Graded activity with and without daily-monitored-walking in patients with type 2 diabetes with low back pain: secondary analysis of a randomized-clinical trial

Background Graded activity is gradually emerging as a preferred choice in improving psychosocial outcomes including pain self-efficacy, fear-avoidance beliefs, and back-pain beliefs in the general population with low back pain (LBP). Such evidence is, however, lacking among patients with concomitant LBP and type-2 diabetes mellitus (T2DM). This secondary analysis of a randomized control trial aimed to compare the efficacy between graded activity augmented with additional daily-monitored-walking and graded activity alone on disability, pain self-efficacy (PSE), fear-avoidance beliefs (FAB), back-pain beliefs (BPB) and glycaemic control (HbA1c) in patients with concomitant LBP and T2DM. Methods Fifty-eight patients with concomitant LBP and T2DM were randomised into two groups, graded activity with daily-monitored-walking group (GAMWG = 29) or (graded activity group (GAG = 29) in this 12-week single-blind trial. Both groups received graded activity (home/work-place visits, back school and sub-maximal exercises) while the GAMWG received additional daily-monitored-walking. Disability and selected psychosocial outcomes were assessed at weeks 0, 4, 8 and 12 using Roland-Morris disability, fear-avoidance behaviour, pain self-efficacy and back belief questionnaires. Glycaemic control was assessed at weeks 0 and 12 using a point-of-care system (In2it, Biorad Latvia). Data were analysed using mean, median, Friedman’s ANOVA, Mann-Whitney test and t-tests. Results Participants’ mean age was 48.3 ± 9.4 years (95%CI: 45.6, 50.9) while 35.3% were males. The GAMWG participants (n = 25) had better outcomes (P < 0.05) than GAG participants (n = 26) on PSE (1.0, 3.0; r = − 0.1) and FAB (0.01, − 2.0; r = − 0.1) at week 4, LBP-related disability (0.01, − 2.0; r = − 0.2) at week 8 and glycaemic control at week 12 (− 0.59 ± 0.51%,-0.46 ± 0.22%). No other between-group comparisons were statistically significant. Conclusion Graded activity with daily-monitored-walking provided earlier improvements on disability, pain self-efficacy, fear-avoidance beliefs, and glycaemic control, but not back pain beliefs, in patients with concomitant LBP and T2DM. Trial registration PACTR201702001728564; 26 July, 2016 (retrospectively registered).

Evidence supporting a time-limited hippocampal role in retrieving autobiographical memories

The necessity of the human hippocampus for remote autobiographical recall remains fiercely debated. The standard model of consolidation predicts a time-limited role for the hippocampus, but the competing multiple trace/trace transformation theories posit indefinite involvement. Lesion evidence remains inconclusive, and the inferences one can draw from functional MRI (fMRI) have been limited by reliance on covert (silent) recall, which obscures dynamic, moment-to-moment content of retrieved memories. Here, we capitalized on advances in fMRI denoising to employ overtly spoken recall. Forty participants retrieved recent and remote memories, describing each for approximately 2 min. Details associated with each memory were identified and modeled in the fMRI time-series data using a variant of the Autobiographical Interview procedure, and activity associated with the recall of recent and remote memories was then compared. Posterior hippocampal regions exhibited temporally graded activity patterns (recent events > remote events), as did several regions of frontal and parietal cortex. Consistent with predictions of the standard model, recall-related hippocampal activity differed from a non-autobiographical control task only for recent, and not remote, events. Task-based connectivity between posterior hippocampal regions and others associated with mental scene construction also exhibited a temporal gradient, with greater connectivity accompanying the recall of recent events. These findings support predictions of the standard model of consolidation and demonstrate the potential benefits of overt recall in neuroimaging experiments.

Follow-Up of a Case of Dopamine-Mediated Yawning-Fatigue-Syndrome Responsive to Opioids, Successful Desensitization via Graded Activity Treatment

A 60-year-old man suffering from recurrent attacks of yawning-fatigue-syndrome, triggered by mild exercise of his right leg since a temporary lumbar disc herniation 9 years ago, was initially treated with the oral µ-opioid-receptor agonist tilidine before each bout of exercise (see Dibaj et al. 2019 JAMA Neurology 2019;77:254). During the first few months, this treatment continuously prolonged the time without exercise-triggered yawning and fatigue. In the next few months of treatment, exercise was increased in a graded manner to alleviate the yawning-fatigue-syndrome. The number of repetitions of the physical exercises was gradually increased without taking the opioid beforehand. After several months, almost the same effort level without medication could be achieved by graded activity as before under the influence of opioid medication. Graded physical activity can thus disrupt complex pathophysiological mechanisms leading to yawning and fatigue.

Which Exercise for Low Back Pain? (WELBack) trial predicting response to exercise treatments for patients with low back pain: a validation randomised controlled trial protocol

IntroductionExercise therapy is the most recommended treatment for chronic low back pain (LBP). Effect sizes for exercises are usually small to moderate and could be due to the heterogeneity of people presenting with LBP. Thus, if patients could be better matched to exercise based on individual factors, then the effects of treatment could be greater. A recently published study provided evidence of better outcomes when patients are matched to the appropriate exercise type. The study demonstrated that a 15-item questionnaire, the Lumbar Spine Instability Questionnaire (LSIQ), could identify patients who responded best to one of the two exercise approaches for LBP (motor control and graded activity). The primary aim of the current study isill be to evaluate whether preidentified baseline characteristics, including the LSIQ, can modify the response to two of the most common exercise therapies for non-specific LBP. Secondary aims include an economic evaluations with a cost-effectiveness analysis.Methods and analysisParticipants (n=414) will be recruited by primary care professionals and randomised (1:1) to receive motor control exercises or graded activity. Participants will undergo 12 sessions of exercise therapy over an 8-week period. The primary outcome will be physical function at 2 months using the Oswestry Disability Index. Secondary outcomes will be pain intensity, function and quality of life measured at 2, 6 and 12 months. Potential effect modifiers will be the LSIQ, self-efficacy, coping strategies, kinesiophobia and measures of nociceptive pain and central sensitisation. We will construct linear mixed models with terms for participants (fixed), treatment group, predictor (potential effect modifier), treatment group×predictor (potential effect modifier), physiotherapists, treatment group×physiotherapists and baseline score for the dependent variable.Ethics and disseminationThis study received ethics approval from the Hamilton Integrate Research Ethics Board. Results will be submitted for publication in peer-reviewed journals.Trial registration numberNCT04283409.

The human hippocampus plays a time-limited role in retrieving autobiographical memories

ABSTRACTThe necessity of the human hippocampus for remote autobiographical recall remains fiercely debated. The standard model of consolidation predicts a time-limited role for the hippocampus, but the competing multiple trace/trace transformation theories posit indefinite involvement. Lesion evidence remains inconclusive, and the inferences one can draw from fMRI have been limited by reliance on covert (silent) recall, which obscures dynamic, moment-to-moment content of retrieved memories. Here, we capitalized on advances in fMRI denoising to employ overtly spoken recall. Forty participants retrieved recent and remote memories, describing each for approximately two minutes. Details associated with each memory were identified and modeled in the fMRI timeseries data using a variant of the Autobiographical Interview procedure, and activity associated with the recall of recent and remote memories was then compared. Posterior hippocampal regions exhibited temporally-graded activity patterns (recent events > remote events), as did several regions of frontal and parietal cortex. Consistent with predictions of the standard model, recall-related hippocampal activity differed from a non-autobiographical control task only for recent, and not remote, events. Task-based connectivity between posterior hippocampal regions and others associated with mental scene construction also exhibited a temporal gradient, with greater connectivity accompanying the recall of recent events. These findings support predictions of the standard model of consolidation and demonstrate the potential benefits of overt recall in neuroimaging experiments.

The validity of activity trackers is affected by walking speed: the criterion validity of Garmin Vivosmart® HR and StepWatch™ 3 for measuring steps at various walking speeds under controlled conditions

Introduction The use of activity trackers has increased both among private consumers and in healthcare. It is therefore relevant to consider whether a consumer-graded activity tracker is comparable to or may substitute a research-graded activity tracker, which could further increase the use of activity trackers in healthcare and rehabilitation. Such use will require knowledge of their accuracy as the clinical implications may be significant. Studies have indicated that activity trackers are not sufficiently accurate, especially at lower walking speeds. The present study seeks to inform decision makers and healthcare personnel considering implementing physical activity trackers in clinical practice. This study investigates the criterion validity of the consumer-graded Garmin Vivosmart® HR and the research-graded StepWatch™ 3 compared with manual step count (gold standard) at different walking speeds under controlled conditions. Methods Thirty participants, wearing Garmin Vivosmart® HR at the wrist and StepWatch™ 3 at the ankle, completed six trials on a treadmill at different walking speeds: 1.6 km/h, 2.4 km/h, 3.2 km/h, 4.0 km/h, 4.8 km/h, and 5.6 km/h. The participants were video recorded, and steps were registered by manual step count. Medians and inter-quartile ranges (IQR) were calculated for steps and differences in steps between manually counted steps and the two devices. In order to assess the clinical relevance of the tested devices, the mean absolute percentage error (MAPE) was determined at each speed. A MAPE ≤3% was considered to be clinically irrelevant. Furthermore, differences between manually counted steps and steps recorded by the two devices were presented in Bland–Altman style plots. Results The median of differences in steps between Garmin Vivosmart® HR and manual step count ranged from −49.5 (IQR = 101) at 1.6 km/h to −1 (IQR = 4) at 4.0 km/h. The median of differences in steps between StepWatch™ 3 and manual step count were 4 (IQR = 14) at 1.6 km/h and 0 (IQR = 1) at all other walking speeds. The results of the MAPE showed that differences in steps counted by Garmin Vivosmart® HR were clinically irrelevant at walking speeds 3.2–4.8 km/h (MAPE: 0.61–1.27%) as the values were below 3%. Differences in steps counted by StepWatch™ 3 were clinically irrelevant at walking speeds 2.4–5.6 km/h (MAPE: 0.08–0.35%). Conclusion Garmin Vivosmart® HR tended to undercount steps compared with the manual step count, and StepWatch™ 3 slightly overcounted steps compared with the manual step count. Both the consumer-graded activity tracker (Garmin Vivosmart® HR) and the research-graded (StepWatch™ 3) are valid in detecting steps at selected walking speeds in healthy adults under controlled conditions. However, both activity trackers miscount steps at slow walking speeds, and the consumer graded activity tracker also miscounts steps at fast walking speeds.

A Blended Physiotherapy Intervention for Persons With Hemophilic Arthropathy: Development Study

Background Joint bleeds are the hallmark of hemophilia, leading to a painful arthritic condition called as hemophilic arthropathy (HA). Exercise programs are frequently used to improve the physical functioning in persons with HA. As hemophilia is a rare disease, there are not many physiotherapists who are experienced in the field of hemophilia, and regular physiotherapy sessions with an experienced physiotherapist in the field of hemophilia are not feasible for persons with HA. Blended care is an innovative intervention that can support persons with HA at home to perform the advised physical activities and exercises and provide self-management information. Objective The aim of this study was to develop a blended physiotherapy intervention for persons with HA. Methods The blended physiotherapy intervention, namely, e-Exercise HA was developed by cocreation with physiotherapists, persons with HA, software developers, and researchers. The content of e-Exercise HA was compiled using the first 3 steps of the Center for eHealth Research roadmap model (ie, contextual inquiry, value specification, and design), including people with experience in the development of previous blended physiotherapy interventions, a literature search, and focus groups. Results A 12-week blended intervention was developed, integrating face-to-face physiotherapy sessions with a web-based app. The intervention consists of information modules for persons with HA and information modules for physiotherapists, a graded activity program using a self-chosen activity, and personalized video-supported exercises. The information modules consist of text blocks, videos, and reflective questions. The patients can receive pop-ups as reminders and give feedback on the performance of the prescribed activities. Conclusions In this study, we developed a blended physiotherapy intervention for persons with HA, which consists of information modules, a graded activity program, and personalized video-supported exercises.

Behavioral Graded Activity+ (BGA+) for Osteoarthritis: A Paradigm Shift from Disease-Based Treatment to Personalized Activity Self-Management

Three promising directions for improving care for osteoarthritis (OA) include novel education strategies to target unhelpful illness and treatment beliefs; methods to enhance the efficacy of exercise interventions; and innovative, brain-directed treatments. Here we explain that each of those three promising directions can be combined through a paradigm-shift from disease-based treatments to personalized activity self-management for patients with OA. Behavioral graded activity (BGA) accounts for the current understanding of OA and OA pain and allows a paradigm shift from a disease-based treatment to personalized activity self-management for patients with OA. To account for the implementation barriers of BGA, we propose adding pain neuroscience education to BGA (referred to as BGA+). Rather than focusing on the biomedical (and biomechanical) disease characteristics of OA, pain neuroscience education implies teaching people about the underlying biopsychosocial mechanisms of pain. To account for the lack of studies showing that BGA is “safe” with respect to disease activity and the inflammatory nature of OA patients, a trial exploring the effects of BGA+ on the markers of inflammation is needed. Such a trial could clear the path for the required paradigm shift in the management of OA (pain) and would allow workforce capacity building that de-emphasizes biomedical management for OA.

A Substantia Innominata-midbrain Circuit Controls a General Aggressive State

SUMMARYAnimals display various aggressive behaviors essential for survival, while ‘uncontrollable’ attacks and abnormal aggressive states have massive social costs. Neural circuits regulating specific forms of aggression under defined conditions have been described, but whether there are circuits governing a general aggressive state to promote diverse aggressive behaviors remains unknown. Here, we found that posterior substantia innominata (pSI) neurons responded to multiple aggression-provoking cues with graded activity of differential dynamics, predicting the aggressive state and the topography of aggression in mice. Activation of pSI neurons projecting to the periaqueductal gray (PAG) increased aggressive arousal and robustly initiated/promoted all the types of aggressive behavior examined in an activity level-dependent manner. Inactivation of the pSI circuit largely blocked diverse aggressive behaviors, but not mating. By encoding a general aggressive state, the pSI-PAG circuit universally drives multiple aggressive behaviors and thus may provide a potential target for alleviating human pathological aggression.