Can Modied Neuromuscular Training Support the Treatment of Chronic Pain in Adolescents?

Staci M. Thomas, MS,1 Soumitri Sil, PhD,2 Susmita Kashikar-Zuck, PhD,2 and Gregory D. Myer, PhD,1,36 Cincinnati Childrens Hospital Medical Center, Division of Sports Medicine, Sports Medicine Biodynamics Center and Human Performance Laboratory, Cincinnati, Ohio; 2Cincinnati Childrens Hospital Medical Center, Division of Behavioral 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 Medical Professions, The Ohio State University, Columbus, Ohio; and 6Departments of Athletic Training, Rocky Mountain University of Health Professions, Provo, Utah

ABSTRACT
MANY ADOLESCENT PATIENTS WHO SUFFER FROM CHRONIC MUSCULOSKELETAL PAIN LIVE SEDENTARY LIVES BECAUSE OF DISCOMFORT AND FEAR OF FLAREUPS WITH ACTIVITY. THEREFORE, BEFORE INITIATING PHYSICAL ACTIVITY, PATIENTS WITH CHRONIC PAIN WHO ARE INACTIVE SHOULD UNDERGO ADEQUATE TRAINING TO REDUCE THE RISK OF PAIN FLARE-UPS AND EVEN INJURY. IMPLEMENTING A NEUROMUSCULAR TRAINING PROGRAM, WHICH FOCUSES ON GENERAL AND SPECIFIC STRENGTH EXERCISES THAT TEACH PROPER TECHNIQUE AND JOINT MECHANICS, MAY PROVIDE AN OPPORTUNITY TO PREPARE FOR THE DEMANDS OF INCREASING PHYSICAL ACTIVITY. THIS ARTICLE PRESENTS THE DEVELOPMENT OF A NEUROMUSCULAR TRAINING PROTOCOL SPECIFICALLY DESIGNED FOR USE IN THIS CLINICAL POPULATION.

INTRODUCTION

hronic pain, commonly dened 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 2030% of children and adolescents (19). At times, the etiology of pediatric chronic pain is clearly identiable 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 signicant 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 signicant 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 specic chronic pain condition, juvenile bromyalgia, is characterized by widespread musculoskeletal pain, multiple painful tender points on touch, fatigue, sleep difculty, and several other associated symptoms. Youth with juvenile bromyalgia 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).
KEY WORDS:

pain; neuromuscular; training; adolescents; musculoskeletal

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Copyright National Strength and Conditioning Association

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 cognitivebehavioral therapy (CBT) for pediatric chronic pain, including juvenile bromyalgia, has gained strong evidencebased 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 benets for children with chronic pain (Figure) (14). Specically, preliminary data in adults with bromyalgia 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 bromyalgia 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 specically for youth with juvenile bromyalgia to prepare them for increased engagement in physical activity.
ACTIVITY IN PATIENTS WITH CHRONIC PAIN

Just as sufcient 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 are-ups and increased muscle soreness may ultimately lead to cessation of any physical activity involvement. Therefore, sufcient 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

Figure. This gure represents an example of a treatment program which integrates more than one approach for treating adolescents with a chronic pain condition, such as bromyalgia. Coping skills training and neuromuscular training combined may lead to decreased disability, distress, and pain.

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Development of a Neuromuscular Training Protocol

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 tting option for youth who are seeking to treat their chronic pain condition with exercise. Integrative neuromuscular training can be dened as a program or plan that incorporates general and specic strength and conditioning activities, which enhance fundamental skillrelated components of physical tness. 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). Specically, 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

with their active peers (30). Designing an appropriate intervention for bromyalgia patients with chronic pain should, therefore, involve specialized instruction in fundamental movements and strength building while minimizing the likelihood of pain are-ups. A specically designed program, including resistance, dynamic stability, and core focused strength exercises, which target motor control decits, should be implemented while taking into account patients baseline level of tness. 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 difculty 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 bromyalgia. Therefore, implementing a neuromuscular training program where intermittent-type activities are used may be more benecial in reducing the exercise-induced symptoms and soreness. Each exercise in this training program for adolescents with juvenile bromyalgia was selected based on the concept of fundamental skill development and modied from well-established neuromuscular training programs used for healthy active adolescents. These training programs have previously been shown to be effective in signicantly 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 25).
GUIDELINES FOR IMPLEMENTING NEUROMUSCULAR TRAINING WITH PATIENTS WITH CHRONIC PAIN

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) decits 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 decits were also found to be predictive of higher disability (6). In addition, results from our laboratory indicate that adolescents with bromyalgia exhibit decreased knee extension, knee exion, and hip abduction strength and dynamic stability when compared

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 patients 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 nd that the exercise induced soreness is a temporary result and may not be the same pain are-ups that they experience with their condition. As patients adapt to training and gain an appreciation of

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Table 1
A description of each level of progression Level 1Isometric focused exercises (Table 2) The exercises for level 1 are focused on obtaining and then sustaining proper joint position and technique. Before progressing to Level 2, each participant should be able to position himself or herself in the proper alignment and maintain that correct form for the prescribed time. Level 2Concentric focused exercises (Table 3) The exercises for Level 2 are focused on each participant properly, creating the movement for each exercise, thus performing primarily concentric muscle contractions. The use of the TRX Suspension Trainer (Fitness Anywhere LLC, San Francisco, CA) aids in providing assistance to the participants during the eccentric movement phase of the appropriate exercises. Once each participant can correctly and condently produce the movement for each exercise, he or she may progress to Level 3. Level 3Eccentric focused exercises (Table 4) The exercises for Level 3 are focused on resisting movement for each exercise, therefore resulting in each participant primarily performing eccentric muscle actions. The use of the TRX Suspension Trainer allows the participants to gain assistance in performing the concentric movement phase of the appropriate exercises. Once each participant can correctly and condently perform the eccentric muscle contractions necessary for each exercise, he or she may progress to Level 4. Level 4Functional movement exercises (Table 5) The exercises in Level 4 are focused on each participant performing both concentric and eccentric muscle actions, therefore resulting in functional movements, which will aid in preparing patients with chronic pain for increasing their physical activity.

this difference in muscle soreness and pain, the patients adherence to the program will likely improve. This education also helps normalize their experience and gain more condence 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 are 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 specic 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 specic exercise instructions, see Tables 25). As noted previously, adolescents with bromyalgia demonstrate signicant decits 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 bromyalgia after 8 weeks of neuromuscular training (31). In addition, patients with bromyalgia 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 decits after an injury (25). The provided protocol (Tables 25) outlines guidelines and suggestions on training volume and specic 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 modiable 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 bromyalgia, 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 bromyalgia 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 nd this protocol useful when working with patients with conditions such as bromyalgia. 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 bromyalgia, we aim to improve their strength, posture, balance, and biomechanics, so that they gain the ability and condence to engage in a more active lifestyle.

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Table 2
Level 1 isometric exercises for an integrative neuromuscular training program for adolescents with fibromyalgia
Level 1Hold exercises Time/reps Sets

Level 1BOSU Balance Trainer (BOSU, Ashland, OH) double leg deep hold with TRX upper body assistance The patient starts by standing on the BOSU with the round side up and holding onto the TRX handles. Then, the patient bends his or her hips and knees until the knees are bent to approximately 908, using the TRX handles as support. The patient holds this position for the prescribed time. Level 1Double leg pelvic bridge hold The patient starts by laying on the mat with the knees bent and feet on the oor. Then, the patient pushes through the heels of the feet, raising the pelvis off the ground as high as possible. They hold this position for the prescribed time. 10 s 2 10 s 2

Level 1Stability ball hamstring curls (partner assisted) The patient starts by lying on the oor, with the stability ball placed under the heels and the legs extended. With a partner holding onto the stability ball, the patient lifts their hips off the ground. With partner assistance, the patient then bends the knees and pulls the ball into their body as far as possible, then returns to the starting position and repeats. Level 1Kneeling plank on mat The patient positions both knees on the mat and both elbows on the ground. The patient then positions their body so that their hips are in line with their shoulders and knees. They hold this position for the prescribed amount of time. 10 s 2 68 reps 2

Level 1Superman hold (continued)

Table 2 (continued )
The patient lies prone on the mat with their arms extended by their head. They lift their arms and legs off the ground and hold this position for the prescribed time. 10 s 2

Level 1TRX rotary hold 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 his or her footing and leans away from the anchor to assume the starting position. To perform the exercise, the patient will hold onto the handles with arms extended and pull himself or herself into an upright position and will hold this position for the prescribed time. This exercise can be modied by changing the placement of the feet (closer to the anchor will increase difculty, farther from anchor will decrease difculty). Level 1TRX chest press hold The patient stands with a staggered stance, facing away from the TRX anchor point, holding the TRX handles at chest level, with arms extended. The patient leans forward, putting resistance in the legs until reaching a position where the elbows are bent, hands are at chest level, and the patient is supporting himself or herself with the upper body. The patient then holds this position for the prescribed time. This exercise can be modied by changing the placement of the feet (closer to the anchor will increase difculty, farther from anchor will decrease difculty). Level 1TRX row stabilization-multiangle hold The patient grabs both handles, then walks the feet out to the desired position and leans the body back, maintaining a straight line from his or her shoulders to the feet. With arms extended, the patient will adduct the shoulder blades and holds the position for the prescribed amount of time. The patient pulls the upper body into an upper row position and holds for the prescribed time. This exercise can be modied by changing the placement of the feet (closer to the anchor will increase difculty, farther from anchor will decrease difculty). 10 s 2 (per position) 68 reps 2 10 s 2 (per side)

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Table 3
Concentric focused exercises for an integrative neuromuscular training program for adolescents with fibromyalgia
Level 2Creating movement exercises Reps Sets

Level 2BOSU double leg squat upwith TRX assistance down The patient starts by standing on the BOSU with the round side up and holding onto the TRX handles. Then, the patient bends the hips and knees until the knees are bent to approximately 908, using the TRX handles as support on the way down. The patient will slowly (3 count) raise himself or herself back to the starting position, using as little support from the TRX handles as possible (arms are relaxed). Level 2double leg pelvic bridge raise The patient starts by lying on the mat with the knees bent and feet on the oor. Then, the patient pushes through the heels of his or her feet, slowly (3 count) raising the pelvis off the ground as high as possible and returns to the starting position and repeats. 68 reps 2 68 reps 2

Level 2reverse hyperextensions on stability ball The patient starts by lying on the stability ball with the belly on the ball and hands on the oor in front of them, then slowly (3 count) raise their feet and legs off the ground and as high as possible while keeping legs straight. 68 reps 2

Level 2BOSU 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 her trunk backward toward the oor but not to full extension. Then, slowly (3 count) and with as little support from the TRX handles as possible, the patient will return to the starting position. Level 2Superman 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 ground as high as possible, keeping the feet off the ground. 68 reps 2 68 reps 2

(continued)

Table 3 (continued )
Level 2TRX 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 away from the anchor to assume the starting position. To perform the exercise, with their arms extended, the patient will use the trunk muscles to slowly (3 count), pull himself or herself into an upright position, and then retracts the arms close to their body and returns to the starting position. This exercise can be modied by changing the placement of the feet (closer to the anchor will increase difculty, farther from anchor will decrease difculty). Level 2TRX chest press upstaggered stance The patient stands with a staggered stance, facing away from the TRX anchor point, holding the TRX handles at chest level, with arms extended. Without supporting themselves on the handles, the patient leans forward, until reaching a position where the elbows are bent and hands are at chest level. Then she or he engages the upper body and supports himself or herself on the handles. The patient leans the body weight into the handles, then slowly (3 count) pushes away, returning to the starting position. This exercise can be modied by changing the placement of the feet (closer to the anchor will increase difculty, farther from anchor will decrease difculty).
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68 reps

2 (per side)

68 reps

Level 2TRX rowup The patient starts by holding the handles (with the straps tight) and at chest level and the arms straight. Then, the patient takes a big step toward the anchor, while keeping the arms straight and leaning the body backward to maintain tension in the straps, which puts him or her in the starting position. Then, slowly (3 count) the patient engages the upper back and shoulder muscles and performs the rowing motion until reaching an upright position. Taking a step backward will reposition them in the appropriate position to begin the exercise again. This exercise can be modied by changing the placement of the feet (closer to the anchor will increase difculty, farther from anchor will decrease difculty).
The pictures outlined in yellow depict the movement phase, which the participant is actively performing.

68 reps

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Table 4
Eccentric focused exercises for an integrative neuromuscular training program for adolescents with fibromyalgia
Level 3Resisting movement exercises Reps Sets

Level 3BOSU double leg squat downwith TRX assistance up The patient starts by standing on the BOSU with the round side up and holding onto the TRX handles. Then, the patient slowly (count of 3) bends the hips and knees until the knees are bent to approximately 908, using the TRX handles as little as possible for support on the way down. With support from the TRX handles, the patient will raise back to the starting position. Level 3Single leg hip hinge with RDL Standing on 1 leg with the knee slightly exed, the patient will bend at the waist slowly as far as he or she can go without pain (as if touching the toes). Then, the patient will place both the feet back on the ground and return to the starting position bilaterally. Level 3Assisted back extensions on stability ball The patient starts by lying on the stability ball, belly down, with the ball positioned on his or her hips. With a resistance band placed under the arms, the patient loops their thumbs under the band at chest level and starts in a position of trunk extension. Without assistance from the band, the patient slowly (count of 3) lowers to a position where he or she is lying over the ball. Then, with assistance from the trainer, returns to the starting position. 68 reps 2 68 reps 2 (per leg) 68 reps 2

(continued)

Table 4 (continued )
Level 3BOSU crunch-down with TRX assistance up The patient starts by sitting in the middle of the BOSU, round side up. Using the TRX handles for as little support as possible, the patient will lower (count of 3) the trunk backward toward the oor but not to full extension. Then, using the TRX handles for support, the patient will return to the starting position. Level 3Swimmers The patient lies prone on the mat with the arms extended by the head. Lifting his or her upper body off the ground, the patient raises 1 arm and the opposite leg at the same time. Then, the patient lowers both arms and legs and repeats with the opposite sides. Level 3TRX Rotary RESIST with staggered stance The patient stands perpendicular to the anchored position of the TRX system. Holding onto the handles with the arms straight at chest level, the patient secures the footing in a staggered stance. Slowly (count of 3), leaning away from the TRX anchor, using the trunk muscles to control this motion, while keeping the hips in line with the shoulders and feet, until reaching the maximum position. Then, the patient can side step to reposition the feet and relieve the contraction and return to the starting position. This exercise can be modied by changing the placement of the feet (closer to the anchor will increase difculty, farther from anchor will decrease difculty). 68 reps 2 (per side)
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68 reps

68 reps

2 (per side)

(continued)

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Table 4 (continued )
Level 3TRX chest press downstaggered stance The patient stands with a staggered stance, facing away from the TRX anchor point, holding the TRX handles at chest level, with arms extended. While engaging the upper body muscles, the patient supports himself or herself on the handles, and slowly (count of 3) leans forward, until reaching a position where their elbows are bent and hands are at chest level. Then the patient can relax the upper body and use their lower body to push backward and return to the starting position. This exercise can be modied by changing the placement of the feet (closer to the anchor will increase difculty, farther from anchor will decrease difculty). Level 3TRX rowdown The patient starts by holding the handles (with the straps tight) at chest level and the elbows bent at 908. Then, the patient takes a big step toward the anchor, while keeping the arms bent and leaning the body backward to maintain tension in the straps, putting them in the starting position. Then, slowly (3 count) the patient lowers himself or herself to a position in which the arms are fully extended, using the upper back and shoulder muscles to control this motion. Taking a step backward will reposition them in the starting position.
RDL 5 Romanian Dead Lift. Pictures outlined in blue depict the movement phase, which the participant is actively performing.

68 reps

68 reps

Table 5
Functional movement exercises for an integrative neuromuscular training program for adolescents with fibromyalgia
Level 4Functional movement exercises Reps Sets

Level 4BOSU squats with TRX upper body assistance The patient starts by standing on the BOSU with the round side up. Then, the patient bends the hips and knees until the knees are bent to approximately 908. The patient then returns to the starting position and repeats. Using the TRX for as little assistance as possible through the entire range of motion. Level 4Single leg oor touches (RDL) Standing with both knees slightly exed, the patient lifts 1 foot from the ground and bends at the waist slowly as far as he or she can go without pain (as if touching the toes), while extending the opposite leg. Then, while digging the heel into the ground and keeping their knee slightly bent, the patient will slowly return to the starting position. Level 4stability ball hamstring curls The patient lies on the mat, with the stability ball placed under the heels and legs extended. Then, the patient lifts their hips off the ground and pulls the ball into their body, then lifts the hips off the ground. Slowly, the patient extends the legs while keeping the hips off the ground and returns to the starting position. Level 4BOSU double crunchfull The patient starts by sitting in the middle of the BOSU, slightly toward the front and round side up. Placing their arms across their chest, the patient then slowly lowers the upper body to a position below neutral. Using the abdominal muscles, the patient raises the trunk back to the starting position, using as little support from the TRX as possible throughout the entire range of motion. 68 reps 2 68 reps 2
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68 reps

68 reps

(continued)

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Table 5 (continued )
Level 4toe touch swimmers The patient lies prone on the mat with the arms extended by the head. Lifting the upper body off the ground, the patient reaches back with 1 arm to touch the opposite foot, then repeats for the other side. Level 4TRX functional rotation with staggered stance The patient starts perpendicular to the anchor. Holding onto the handles straight out in front of him or her, the patient secures the footing in a staggered stance. Slowly, leans away from the TRX anchor, while keeping the hips in line with the shoulders and feet, until he or she reaches the maximum position. Then, using the trunk muscles, will pull himself or herself into an upright position and repeat. Level 4TRX chest pressfullstaggered stance The patient stands with a staggered stance, facing away from the TRX anchor point, holding the TRX handles at chest level, with arms extended. The patient slowly leans forward, using the arms to hold the trunk in position, until reaching a position where the elbows are bent and hands are at chest level. Then, using the arms and chest, he or she pushes the upper body back to the starting position. Level 4TRX rowfull ROM The patient grabs both handles and holds them at chest level with the palms facing the midline. Slowly, lowering the upper body by extending the arms fully. Then, pulling the upper body upward by bending at the arms, returning to the starting position and repeating. 68 reps 2 68 reps 2 68 reps 2 (per side) 68 reps 2 (per side)

RDL 5 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 count of 3 seconds.

Conicts of Interest and Source of Funding: Supported by the National Institutes of Health/NIAMS Grants R01-AR055563 and K24-AR056687. The authors report no conicts of interest.

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Staci M. Thomas is a clinical research coordinator for the Human Performance Laboratory in the Division of Sports Medicine at Cincinnati Childrens Hospital Medical Center.

Soumitri Sil is a psychology pain fellow specializing in pediatric pain management at Cincinnati Childrens Hospital.

Susmita Kashikar-Zuck is the lead psychologist of the Pediatric and is the lead of the Pediatric Pain Research and Treatment Program at Cincinnati Childrens Hospital.

Gregory D. Myer is the director of research and the Human Performance Laboratory for the Division of Sports Medicine at Cincinnati Childrens Hospital Medical Center.

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Development of a Neuromuscular Training Protocol

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29. Portenov R. Cancer pain: Epidemiology and syndromes. Cancer 63: 22982307, 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 bromyalgia: Deciencies in strength and balance. Presented at: American Pain Society, New Orleans, LA, May 811, 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 bromyalgia 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: 317332, 2000.

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VOLUME 35 | NUMBER 3 | JUNE 2013