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1.  Time-Wise Change in Neck Pain in Response to Rehabilitation with Specific Resistance Training: Implications for Exercise Prescription 
PLoS ONE  2014;9(4):e93867.
Purpose
To determine the time-wise effect of specific resistance training on neck pain among industrial technicians with frequent neck pain symptoms.
Methods
Secondary analysis of a parallel-group cluster randomized controlled trial of 20 weeks performed at two large industrial production units in Copenhagen, Denmark. Women with neck pain >30 mm VAS (N = 131) were included in the present analysis. The training group (N = 77) performed specific resistance training for the neck/shoulder muscles three times a week, and the control group (N = 54) received advice to stay active. Participants of both groups registered neck pain intensity (0–100 mm VAS) once a week.
Results
Neck pain intensity was 55 mm (SD 23) at baseline. There was a significant group by time interaction for neck pain (F-value 2.61, P<0.001, DF = 19). Between-group differences in neck pain reached significance after 4 weeks (11 mm, 95% CI 2 to 20). The time-wise change in pain showed three phases; a rapid decrease in the training group compared with the control group during the initial 7 weeks, a slower decrease in pain during the following weeks (week 8–15), and a plateau during the last weeks (week 16–20). Adherence to training followed a two-phase pattern, i.e. weekly participation rate was between 70–86% during the initial 7 weeks, dropping towards 55–63% during the latter half of the training period.
Conclusion
Four weeks of specific resistance training reduced neck pain significantly, but 15 weeks is required to achieve maximal pain reduction. The time-wise change in pain followed a three-phase pattern with a rapid effect during the initial 7 weeks followed by a slower but still positive effect, and finally a plateau from week 15 and onwards. Decreased participation rate may explain the decreased efficacy during the latter phase of the intervention.
doi:10.1371/journal.pone.0093867
PMCID: PMC3977960  PMID: 24709874
2.  Effect of workplace- versus home-based physical exercise on pain in healthcare workers: study protocol for a single blinded cluster randomized controlled trial 
Background
The prevalence and consequences of musculoskeletal pain is considerable among healthcare workers, allegedly due to high physical work demands of healthcare work. Previous investigations have shown promising results of physical exercise for relieving pain among different occupational groups, but the question remains whether such physical exercise should be performed at the workplace or conducted as home-based exercise. Performing physical exercise at the workplace together with colleagues may be more motivating for some employees and thus increase adherence. On the other hand, physical exercise performed during working hours at the workplace may be costly for the employers in terms of time spend. Thus, it seems relevant to compare the efficacy of workplace- versus home-based training on musculoskeletal pain. This study is intended to investigate the effect of workplace-based versus home-based physical exercise on musculoskeletal pain among healthcare workers.
Methods/Design
This study was designed as a cluster randomized controlled trial performed at 3 hospitals in Copenhagen, Denmark. Clusters are hospital departments and hospital units. Cluster randomization was chosen to increase adherence and avoid contamination between interventions. Two hundred healthcare workers from 18 departments located at three different hospitals is allocated to 10 weeks of 1) workplace based physical exercise performed during working hours (using kettlebells, elastic bands and exercise balls) for 5 × 10 minutes per week and up to 5 group-based coaching sessions, or 2) home based physical exercise performed during leisure time (using elastic bands and body weight exercises) for 5 × 10 minutes per week. Both intervention groups will also receive ergonomic instructions on patient handling and use of lifting aides etc. Inclusion criteria are female healthcare workers working at a hospital. Average pain intensity (VAS scale 0-10) of the back, neck and shoulder (primary outcome) and physical exertion during work, social capital and work ability (secondary outcomes) is assessed at baseline and 10-week follow-up. Further, postural balance and mechanical muscle function is assessed during clinical examination at baseline and follow-up.
Discussion
This cluster randomized trial will investigate the change in self-rated average pain intensity in the back, neck and shoulder after either 10 weeks of physical exercise at the workplace or at home.
Trial registration
ClinicalTrials.gov (NCT01921764).
doi:10.1186/1471-2474-15-119
PMCID: PMC3991922  PMID: 24708570
Musculoskeletal disorders; Occupational health; Health care; Strength training; Back pain; Neck pain; Shoulder pain
3.  Association between Neck/Shoulder Pain and Trapezius Muscle Tenderness in Office Workers 
Pain Research and Treatment  2014;2014:352735.
Background. Neck/shoulder pain is a common musculoskeletal disorder among adults. The pain is often assumed to be related to muscular tenderness rather than serious chronic disease. Aim. To determine the association between neck/shoulder pain intensity and trapezius muscle tenderness in office workers. Methods. 653 employees from two large office workplaces in Copenhagen, Denmark, replied to a questionnaire on health and working conditions (mean: age 43 years, body mass index 24 kg·m−2, computer use 90% of work time, 73% women). Respondents rated intensity of neck/shoulder pain during the previous three months on a scale of 0–10 and palpable tenderness of the upper trapezius muscle on a scale of “no tenderness,” “some tenderness,” or “severe tenderness.” Odds ratios for tenderness as a function of neck/shoulder pain intensity were determined using cumulative logistic regression controlled for age, gender, and chronic disease. Results. The prevalence of “no,” “some,” and “severe” tenderness of the trapezius muscle was 18%, 59%, and 23% in women and 51%, 42%, and 7% in men, respectively (chi-square, P < 0.0001). Participants with “no,” “some,” and “severe” tenderness of the trapezius muscle, respectively, rated their neck/shoulder pain intensity to 1.5 (SD 1.6), 3.8 (SD 2.0), and 5.7 (SD 1.9) for women and 1.4 (SD 1.4), 3.1 (SD 2.2), and 5.1 (SD 1.7) for men. For every unit increase in neck/shoulder pain intensity, the OR for one unit increase in trapezius tenderness was 1.86 (95% confidence interval 1.70 to 2.04). Conclusion. In office workers, a strong association between perceived neck/shoulder pain intensity and trapezius muscle tenderness exists. The present study provides reference values of pain intensity among office workers with no, some, and severe tenderness of the trapezius muscle.
doi:10.1155/2014/352735
PMCID: PMC3985383  PMID: 24800070
4.  Reliability of a Simple Physical Therapist Screening Tool to Assess Errors during Resistance Exercises for Musculoskeletal Pain 
BioMed Research International  2014;2014:961748.
The main objective was to investigate the intra- and intertester reliability of a simple screening tool assessing errors in exercise execution by visual observation. 38 participants with no previous resistance exercise experience practiced for two weeks four typical upper limb exercises using elastic tubing. At 2-week follow-up, the participants were invited for a test-retest assessment on errors in technical execution. The assessment was based on ordinal deviation of joint position from neutral of the shoulder, elbow, and wrist in a single plane by visual observation. Moderate intratester reliability weighted kappa (wΚ) score ranging from 0.50 (0.21–0.71) to 0.57 (0.24–0.82) for observer 1 and a fair to moderate intratester reliability wΚ score ranging from 0.27 (0.09–0.43) to 0.52 (0.15–0.86) for observer 2 across the four exercises was observed. For intertester reliability moderate to substantial mean wΚ scores were found between the two observers, slightly improving from round one to round two ranging from 0.40 (0.20–0.59) to 0.68 (0.45–0.91) in round one to 0.52 (0.20–0.80) to 0.69 (0.39–0.86) in round two. The exercise error assessment demonstrated fair to substantial intratester and intertester reliability, which is congruent with previously published studies. Hence the simplicity of defining a neutral joint position for each of the involved joints in the exercise and categorizing the deviation in “some deviation” and “substantial deviation” to either side in a single plane is a viable and inexpensive solution when assessing for errors during exercise.
doi:10.1155/2014/961748
PMCID: PMC3971509  PMID: 24738079
5.  SPECIFIC AND CROSS OVER EFFECTS OF MASSAGE FOR MUSCLE SORENESS: RANDOMIZED CONTROLLED TRIAL 
Purpose/Background:
Muscle soreness can negatively interfere with the activities of daily living as well as sports performance. In the working environment, a common problem is muscle tenderness, soreness and pain, especially for workers frequently exposed to unilateral high repetitive movements tasks. The aim of the study is therefore to investigate the acute effect of massage applied using a simple device Thera‐band roller Massager on laboratory induced hamstring muscle soreness, and the potential cross over effect to the non‐massaged limb.
Methods:
22 healthy untrained men (Mean age 34 +/− 7 years; mean height 181.7 +/− 6.9 cm; mean weight 80.6 +/− 6.4 kg; BMI: 24.5 +/− 1.3) with no prior history of knee, low back or neck injury or other adverse health issues were recruited. Participants visited the researchers on two separate occasions, separated by 48 hours, each time providing a soreness rating (modified visual analog scale 0‐10), and being tested for pressure pain threshold (PPT) and active range of motion (ROM) of the hamstring muscles. During the first visit, delayed onset muscular soreness of the hamstring muscles was induced by 10 x 10 repetitions of the stiff‐legged dead‐lift. On the second visit participants received either 1) 10 minutes of roller massage on one leg, while the contralateral leg served as a cross over control, or 2) Resting for 10 minutes with no massage at all. Measurement of soreness, PPT and ROM were taken immediately before and at 0, 10, 30 and 60 min. after treatment.
Results:
There was a significant group by time interaction for soreness (p < 0.0001) and PPT (p = 0.0007), with the massage group experiencing reduced soreness and increasing PPT compared with the control group. There was no group by time interaction for ROM (p = 0.18). At 10 min. post massage there was a significant reduction in soreness of the non‐massaged limb in the cross over control group compared to controls but this effect was lost 30 minutes post massage.
Conclusion:
Massage with a roller device reduces muscle soreness and is accompanied by a higher PPT of the affected muscle.
Level of Evidence:
2c; outcomes research
PMCID: PMC3924612  PMID: 24567859
Cross over effect; delayed onset muscle soreness hyperalgesia; pain
6.  High Intensity Physical Exercise and Pain in the Neck and Upper Limb among Slaughterhouse Workers: Cross-Sectional Study 
BioMed Research International  2014;2014:218546.
Slaughterhouse work involves a high degree of repetitive and forceful upper limb movements and thus implies an elevated risk of work-related musculoskeletal disorders. High intensity strength training effectively rehabilitates musculoskeletal disorders among sedentary employees, but less is known about the effect among workers with repetitive and forceful work demands. Before performing randomized controlled trials it may be beneficial to assess the cross-sectional connection between exercise and musculoskeletal pain. We investigated the association between high intensity physical exercise and pain among 595 slaughterhouse workers in Denmark, Europe. Using logistic regression analyses, odds ratios for pain and work disability as a function of physical exercise, gender, age, BMI, smoking, and job position were estimated. The prevalence of pain in the neck, shoulder, elbow, and hand/wrist was 48%, 60%, 40%, and 52%, respectively. The odds for experiencing neck pain were significantly lower among slaughterhouse workers performing physical exercise (OR = 0.70, CI: 0.49–0.997), whereas the odds for pain in the shoulders, elbow, or hand/wrist were not associated with exercise. The present study can be used as general reference of pain in the neck and upper extremity among slaughterhouse workers. Future studies should investigate the effect of high intensity physical exercise on neck and upper limb pain in slaughterhouse workers.
doi:10.1155/2014/218546
PMCID: PMC3910536  PMID: 24527440
7.  Is Borg’s perceived exertion scale a useful indicator of muscular and cardiovascular load in blue-collar workers with lifting tasks? A cross-sectional workplace study 
Purpose
To investigate associations between perceived exertion and objectively assessed muscular and cardiovascular load during a full working day among workers with manual lifting tasks.
Methods
A total of 159 men and 41 women from 14 workplaces with manual lifting tasks participated. Participants reported perceived exertion (BORG-CR10) at midday and after work. Surface electromyography of the thigh, lower back and neck muscles were normalized to isometric voluntary contractions (MVC) to express relative muscle load during the day. Cardiovascular load was measured with electrocardiography and calculated as the average percentage of the heart rate reserve capacity (((heart rate during work – resting heart rate) / (maximum heart rate − resting heart rate)) * 100) during the day.
Results
Using linear regression, significant but weak associations (β < 0.23) were observed between perceived exertion and (1) high muscle activity (>60 % of MVC) of the neck muscles and (2) inactivity (<1 % of MVC) of the thigh muscles and (3) cardiovascular load, respectively. Using logistic regression, perceived exertion ≥4 (high exertion), referencing <4 (low-to-moderate exertion), was related to high activity of the trapezius muscle [OR 18 (95 % CI 2–143)], i.e., the odds for experiencing high exertion during work increased 18-fold for each percentage increase in time above 60 % MVC.
Conclusions
During a full working day among blue-collar workers with lifting tasks, high neck muscle activity increases the odds for experiencing high perceived physical exertion. Perceived exertion of at least 4 on the BORG CR10 scale appears to be a good indicator that high muscular loading occurs.
Electronic supplementary material
The online version of this article (doi:10.1007/s00421-013-2782-9) contains supplementary material, which is available to authorized users.
doi:10.1007/s00421-013-2782-9
PMCID: PMC3895215  PMID: 24337669
Borg; EMG; Heart rate; Self-report; Pain
8.  PERCEIVED LOADING AND MUSCLE ACTIVITY DURING HIP STRENGTHENING EXERCISES: COMPARISON OF ELASTIC RESISTANCE AND MACHINE EXERCISES 
Objective:
Decreased hip muscle strength is frequently reported in patients with hip injury or pathology. Furthermore, soccer players suffering from groin injury show decreased strength of hip muscles. Estimating 10‐repetition maximum can be time‐consuming and difficult, thus, using the Borg category rating 10 scale (Borg CR10 scale) can be a useful tool for estimating the intensity of exercise. The aims of this study were 1) to investigate the feasibility of the use of the Borg CR10 scale for rating strength training intensity of the hip abductor and hip adductor muscles, and 2) to compare hip muscle activity during hip abduction and hip adduction exercises using elastic resistance and isotonic machines, using electromyography (EMG).
Methods:
EMG activity was recorded from 11 muscles at the hip, thigh and trunk during hip adduction and hip abduction exercises in 16 untrained women, using elastic resistance and isotonic exercise machines. These recordings were normalized to maximal voluntary contraction (MVC) EMG (nEMG). The exercises were performed at four levels of perceived loading reported using the Borg CR10: light (Borg ≤2), moderate (Borg >2–<5), heavy (Borg ≥5–<7) and near maximum (Borg ≥7).
Results:
Moderate to strong associations were observed between perceived loading and nEMG obtained during the adduction exercise with elastic resistance (r=0.8±0.3) as well as in machine (r=0.69±0.55) and the abduction exercise with elastic resistance (r=0.66±0.29) as well as in machine (r =0.62±0.54). The abduction exercise performed with elastic resistance displayed significantly higher gluteus medius nEMG recruitment than the in machine exercise.
Conclusions:
The results of this study show that the Borg CR10 scale can be a useful tool for estimating intensity levels during resistance training of the hip adductor and hip abductor muscles. Although elastic resistance and exercise machine seem equally effective for recruiting muscle activity of the hip adductors, the elastic resistance condition was able to demonstrate greater muscle recruitment than the exercise machine during hip abduction.
PMCID: PMC3867074  PMID: 24377067
Elastic resistance; hip adduction; hip abduction; strength training
9.  Cardiovascular Health Effects of Internet-Based Encouragements to Do Daily Workplace Stair-Walks: Randomized Controlled Trial 
Background
Although the hazardous health effects of a sedentary lifestyle are well known, many adults struggle with regular physical activity. Simple and efficient encouragements for increased physical activity are needed.
Objective
To determine the effect on cardiovascular health of email-based encouragements to do daily stair-walks at work together with colleagues among adults in sedentary occupations.
Methods
A single-blind randomized controlled trial was performed at a large administrative company in Copenhagen, Denmark. Participants were 160 office workers (125 women, 35 men; mean age 42 years, SD 10; sitting 89.5% of work time). At baseline, aerobic fitness was 37 mL/min/kg (SD 9), mean blood pressure was 118/79 mmHg (SD 14/9), and mean body mass index (BMI) was 23 kg/m2 (SD 4). Participants were randomly assigned (2:1 ratio) to an email group receiving weekly email-based encouragements to walk the stairs for 10 minutes a day or to a control group receiving weekly reminders to continue their usual physical activities. The primary outcome was the change from baseline to 10-week follow-up in aerobic fitness determined from a maximal cycle test. The examiner was blinded to group allocation.
Results
Adherence to the email encouragements was fairly high with 82.7% of the participants performing at least 3 sessions of 10-minute stair-walks per week (mean 3.3, SD 1.3). Mean heart rate reached 167 beats/min (SD 10) during stair-walks. In the intention-to-treat analysis, aerobic fitness increased 1.45 mL/min/kg (95% CI 0.64-2.27) at 10-week follow-up in the email group compared with the control group. In participants with low aerobic fitness at baseline (n=56), aerobic fitness increased 1.89 mL/min/kg (95% CI 0.53-3.24), and systolic and diastolic blood pressure decreased 4.81 mmHg (95% CI 0.47-9.16) and 2.67 mmHg (95% CI 0.01-5.32), respectively, in the email group compared with the control group. Body weight decreased in the email group of those with low aerobic fitness compared with the control group, but this was not statistically significant.
Conclusions
Simple and inexpensive email-based encouragements to do daily stair-walks together with colleagues at work improves cardiovascular health among adults in sedentary occupations. There exists an enormous potential to prevent the hazardous health effects of a sedentary lifestyle through the use of email-based encouragements to do short bouts of physical activity at the workplace.
Trial Registration
Clinicaltrials.gov NCT01293253; http://clinicaltrials.gov/ct2/show/NCT01293253 (Archived by WebCite at http://www.webcitation.org/6HWG2jw68).
doi:10.2196/jmir.2340
PMCID: PMC3713894  PMID: 23793032
physical activity; Internet technology; sedentary; fitness; vigorous activity; intervention; randomized controlled trial; stair-walk; blood pressure; body mass index
10.  Participatory ergonomic intervention versus strength training on chronic pain and work disability in slaughterhouse workers: study protocol for a single-blind, randomized controlled trial 
Background
The prevalence of musculoskeletal pain in the shoulder, arm and hand is high among slaughterhouse workers, allegedly due to the highly repetitive and forceful exposure of these body regions during work. Work disability is a common consequence of these pains. Lowering the physical exposure through ergonomics intervention is the traditional strategy to reduce the workload. An alternative strategy could be to increase physical capacity of the worker through strength training. This study investigates the effect of two contrasting interventions, participatory ergonomics versus strength training on pain and work disability in slaughterhouse workers with chronic pain.
Methods/design
66 slaughterhouse workers were allocated to 10 weeks of (1) strength training of the shoulder, arm and hand muscles for 3 x 10 minutes per week, or (2) participatory ergonomics involving counseling on workstation adjustment and optimal use of work tools (~usual care control group). Inclusion criteria were (1) working at a slaughterhouse for at least 30 hours per week, (2) pain intensity in the shoulder, elbow/forearm, or hand/wrist of at least 3 on a 0–10 VAS scale during the last three months, (3) pain lasting for more than 3 months, (4) frequent pain (at least 3 days per week) (5) at least moderate work disability, (6) no strength training during the last year, (7) no ergonomics instruction during the last year.
Perceived pain intensity (VAS scale 0–10) of the shoulder, elbow/forearm and hand/wrist (primary outcome) and Disability of the Arm, Shoulder and Hand (Work module, DASH questionnaire) were measured at baseline and 10-week follow-up. Further, total muscle tenderness score and muscle function were assessed during clinical examination at baseline and follow-up.
Discussion
This RCT study will provide experimental evidence of the effectiveness of contrasting work-site interventions aiming at reducing chronic pain and work disability among employees engaged in repetitive and forceful work.
Trial registration
ClinicalTrials.gov:NCT01671267
doi:10.1186/1471-2474-14-67
PMCID: PMC3606231  PMID: 23433448
Musculoskeletal disorders; Occupational health; Shoulder pain; Tennis elbow; Repetitive and forceful movements
11.  MUSCLE ACTIVITY DURING KNEE‐EXTENSION STRENGTHENING EXERCISE PERFORMED WITH ELASTIC TUBING AND ISOTONIC RESISTANCE 
Background/Purpose:
While elastic resistance training, targeting the upper body is effective for strength training, the effect of elastic resistance training on lower body muscle activity remains questionable. The purpose of this study was to evaluate the EMG‐angle relationship of the quadriceps muscle during 10‐RM knee‐extensions performed with elastic tubing and an isotonic strength training machine.
Methods:
7 women and 9 men aged 28‐67 years (mean age 44 and 41 years, respectively) participated. Electromyographic (EMG) activity was recorded in 10 muscles during the concentric and eccentric contraction phase of a knee extension exercise performed with elastic tubing and in training machine and normalized to maximal voluntary isometric contraction (MVC) EMG (nEMG). Knee joint angle was measured during the exercises using electronic inclinometers (range of motion 0‐90°).
Results:
When comparing the machine and elastic resistance exercises there were no significant differences in peak EMG of the rectus femoris (RF), vastus lateralis (VL), vastus medialis (VM) during the concentric contraction phase. However, during the eccentric phase, peak EMG was significantly higher (p<0.01) in RF and VM when performing knee extensions using the training machine. In VL and VM the EMG‐angle pattern was different between the two training modalities (significant angle by exercise interaction). When using elastic resistance, the EMG‐angle pattern peaked towards full knee extension (0°), whereas angle at peak EMG occurred closer to knee flexion position (90°) during the machine exercise. Perceived loading (Borg CR10) was similar during knee extensions performed with elastic tubing (5.7±0.6) compared with knee extensions performed in training machine (5.9±0.5).
Conclusion:
Knee extensions performed with elastic tubing induces similar high (>70% nEMG) quadriceps muscle activity during the concentric contraction phase, but slightly lower during the eccentric contraction phase, as knee extensions performed using an isotonic training machine. During the concentric contraction phase the two different conditions displayed reciprocal EMG‐angle patterns during the range of motion.
Level of Evidence:
5
PMCID: PMC3537465  PMID: 23316424
Electromyography; strength training; quadriceps; perceived exertion
12.  SWISS BALL ABDOMINAL CRUNCH WITH ADDED ELASTIC RESISTANCE IS AN EFFECTIVE ALTERNATIVE TO TRAINING MACHINES 
Background:
Swiss ball training is recommended as a low intensity modality to improve joint position, posture, balance, and neural feedback. However, proper training intensity is difficult to obtain during Swiss ball exercises whereas strengthening exercises on machines usually are performed to induce high level of muscle activation.
Purpose:
To compare muscle activation as measured by electromyography (EMG) of global core and thigh muscles during abdominal crunches performed on Swiss ball with elastic resistance or on an isotonic training machine when normalized for training intensity.
Methods:
42 untrained individuals (18 men and 24 women) aged 28–67 years participated in the study. EMG activity was measured in 13 muscles during 3 repetitions with a 10 RM load during both abdominal crunches on training ball with elastic resistance and in the same movement utilizing a training machine (seated crunch, Technogym, Cesena, Italy). The order of performance of the exercises was randomized, and EMG amplitude was normalized to maximum voluntary isometric contraction (MVIC) EMG.
Results:
When comparing between muscles, normalized EMG was highest in the rectus abdominis (P<0.01) and the external obliques (P<0.01). However, crunches on Swiss ball with elastic resistance showed higher activity of the rectus abdominis than crunches performed on the machine (104±3.8 vs 84±3.8% nEMG respectively, P<0.0001). By contrast, crunches performed on Swiss ball induced lower activity of the rectus femoris than crunches in training machine (27±3.7 vs 65±3.8% nEMG respectively, P<0.0001) Further, gender, age and musculoskeletal pain did not significantly influence the findings.
Conclusion:
Crunches on a Swiss ball with added elastic resistance induces high rectus abdominis activity accompanied by low hip flexor activity which could be beneficial for individuals with low back pain. In opposition, the lower rectus abdominis activity and higher rectus femoris activity observed in machine warrant caution for individuals with lumbar pain. Importantly, both men and women, younger and elderly, and individuals with and without pain benefitted equally from the exercises.
PMCID: PMC3414069  PMID: 22893857
abdominal crunch; elastic resistance; electromyographic activity; exercise ball

Results 1-12 (12)