pelvis off the ground as high as possible.They hold this position for the prescribed time.

10 s 2

Level 1—Stability ball hamstring curls (partner assisted)

The patient starts by lying on the floor, with the stability ball placedunder the heels and the legs extended. With a partner holdingonto the stability ball, the patient lifts their hips off the ground.With partner assistance, the patient then bends the knees andpulls the ball into their body as far as possible, then returns tothe starting position and repeats.

6–8 reps 2

Level 1—Kneeling plank on mat

The patient positions both knees on the mat and bothelbows on the ground. The patient then positions their body sothat their hips are in line with their shoulders and knees. Theyhold this position for the prescribed amount of time.

10 s 2

Level 1—Superman hold

(continued)

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Table 2(continued)

The patient lies prone on the mat with their arms extended bytheir head. They lift their arms and legs off the ground andhold this position for the prescribed time.

10 s 2

Level 1—TRX rotary hold with staggered stance

The patient stands away from the anchored position of the TRXsystem, positioned perpendicular to the anchor. Holding ontothe handles, the patient secures his or her footing and leansaway from the anchor to assume the starting position. To performthe exercise, the patient will hold onto the handles with armsextended and pull himself or herself into an upright position andwill hold this position for the prescribed time. This exercise can bemodified by changing the placement of the feet (closer to theanchor will increase difficulty, farther from anchor will decreasedifficulty).

10 s 2 (per side)

Level 1—TRX chest press hold

The patient stands with a staggered stance, facing away from theTRX anchor point, holding the TRX handles at chest level, witharms extended. The patient leans forward, putting resistance inthe legs until reaching a position where the elbows are bent,hands are at chest level, and the patient is supporting himselfor herself with the upper body. The patient then holds this positionfor the prescribed time. This exercise can be modified by changingthe placement of the feet (closer to the anchor will increasedifficulty, farther from anchor will decrease difficulty).

6–8 reps 2

Level 1—TRX row stabilization-multiangle hold

The patient grabs both handles, then walks the feet out to thedesired position and leans the body back, maintaining a straightline from his or her shoulders to the feet. With arms extended,the patient will adduct the shoulder blades and holds the positionfor the prescribed amount of time. The patient pulls the upperbody into an upper row position and holds for the prescribedtime. This exercise can be modified by changing the placement ofthe feet (closer to the anchor will increase difficulty, farther fromanchor will decrease difficulty).

10 s 2 (per position)

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Table 3Concentric focused exercises for an integrative neuromuscular training program for adolescents with fibromyalgia

Level 2—Creating movement exercises Reps Sets

Level 2—BOSU double leg squat up—with TRX assistance down

The patient starts by standing on the BOSU with the round side up andholding onto the TRX handles. Then, the patient bends the hips andknees until the knees are bent to approximately 908, using the TRXhandles as support on the way down. The patient will slowly (3 count)raise himself or herself back to the starting position, using as littlesupport from the TRX handles as possible (arms are relaxed).

6–8 reps 2

Level 2—double leg pelvic bridge raise

The patient starts by lying on the mat with the knees bent and feet onthe floor. Then, the patient pushes through the heels of his or her feet,slowly (3 count) raising the pelvis off the ground as high as possibleand returns to the starting position and repeats.

6–8 reps 2

Level 2—reverse hyperextensions on stability ball

The patient starts by lying on the stability ball with the belly on the balland hands on the floor in front of them, then slowly (3 count) raisetheir feet and legs off the ground and as high as possible whilekeeping legs straight.

6–8 reps 2

Level 2—BOSU crunch-up with TRX assistance down

The patient starts by sitting in the middle of the BOSU, round side up.Using the TRX handles for support, the patient will lower his or hertrunk backward toward the floor but not to full extension. Then,slowly (3 count) and with as little support from the TRX handles aspossible, the patient will return to the starting position.

6–8 reps 2

Level 2—Superman arms raises

The patient lies prone on the mat with the arms extended by the head.Then, the patient slowly (3 count) lifts the upper body off the groundas high as possible, keeping the feet off the ground.

6–8 reps 2

(continued)


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Table 3(continued)

Level 2–TRX rotary pull up with staggered stance

The patient stands away from the anchored position of the TRX system,positioned perpendicular to the anchor. Holding onto the handles,the patient secures their footing in a staggered stance and leans awayfrom the anchor to assume the starting position. To perform theexercise, with their arms extended, the patient will use the trunkmuscles to slowly (3 count), pull himself or herself into an uprightposition, and then retracts the arms close to their body and returns tothe starting position. This exercise can be modified by changing theplacement of the feet (closer to the anchor will increase difficulty,farther from anchor will decrease difficulty).

6–8 reps 2 (per side)

Level 2—TRX chest press up—staggered stance

The patient stands with a staggered stance, facing away from the TRXanchor point, holding the TRX handles at chest level, with armsextended. Without supporting themselves on the handles, the patientleans forward, until reaching a position where the elbows are bentand hands are at chest level. Then she or he engages the upper bodyand supports himself or herself on the handles. The patient leans thebody weight into the handles, then slowly (3 count) pushes away,returning to the starting position. This exercise can be modified bychanging the placement of the feet (closer to the anchor will increasedifficulty, farther from anchor will decrease difficulty).

6–8 reps 2

Level 2—TRX row—up

The patient starts by holding the handles (with the straps tight) and atchest level and the arms straight. Then, the patient takes a big steptoward the anchor, while keeping the arms straight and leaning thebody backward to maintain tension in the straps, which puts him orher in the starting position. Then, slowly (3 count) the patientengages the upper back and shoulder muscles and performs therowing motion until reaching an upright position. Taking a stepbackward will reposition them in the appropriate position to beginthe exercise again. This exercise can be modified by changing theplacement of the feet (closer to the anchor will increase difficulty,farther from anchor will decrease difficulty).

6–8 reps 2

The pictures outlined in yellow depict the movement phase, which the participant is actively performing.

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Table 4Eccentric focused exercises for an integrative neuromuscular training program for adolescents with fibromyalgia

Level 3—Resisting movement exercises Reps Sets

Level 3—BOSU double leg squat down—withTRX assistance up

The patient starts by standing on the BOSU withthe round side up and holding onto the TRXhandles. Then, the patient slowly (count of 3)bends the hips and knees until the knees arebent to approximately 908, using the TRXhandles as little as possible for support on theway down. With support from the TRX handles,the patient will raise back to the startingposition.

6–8 reps 2

Level 3—Single leg hip hinge with RDL

Standing on 1 leg with the knee slightly flexed,the patient will bend at the waist slowly as faras he or she can go without pain (as if touchingthe toes). Then, the patient will place both thefeet back on the ground and return to thestarting position bilaterally.

6–8 reps 2 (per leg)

Level 3—Assisted back extensions on stabilityball

The patient starts by lying on the stability ball,belly down, with the ball positioned on his orher hips. With a resistance band placed underthe arms, the patient loops their thumbs underthe band at chest level and starts in a positionof trunk extension. Without assistance from theband, the patient slowly (count of 3) lowers toa position where he or she is lying over the ball.Then, with assistance from the trainer, returnsto the starting position.

6–8 reps 2

(continued)


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Table 4(continued)

Level 3—BOSU crunch-down with TRX assistanceup

The patient starts by sitting in the middle of theBOSU, round side up. Using the TRX handles foras little support as possible, the patient willlower (count of 3) the trunk backward towardthe floor but not to full extension. Then, usingthe TRX handles for support, the patient willreturn to the starting position.

6–8 reps 2

Level 3—Swimmers

The patient lies prone on the mat with the armsextended by the head. Lifting his or her upperbody off the ground, the patient raises 1 armand the opposite leg at the same time. Then,the patient lowers both arms and legs andrepeats with the opposite sides.


Level 3—TRX Rotary RESIST with staggeredstance

The patient stands perpendicular to the anchoredposition of the TRX system. Holding onto thehandles with the arms straight at chest level,the patient secures the footing in a staggeredstance. Slowly (count of 3), leaning away fromthe TRX anchor, using the trunk muscles tocontrol this motion, while keeping the hips inline with the shoulders and feet, until reachingthe maximum position. Then, the patient canside step to reposition the feet and relieve thecontraction and return to the starting position.This exercise can be modified by changing theplacement of the feet (closer to the anchor willincrease difficulty, farther from anchor willdecrease difficulty).


(continued)

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Table 4(continued)

Level 3—TRX chest press down—staggeredstance

The patient stands with a staggered stance,facing away from the TRX anchor point,holding the TRX handles at chest level, witharms extended. While engaging the upperbody muscles, the patient supports himself orherself on the handles, and slowly (count of 3)leans forward, until reaching a position wheretheir elbows are bent and hands are at chestlevel. Then the patient can relax the upperbody and use their lower body to pushbackward and return to the starting position.This exercise can be modified by changing theplacement of the feet (closer to the anchor willincrease difficulty, farther from anchor willdecrease difficulty).

6–8 reps 2

Level 3—TRX row—down

The patient starts by holding the handles (withthe straps tight) at chest level and the elbowsbent at 908. Then, the patient takes a big steptoward the anchor, while keeping the armsbent and leaning the body backward tomaintain tension in the straps, putting them inthe starting position. Then, slowly (3 count) thepatient lowers himself or herself to a position inwhich the arms are fully extended, using theupper back and shoulder muscles to controlthis motion. Taking a step backward willreposition them in the starting position.

6–8 reps 2

RDL 5 Romanian Dead Lift. Pictures outlined in blue depict the movement phase, which the participant is actively performing.


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Table 5Functional movement exercises for an integrative neuromuscular training program for adolescents with fibromyalgia

Level 4—Functional movement exercises Reps Sets

Level 4—BOSU squats with TRX upper bodyassistance

The patient starts by standing on the BOSU with theround side up. Then, the patient bends the hipsand knees until the knees are bent toapproximately 908. The patient then returns to thestarting position and repeats. Using the TRX for aslittle assistance as possible through the entirerange of motion.

6–8 reps 2

Level 4—Single leg floor touches (RDL)

Standing with both knees slightly flexed, the patientlifts 1 foot from the ground and bends at the waistslowly as far as he or she can go without pain (as iftouching the toes), while extending the oppositeleg. Then, while digging the heel into the groundand keeping their knee slightly bent, the patientwill slowly return to the starting position.

6–8 reps 2

Level 4—stability ball hamstring curls

The patient lies on the mat, with the stability ballplaced under the heels and legs extended. Then,the patient lifts their hips off the ground and pullsthe ball into their body, then lifts the hips off theground. Slowly, the patient extends the legs whilekeeping the hips off the ground and returns to thestarting position.

6–8 reps 2

Level 4—BOSU double crunch—full

The patient starts by sitting in the middle of theBOSU, slightly toward the front and round side up.Placing their arms across their chest, the patientthen slowly lowers the upper body to a positionbelow neutral. Using the abdominal muscles, thepatient raises the trunk back to the startingposition, using as little support from the TRX aspossible throughout the entire range of motion.

6–8 reps 2

(continued)

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Table 5(continued)

Level 4—toe touch swimmers

The patient lies prone on the mat with the armsextended by the head. Lifting the upper body offthe ground, the patient reaches back with 1 arm totouch the opposite foot, then repeats for the otherside.


Level 4—TRX functional rotation with staggeredstance

The patient starts perpendicular to the anchor.Holding onto the handles straight out in front ofhim or her, the patient secures the footing ina staggered stance. Slowly, leans away from theTRX anchor, while keeping the hips in line withthe shoulders and feet, until he or she reaches themaximum position. Then, using the trunk muscles,will pull himself or herself into an upright positionand repeat.


Level 4—TRX chest press—full—staggered stance

The patient stands with a staggered stance, facingaway from the TRX anchor point, holding the TRXhandles at chest level, with arms extended. Thepatient slowly leans forward, using the arms tohold the trunk in position, until reachinga position where the elbows are bent and handsare at chest level. Then, using the arms and chest,he or she pushes the upper body back to thestarting position.

6–8 reps 2

Level 4—TRX row—full ROM

The patient grabs both handles and holds them atchest level with the palms facing the midline.Slowly, lowering the upper body by extending thearms fully. Then, pulling the upper body upwardby bending at the arms, returning to the startingposition and repeating.

6–8 reps 2

RDL5 Romanian Dead Lift. Pictures outlined in green depict the movement phase, which the participant is actively performing. Each phase of movement should be performed for a countof 3 seconds.


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Conflicts of Interest and Source of Funding:Supported by the National Institutes ofHealth/NIAMS Grants R01-AR055563and K24-AR056687. The authors reportno conflicts of interest.

Staci M.

Thomas is a clin-ical researchcoordinator forthe Human Per-formance Labo-ratory in theDivision ofSports Medicine

at Cincinnati Children’s Hospital Med-ical Center.

Soumitri Sil isa psychology painfellow specializ-ing in pediatricpain manage-ment at Cincin-nati Children’sHospital.

Susmita

Kashikar-Zuck

is the lead psy-chologist of thePediatric and isthe lead of thePediatric PainResearch andTreatment Pro-gram at Cincin-nati Children’s

Hospital.

Gregory D.

Myer is the direc-tor of researchand the HumanPerformanceLaboratory forthe Division ofSports Medicineat CincinnatiChildren’s Hos-pital Medical

Center.

REFERENCES1. American Pain Society. Guideline for

Management of Fibromyalgia Syndrome

Pain in Adults and Children. Glenview, IL:

American Pain Society, 2005.

2. Andersson G. Juvenile arthritis—who gets it,

where and when? A review of current data

on incidence and prevalence. Clin Exp

Rheumatol 17: 367–374, 1999.

3. Ballas SK. Pain management of sickle cell

disease. Hematol Oncol Clin North Am 19:

785–802, v, 2005.

4. Faigenbaum AD, Kraemer WJ, Blimkie CJ,

Jeffreys I, Micheli LJ, Nitka M, and

Rowland TW. Youth resistance training:

updated position statement paper from the

national strength and conditioning

association. J Strength Cond Res 23:

S60–S79, 2009.

5. Filipa A, Byrnes R, Paterno MV, Myer GD,

and Hewett TE. Neuromuscular training

improves performance on the star

excursion balance test in young female

athletes. J Orthop Sports Phys Ther 40:

551–558, 2010.

6. Ford KR, Myer GD, Melson PG, Darnell SC,

Brunner HI, and Hewett TE. Land-jump

performance in patients with juvenile

idiopathic arthritis (JIA): A comparison to

matched controls. Int J Rheumatol 2009:

478526, 2009.

7. Hauser W, Klose P, Langhorst J, Moradi B,

Steinbach M, Schiltenwolf M, and Busch A.

Efficacy of different types of aerobic

exercise in fibromyalgia syndrome: A

systematic review and meta-analysis of

randomised controlled trials. Arthritis Res

Ther 12: R79, 2010.

8. Hewett TE, Lindenfeld TN, Riccobene JV,

and Noyes FR. The effect of neuromuscular

training on the incidence of knee injury in

female athletes. A prospective study. Am J

Sports Med 27: 699–706, 1999.

9. Hewett TE, Myer GD, and Ford KR. Reducing

knee and anterior cruciate ligament injuries

among female athletes: A systematic review

of neuromuscular training interventions.

J Knee Surg 18: 82–88, 2005.

10. Institute of Medicine of the National

Academies. Relieving Pain in America: A

Blueprint for Transforming Prevention,

Care, Education, and Research.

Washington, DC: Committee on

Advancing Pain Research, Care, and

Education, 2001.

11. Jones GT, Power C, and Macfarlane GJ.

Adverse events in childhood and chronic

widespread pain in adult life: Results from

the 1958 British Birth Cohort Study. Pain

143: 92–96, 2009.

12. Kashikar-Zuck S, Flowers SR, Claar RL,

Guite JW, Logan DE, Lynch-Jordan AM,

Palermo TM, and Wilson AC. Clinical utility

and validity of the Functional Disability

Inventory among a multicenter sample of

youth with chronic pain. Pain 152: 1600–

1607, 2011.

13. Kashikar-Zuck S, Goldschneider KR,

Powers SW, Vaught MH, and Hershey AD.

Depression and functional disability in

chronic pediatric pain. Clin J Pain 17:

341–349, 2001.

14. Kashikar-Zuck S, Myer G, and Ting TV. Can

behavorial treatments be enhanced by

integrative neuromuscular training in the

treatment of juvenile fibromyalgia? Pain

Manag 2: 9–12, 2012.

15. Kashikar-Zuck S, Ting TV, Arnold LM,

Bean J, Powers SW, Graham TB,

Passo MH, Schikler KN, Hashkes PJ,

Spalding S, Lynch-Jordan AM, Banez G,

Richards MM, and Lovell DJ. Cognitive

behavioral therapy for the treatment

of juvenile fibromyalgia: a multisite,

single-blind, randomized, controlled

clinical trial. Arthritis Rheum 64: 297–

305, 2012.

16. Kashikar-Zuck S, Vaught MH,

Goldschneider KR, Graham TB, and

Miller JC. Depression, coping, and functional

disability in juvenile primary fibromyalgia

syndrome. J Pain 3: 412–419, 2002.

17. Kinzey SJ and Armstrong CW. The

reliability of the star-excursion test in

assessing dynamic balance. J Orthop

Sports Phys Ther 27: 356–360, 1998.

18. Lloyd RS, Faigenbaum AD, Myer GD,

Stone MH, Oliver JL, Jefferys I, Moody J,

Brewer C, and Pierce K. United Kingdom

strength and conditioning association

(UKSCA) position statement on youth

resistance training. Prof Strength Cond J,

2012.

19. Mayday Fund. A Call to Revolutionize

Chronic Pain Care in America: An

Opportunity in Health Care Reform.

Washington, DC: Special Committee on

Pain and the Practice of Medicine, 2009.

20. Myer GD, Chu DA, Brent JL, and

Hewett TE. Trunk and hip control

neuromuscular training for the prevention

of knee joint injury. Clin Sports Med 27:

425–448, ix, 2008.

21. Myer GD, Faigenbaum AD, Chu DA,

Falkel J, Ford KR, Best TM, and Hewett TE.

Integrative training for children and

adolescents: techniques and practices for

reducing sports-related injuries and

enhancing athletic performance. Phys

Sportsmed 39: 74–84, 2011.


22. Myer GD, Faigenbaum AD, Ford KR,

Best TM, Bergeron MF, and Hewett TE.

When to initiate integrative neuromuscular

training to reduce sports-related injuries

and enhance health in youth? Curr Sports

Med Rep 10: 155–166, 2011.

23. Myer GD, Ford KR, Brent JL, and

Hewett TE. The effects of plyometric vs.

dynamic stabilization and balance training

on power, balance, and landing force in

female athletes. J Strength Cond Res 20:

345–353, 2006.

24. Myer GD, Ford KR, McLean SG, and

Hewett TE. The effects of plyometric

versus dynamic stabilization and balance

training on lower extremity

biomechanics. Am J Sports Med 34:

445–455, 2006.

25. Olmsted LC, Carcia CR, Hertel J, and

Shultz SJ. Efficacy of the star excursion

balance tests in detecting reach

deficits in subjects with chronic ankle

instability. J Athl Train 37: 501–506,

2002.

26. Palermo TM. Impact of recurrent and

chronic pain on child and family daily

functioning: a critical review of the

literature. J Dev Behav Pediatr 21: 58–69,

2000.

27. Palermo TM, Eccleston C,

Lewandowski AS, Williams AC, and

Morley S. Randomized controlled trials

of psychological therapies for

management of chronic pain in children

and adolescents: an updated meta-

analytic review. Pain 148: 387–397,

2010.

28. Palermo T and von Baeyer C. How to talk to

parents about recurrent and chronic pain.

Pain in Children: A Practice Guide for

Primary Care. Totowa, New Jersey:

Humana Press, 2008.

29. Portenov R. Cancer pain: Epidemiology and

syndromes. Cancer 63: 2298–2307, 2006.

30. Sil S, Thomas S, Strotman D, DiCesare C,

Ting T, Myer G, and Kashikar-Zuck S.

Evidence of physical deconditioning in

adolescents with juvenile fibromyalgia:

Deficiencies in strength and balance.

Presented at: American Pain Society, New

Orleans, LA, May 8–11, 2013.

31. Thomas S SS, Strotman D, Ting T,

DiCesare C, Kashikar-Zuck S, and Myer G.

The implementation of a neuromuscular

training program with two adolescent

fibromyalgia patients: A case report.

Presented at: American College of Sports

Medicine, Indianapolis, Indiana, New

Orleans, LA, May 28-June 1, 2013.

32. Vlaeyen JW and Linton SJ. Fear-avoidance

and its consequences in chronic

musculoskeletal pain: A state of the art.

Pain 85: 317–332, 2000.

Development of a Neuromuscular Training Protocol

VOLUME 35 | NUMBER 3 | JUNE 201326

Documents

Can Modified Neuromuscular Training Support the