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Can Exercise Targeting Mid-Thoracic Spine Segmental Movement Reduce

Back Pain and Improve Sensory Perception in Cross-Country Skiers?

Article  in  Clinical Journal of Sport Medicine · November 2018

DOI: 10.1097/JSM.0000000000000699

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 Original Research

Can Exercise Targeting Mid-Thoracic Spine

Segmental Movement Reduce Back Pain and
Improve Sensory Perception in Cross-
Country Skiers?
Alena Kobesova, MD, PhD,* Ross Andel, PhD,†‡ Karolina Cizkova, MPT,* Pavel Kolar, PaedDr, PhD,* and
Jiri Kriz, MD, PhD*

Abstract
Objective: To assess the role of exercise targeting proper trunk stabilization and segmental spinal movement in back pain and
sensory perception among cross-country skiers. Design: Randomized, controlled trial with blinded outcome assessors. Setting:
University Hospital, Department of Rehabilitation and Sports Medicine. Participants: Twenty elite cross-country skiers aged 17
to 27 years. Interventions: Ten cross-country skiers integrated 3 types of exercise targeting segmental motion in mid-thoracic
spine into their routine training practice for 2 months. The 10 controls performed routine athletic training. Main Outcome
Measures: The Young Spine Questionnaire to measure intensity and frequency of back pain was completed at the start and end
of study. Tactile sensory perception using 10-g Semmes–Weinstein monofilament, thermic perception using TIP THERM device,
graphesthesia assessed by a touch monitor pencil, 2-point discrimination assessed by a digital caliper, and vibration perception
assessed by a 128-Hz tuning fork measured in mid-thoracic spine 5 times. Results: No significant group differences in pain and
sensory perception were identified at baseline. Over the 2-month study interval, repeated-measures analysis of variance revealed
that the experimental group improved significantly relative to the control group on pain intensity (P 5 0.005 for cervical, P 5 0.004 for
thoracic, and P 5 0.014 for lumbar) and frequency of pain in the thoracic area only (P 5 0.011). Improvements were also observed in
the experimental relative to control group on graphesthesia (P , 0.001), vibration perception (P 5 0.002), and 2-point discrimination
(P , 0.001). Conclusions: Exercise targeting the mid-thoracic spine may decrease back pain and improve sensory perception in
cross-country skiers. Level of Evidence: Original research, level I.
Key Words: spine, back pain, exercise, sensory perception, cross-country skiing
(Clin J Sport Med 2018;00:1–9)

INTRODUCTION interaction of cross-country skiing with other physical

activities.8 The most commonly reported pain locations are
Cross-country skiing is a popular sport in many north
low back,2–6,9,10 lower extremity,4,5,11,12 chest,13 and upper
European countries as well as in North America and other
extremity.5
regions. The movement overlaps at least to some extent with
To build on research in this area, we set out to assess how
many other sports such as ice/roller skating, downhill skiing,
a novel exercise based on the principles of dynamic
and running. Cross-country skiing is very challenging for
neuromuscular stabilization (DNS), which targets trunk
athlete’s cardiovascular and musculoskeletal system and can
stabilization and mid-thoracic spine segmental movement,
lead to overstrain injury and pain.1 Back pain is quite frequent
may affect the quality of sensory perception in spinal region
among competitive cross-country skiers2 and various causes
and its relation to low back pain (LBP) in cross-country skiers.
have been proposed3 such as skiing biomechanics, technique
Specifically, we examined tactile, thermic, and vibration
and style,2–5 training length and intensity,6,7 and the
perception, two-point discrimination, and graphesthesia at
Submitted for publication February 1, 2018; accepted October 13, 2018. the area of the mid-thoracic spine, as well as pain perception,
From the *Department of Rehabilitation and Sports Medicine, 2nd Faculty of in 20 elite cross-country skiers. Based on previous
Medicine, Charles University, University Hospital Motol, Prague, Czech Republic; research14–16 pointing to deficits in sensory function over
†
‡
School of Aging Studies, University of South Florida, Tampa, Florida; and the lumbar spine16,17 and impairment of tactile acuity in
International Clinical Research Center, St. Anne’s University Hospital Brno, Brno,
Czech Republic.
chronic LBP individuals,18,19 we hypothesized that adding
these exercises would improve body perception and decrease
Supported by the foundation Movement Without Help, Prague, Czech Republic,
and by Institutional Program Progres Q41. back pain. The experimental group of 10 skiers integrated into
The authors report no conflicts of interest.
their routine training 3 types of exercise targeting segmental
motion and sensory body awareness training in the mid-
Corresponding Author: Alena Kobesova, MD, PhD, Department of Rehabilitation
and Sports Medicine, Second Medical Faculty, Charles University, University thoracic spine area for a period of 2 months. The control
Hospital Motol, V Uvalu 84, Prague 5, 150 00, Czech Republic (alenamudr@me. group performed routine athletic training. The goal was to
com). determine whether the exercise can influence paraspinal
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. sensory perception and whether improved sensation corre-
http://dx.doi.org/10.1097/JSM.0000000000000699 lates with pain reduction in the observed area of the body.

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A. Kobesova et al. (2018) Clin J Sport Med

MATERIAL AND METHODS valid to be used as part of the assessment battery. The YSQ
was translated to Czech language, and then independently
Participants
back-translated to English to ensure the accuracy of the
translation. The questionnaire was completed by each subject
Twenty male, elite cross-country skiers from a local athletic
on the first day and the last day of the study. The last part of
club participated in the study. These participants would
the YSQ evaluating parent’s spinal problems was omitted
normally train cross-country skiing 10 times per week, which
because of its irrelevance to this study. For the purposes of this
equates to at least 20 hours of physical activity per week. The
study, the one most relevant item from the YSQ was used:
mean age was 21.65 6 3.17 years ranging from 17 to 27 years.
“How often have you had pain in the neck (or middle back or
The average height and weight of participants were 181 6
lower back)?,” with possible answers of “often,” “once in
5.33 cm and 72.8 6 5.84 kg, respectively, corresponding to
a while,” “once or twice,” and “never,” and the 6-grade visual
the body mass index (BMI) of 22.2 6 1.47.
analog scale showing pain intensity. The YSQ visual analog
The subjects were randomly assigned to the intervention or
scale allows respondents to rate pain based on 6 facial
control groups. There were no significant differences between
expressions ranging from a face expressing “No pain” to
the groups in terms of age, BMI, pain as evaluated by
a face expressing “Very much pain.”
the Young Spine Questionnaire (YSQ),20 or sensory percep-
During the entire sensory assessment, the participants were
tion (P . 0.05). The descriptive characteristics of both groups
lying prone, always in the same room with the same
are given in Table 1.
temperature. All sensory perception measures in the mid-
This study was approved by an institutional review board,
thoracic spine region, between thoracic spinous processes T4
and all subjects were informed of the benefits and risks of the
and T6, were taken on the first day of the study for all 20
investigation before signing an institutionally approved
participants in the following order: tactile perception, thermic
informed consent document to participate in the study.
perception, graphesthesia, 2-point discrimination, and vibra-
tion perception. The same measurements were taken 3 times
Measures
on the same week day, once a week during the first month of
The YSQ measures spinal pain frequency and intensity, study, and then at the end of study, ie, 8 weeks after the first
activity restrictions, care-seeking behavior, and influence of measurements. Thus, 5 measurements in total were taken for
parental back pain.20 It was deemed sufficiently brief and each participant. This was a blind study with the assessor not

TABLE 1. Baseline Characteristics

Experimental Group Control Group
Average SD Min Max Average SD Min Max P*
Age 21.0 1.7 18.0 23.0 22.3 4.3 17.0 27.0 0.391
BMI 22.2 1.5 20.4 25.5 22.2 1.6 20.7 26.4 0.978
Graphesthesia 3.8 2.4 1.0 8.0 5.5 2.2 0.0 7.0 0.117
Two-point discrimination 36.6 8.9 22.0 52.0 39.3 10.8 25.0 57.0 0.551
Vibration 5.6 1.2 4.0 8.0 5.7 0.9 4.0 7.0 0.836
YSQ, frequency, cervical
Never, n 5 3
Once or twice, n 2 3
Once in a while, n 2 3
Often, n 1 1 0.825
YSQ, frequency, thoracic
Never, n 3 1
Once or twice, n 1 4
Once in a while, n 6 5
Often, n 0 0 0.236
YSQ, frequency, lumbar
Never, n 3 1
Once or twice, n 5 6
Once in a while, n 2 3
Often, n 0 0 0.232
YSQ, intensity
Cervical area 1.4 1.6 0 4 1.7 1.5 0 5 0.668
Thoracic area 1.3 1.2 0 3 2.0 1.2 0 4 0.193
Lumbar area 2.4 0.8 0 4 3.5 1.5 0 5 0.098
* P-values are based on a t test statistic for comparison on mean values and x 2 for comparison of frequencies.

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Figure 1. A, Semmes–Weinstein filament, (B) TIP THERM, (C)
touchscreen pen, (D) digital caliper, and (E) 128-Hz tuning fork.
being aware if the participant was from the experimental or
the control group.
Tactile perception assessment was performed using 10-g
nylon Semmes–Weinstein filament (Figure 1A). The assessor
touched T4, T5, and T6 spinous process with the filament and
then applied 3 paravertebral touches on the left and 3 on the
right in the same thoracic region, ie, 9 touches were applied.
The participant was asked to inform the assessor immediately
when feeling each touch. The number of all perceived touches
was counted.
Thermic perception assessment was performed using the
TIP THERM device (Figure 1B) in the same order as in tactile
filament assessment. The examiner randomly placed the cold
or warm flat surface of the device first between and then next
to the T4-T6 spinal processes on each side. The participant
informed the assessor whether perceiving the touch as cold or
warm. The number of correct answers was recorded.
To assess graphesthesia, a touchscreen pen (Figure 1C) was
used. The applied pressure was 30 g. The assessor wrote digits
2 cm large, choosing randomly 1 to 9 digits, writing them first
between T4-T6 spinous processes and then paravertebrally on
the left and on the right. Each subject was asked to identify 9
digits and the assessor recorded a number of correct answers.
Two-point discrimination was assessed using a digital caliper
(Figure 1D). The caliper was applied with a pressure of 30 g,
tips placed cranially and caudally, with the T5 spinous process
being placed exactly in the middle. The initial distance between
the 2 caliper tips was 10 cm. The assessor was decreasing the
distance by 0.5 cm until the subject perceived the contact as
a single point touch. From this point, the assessor was
increasing the distance by 1 mm to measure exactly the shortest
distance between the 2 tips perceived as a 2-point touch.
A 128-Hz tuning fork (Figure 1E) with 8 grade scale was
used to measure vibration perception. Fully vibrating tuning
fork was applied on T5 spinous process. The subject reported
the moment when the vibration perception stopped. The
vibration grade was deducted from the scale.
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Procedures
Experimental group participants performed training targeting
selective movement in the mid-thoracic spine and body
awareness in this region along with their routine off-season
athletic training practice daily for 2 months. During the first
week of the study, the subjects were individually instructed in
the exercise by the therapist every day. During the next 3
weeks, each experimental group subject exercised 3 times per
week under the therapist’s supervision and 4 times per week
by themselves. During the second month, each experimental
group subject performed daily self-training and the therapist
checked on exercise quality twice during that month.
The exercise procedures were chosen to train selective
moment and somatognosis, ie, body awareness, specifically in
the mid-thoracic area. At the same time, all participants were
instructed to stabilize their trunk and breathe properly during
their exercises. The principles of the DNS21,22 concept were
applied to maintain proper stabilization and breathing
stereotype during the training. The following positions were
used: supine (Figure 2), prone (Figure 3), and quadruped
position (Figure 4). The experimental group participants were
instructed to maintain optimal postural and breathing
stereotype as defined by developmental principles while
performing segmental movement in the mid-thoracic spine
into flexion, extension, and rotation to both sides. Each
movement was performed 10 times. However, the exercise
was stopped earlier if any pain or excessive fatigue occurred.
The participants were repeatedly instructed to focus on the
quality of each movement, performing fluent movement
segment by segment starting in the mid-thoracic spine and
Figure 2. Exercise in supine. Instructions: Elongate your spine, support
your head on the nuchal line, and keep the entire spine in contact with the
table (floor) without arching your back. Keep your shoulders and arms
relaxed. The legs are bent at 90 degrees in the hips and knees (the calves
may be supported if the position is too challenging). Direct your breath into
the pelvis. Train flexing the thoracic and cervical spine by lifting your head,
slowly performing flexion moving segment by segment, starting in the
upper cervical spine moving as far as the mid-thoracic spine; move to the
point when your shoulder blades start to come off the table and then
slowly, segment by segment, move back to the initial position. Perform
this exercise preferably 10 times but stop earlier if any pain or fatigue
occurs or if you deviate from the proper initial position (eg, you start to arch
your back or protract your shoulders or the legs start to fall down).
A. Kobesova et al. (2018) Clin J Sport Med

performance), and a time-by-treatment interaction (ie, differ-

ences in performance over time as a function of group).
Unstructured covariance matrix was used because it yielded
best model fit. Pretest to posttest differences for the training
versus control group in frequency and intensity of pain across
the categories on the YSQ were analyzed using ordered logistic
regression in SAS procedure LOGISTIC. There were no
missing data in this data set. A 2-tailed 0.05 level of
significance was used throughout.

RESULTS
Participants in the control and training groups did not differ
significantly in baseline characteristics (Table 1).

Pain Perception
Results of the assessment of frequency and intensity of pain in
Figure 3. Exercise in prone. Instructions: Place your elbows in front of the cervical, thoracic, and lumbar region using the YSQ are
your shoulders at the level of the ears and support your head on the presented in Table 2. There was some increase in frequency
forehead. Pull your shoulder blades back and keep them broad, adhering and intensity of pain in the control group along with
to the ribcage. Support your pelvis at the symphysis. Lift the head slightly
decreasing frequency and intensity of pain in the training
with the cervical and upper thoracic spine upright, initiate the movement
in the mid-thoracic spine between the shoulder blades, and continue to lift
group, leading to significant decreases in pain intensity in the
your head by moving the spine segment by spine segment. Perform 10 training versus control groups in all 3 assessed areas of the
repetitions if feeling no pain, fatigue, or deviation from the correct initial back. There was also a significant decrease in reported
position. After a short break, perform 10 head rotations to each side frequency of pain in the mid-back area for the training group
starting the movement in the mid-thoracic spine, moving one segment at relative to the control group.
a time. During the exercise, breathe normally and direct your inhalation
into the lower abdominal wall.
Assessment of Sensory Perception
The main results generated by the mixed-effects models are
moving up the spine as far as the upper cervical segments. To presented in Table 3 and in Figures 5-7. Regarding
check the compliance of the prescribed daily experimental graphesthesia (Figure 5), there was an overall significant
routine on days without supervision, the experimental group change in scores across assessments, with scores declining at
participants recorded everyday exercise in their diary that was
returned to the assessor at the end of the study. Besides this
specific training, the experimental group participants were
involved in their regular off-season training program. The
control group participants simply performed their regular
routine off-season training program of the same intensity and
frequency as experimental group. The off-season routine
training of both groups consisted of resistance training
exercises 3 times a week that focused especially on strength-
ening of abdominal, pectoralis, trapezius, and quadriceps
muscles. In addition, daily bicycling, running, and roller skiing
was performed along with some other cross-country–specific
types of exercises.

Analyses
Assessment of Perception
All measures were normally distributed, with low levels of
skewness and kurtosis. The outcome measures were converted
into z-scores before main analysis to allow for comparisons Figure 4. Exercise in a quadruped position. Instructions: Position your
across outcome variables, which were measured on largely shoulders over your hands and make sure you are well supported. Make
different scales. We used mixed-effects models in SAS (version sure that weight distribution on your palms is proportional on all its sec-
9; SAS Institute, Cary, NC) procedure MIXED to evaluate tions, ie, load equally on the thenar and hypothenar. The hip joints are in
slight external rotation, positioned above the supported knees, while the
differences in outcome variables over time as a function of
shins and feet converge. The whole spine and the trunk are upright.
assignment to the intervention versus control group. The Perform neck and thoracic spine extension and rotation as in the prone
models estimate fixed effects of time (ie, change in perfor- position while breathing into your groin.
mance over time), treatment (ie, intervention vs control group

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TABLE 2. Frequency and Intensity of Back Pain in Both Groups at the Start and at the End of the Study
Training Control
Location Pre Post Pre Post P*
Cervical Never, n 5 5 3 2
Once or twice, n 2 4 3 2
Once in a while, n 2 1 3 6
Often, n 1 0 1 0 0.870
Intensity, mean (SD) 1.4 (1.6) 0.8 (0.9) 1.7 (1.5) 2.2 (1.5) 0.005
Thoracic Never, n 3 5 1 1
Once or twice, n 1 4 4 3
Once in a while, n 6 1 5 6
Often, n 0 0 0 0 0.011
Intensity, mean (SD) 1.3 (1.2) 0.6 (0.7) 2.0 (1.2) 2.4 (1.3) 0.004
Low back Never, n 3 2 1 1
Once or twice, n 5 4 6 5
Once in a while, n 2 4 3 4
Often, n 0 0 0 0 0.987
Intensity, mean (SD) 2.4 (0.8) 1.2 (0.9) 3.5 (1.5) 3.8 (1.3) 0.014
* P-values are based on ordered logistic regression where posttest scores are the outcome, pretest scores are the covariate, and training (yes/no) is the predictor.

a rate of 0.14 SD per assessment (estimate 5 20.14, SE 5 0.06,
P 5 0.045), for a total of 0.56 SD difference across the period of
observation. The group difference in baseline performance was
not significant (P 5 0.357), although the control group had
scores 0.37 SD lower than the training group. Finally, there was
a significant group-by-time interaction (estimate 5 0.53, SE 5
0.09, P , 0.001), indicating that the training group scores were
increasing across assessments at a rate of about one half SD per
assessment compared with the scores for the control group
(Table 3), for an overall increase of more than 2 SD units. For 2-
point perception (Figure 6), any change in performance across
assessments was not significant (P 5 0.371). Also, any baseline
group differences were nonsignificant (P 5 0.135). However,
the scores for training group were changing (declining) across
assessments at a faster rate than corresponding scores for the
control group (estimate 5 20.39, SE 5 0.06, P , 0.001)
(Table 3), indicating an overall difference of about 1.5 SD units
over the period of observation. Finally, there was a significant
overall decline in scores on vibration perception (Figure 7)
(estimate 5 20.11, SE 5 0.04, P , 0.030), no significant
baseline group differences (P 5 0.616), and a significant
difference in changes in scores across assessments by group
(estimate 5 0.21, SE 5 0.06, P 5 0.002), whereby the training
group scores were increasing at a faster rate than scores for the
control group (Table 3) for an overall difference of 0.84 SD
units by the end of the study.

TABLE 3. Results of Mixed-Effects Models Depicting the Comparisons of Experimental and Training
Groups at Baseline and Over the Course of the Study
Outcome Estimate SE P
Graphesthesia
Intercept 20.07 0.29 0.813
Change across assessments 20.14 0.06 0.045
Baseline group differences 20.37 0.40 0.357
Change 3 group 0.53 0.09 <0.001
Two-point discrimination
Intercept 0.54 0.22 0.025
Change across assessments 0.04 0.04 0.371
Baseline group differences 20.48 0.31 0.135
Change 3 group 20.39 0.06 <0.001
Vibration perception
Intercept 20.11 0.29 0.725
Change across assessments 20.11 0.04 0.030
Baseline group differences 0.21 0.42 0.616
Change 3 group 0.21 0.06 0.002
Estimate, unstandardized regression coefficient; SE, standard error of measurement.

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A. Kobesova et al. (2018)
DISCUSSION
We set out to examine the role of a set of exercises based on the
principles of DNS targeting stabilization and segmental
movement in the mid-thoracic spine on sensory perception
and back pain in elite cross-country skiers. The experimental
group demonstrated a significant reduction in back pain
intensity in the cervical, thoracic, and lumbar regions, and
reduced pain frequency in the thoracic region relative to the
control group. The results also revealed that when compared
to a control group engaged in training as usual, those
participating in the experimental exercise exhibited significant
improvement in graphesthesia (Figure 5), 2-point discrimina-
tion (Figure 6), and vibration perception (Figure 7) over the 2-
month period relative to the control group (Table 3).
Existing literature examining the association between
chronic back pain and superficial sensory changes suggests
that observed deficits may result either from peripheral
impairment such as local reduction in cutaneous receptor
field density16 or from central reorganization with changed
integrity of the primary sensory cortex.16,18,19 Existing
studies16,23 indicate that amelioration of sensory dysfunction
may present a target for therapeutic intervention. Report on
the effects of exercises on tactile acuity, movement control,
and pain are scarce23,24 and it is still not clear how much
change would need to take place for each sensory measure-
ment to have a measurable effect on pain. Establishing the fact
that change in sensory perception may result in amelioration
of pain is crucial in the effort to affirm the sensory
perception–pain link.
Comparing the initial and final measurements in our
control group, no significant changes in perception modalities
were found. However, it is interesting that, unlike in the
experimental group, the control group exhibits some de-
terioration in graphesthesia, 2-point discrimination, and
vibration (Figures 5-7). We may speculate that this is due to
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Clin J Sport Med
increasingly progressive physical loading of the cross-country
skiers during summer off-season training. Perhaps, in the
experimental group, this overloading was compensated for by
the specific exercise that targeted sensory perception and
selective movement in the thoracic spine, resulting in
improved sensation and decreased pain.
The YSQ20 was chosen to evaluate pain for its simplicity,
validity, and feasibility. After the 2 months, significant
difference in pain intensity in all spinal areas was identified
between the groups. Relative to the control group, the
experimental group perceived less intensive pain in cervical,
thoracic, and lumbar spine, whereas pain frequency decreased
significantly in the thoracic region only. In the control group,
nonsignificant increase in pain intensity was found for the
cervical, thoracic, and lumbar spine at the end of off-season
training compared with the initial measurements in this group.
Again, this pain progression in the control group may result
from physical overload without any compensatory exercise
during increasingly intensive off-season training. All skiers
had daily strenuous training, and the results of the study
suggest that stabilization exercise with body awareness
training in the experimental group may have compensated
for this extreme physical overload. Conversely, the lack of
such compensatory program in the training routine of the
control group subject may have contributed to the more
intense and frequent spinal pain.
The intervention procedures consisted of exercises where
proper trunk stabilization as defined by developmental
kinesiology models was emphasized.21,22 At the same time,
the exercise was performed with full body awareness. The
skiers had to focus on proper initial position, and on the
movement itself, imagining and feeling for proper muscle
activation and selective movement into extension and
rotation, mobilizing the spine segment by segment. Special
emphasis was placed on exercise quality and not the number
of repetitions. The moment the skier felt any pain or
Figure 5. Graphical presentation of changes in gra-
phesthesia as a function of group assignment.
Volume 00
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overstrain, the exercise was stopped. The frequent problem
the therapist had to correct when supervising the exercise was
the excessive hyperactivity of the upper part of the trapezius,
pectoralis major, levator scapulae, upper part of the rectus
abdominis, and lumbar erector spinae.
The reported pain frequency and intensity (Table 2) in both
groups did not seem to be very severe. However, practically all
the skiers admitted that slight soreness or feeling of tightness
between the shoulder blades was present almost constantly,
although they do not even consider this to be pain. In the YSQ,
they only reported “real pain” that bothered them or limited
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Figure 6. Graphical presentation of changes in 2-point
discrimination as a function of group assignment.
their activities. To ensure good compliance, the experimental
group individuals recorded every exercise session in a diary.
Two athletes interrupted the exercise for a period of 1 week
because of virus infection; otherwise everybody followed the
paradigm training the series of exercises in 3 prescribed
positions daily. At the end of the study, most experimental
group members confirmed positive influence of the exercise on
back pain, planning to continue with the exercise even after
the end of study.
Strenuous physical activity may increase the risk of
developing hyperkyphosis and pain25 especially in young
Figure 7. Graphical presentation of changes in vibra-
tion perception as a function of group assignment.
A. Kobesova et al. (2018)
athletes. In cross-country skiing, thoracic spine plays a critical
role during performance and, therefore, we put a special focus
on this spinal section. In both classic and skating styles, the
thoracic segmental extension and rotation is essential for
the performance, with skating style potentially particularly
pain-inducing.2 Lack of segmental movement in middle back
as a result of body awareness neglect, or pain, or a poor
training strategy must be substituted by other parts of the
spine that in turn become overloaded and painful.26 In-
corporating exercises targeting stabilization and segmental
movement in the mid-thoracic spine may ameliorate some of
the strain on mid-thoracic spine caused by frequent cross-
country skiing and similar activities, hence potentially
alleviating LBP.
According to Hodges,27 the afferent inputs from peripheral
mechanoreceptors participate in a coordinated response of the
trunk muscles so that muscle activity occurs at the correct
time, with the correct amplitude and in a coordinated manner.
Lotze and Moseley28 report the relationship between the
extent of the body image distortion, disruption of cortical
representation, and pain, suggesting that therapeutic
approaches based on these relationships seem effective, at
least in some patients. This study is in line with those
hypotheses. In the experimental group, we focused on
simultaneous body image training, proper trunk stabilization,
and optimal movement practice, and this approach resulted in
pain reduction and better sensory perception.
There are several limitations in this study. First, no
difference in tactile and thermic perception was identified
because all measurements reached full score in all individuals
(ie, a ceiling effect). More sensitive and sophisticated measure-
ments methods need to be used to determine any subtle
differences in those sensory modalities. Second, only 10
individuals were involved in each group. However, the fact
that we reached statistical significance even with such a small
sample can be viewed as evidence of the magnitude of the
observed benefits. Third, the experimental group participants
were not supervised in daily exercise during the whole 2-
month period. Especially during the second month, the
exercise consisted mainly of self-training and therefore the
quality of training and compliance could not be absolutely
secured. Fourth, the participants were unlikely to report severe
pain, somewhat reducing the range of responses. This may be
attributable to the fact that all participants were competitive
athletes who may perceive pain differently (ie, as less severe)
than the general population. Finally, the YSQ was not
designed for this population. However, for the purposes of
this study, we only extrapolated items about the intensity and
frequency of pain in the neck, middle back, or lower back,
which were very straightforward and therefore unlikely to
lead to any bias.
CONCLUSIONS
This study suggests that a new exercise program based on
the principles of DNS that targets stabilization and
segmental motion in the mid-thoracic spine may reduce
back pain and improve the quality of sensory perception in
cross-country skiers. These findings underscore the notion
that although the number of exercise repetitions, the length
of training sessions, and other common variables may be
important, constant body awareness may help “tune” the
Copyright Ó 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Clin J Sport Med
movement stereotype and adjust muscle tone distribution
favorably, preventing repetitive strain even during chal-
lenging sport styles. This principle of body awareness
integration within sport training may be applicable to
reduce musculoskeletal painful syndromes in various sport
disciplines. Future research is needed to extend the results of
this study to the general population performing resistance
exercise at a recreational level.
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