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peer-reviewed The full text of this article will not be available in ULIR until the embargo expires on the 07/08/2021 The high incidence of injury during swim training and the increasing demands of the sports make monitoring of the swimmer's training load a key concept requiring further investigation. Research has previously introduced numerous methods for the purposes of monitoring the swimmer's training load, but a narrative review discussing the strengths and limitations of each method is lacking. Consequently, this narrative review aims to summarize the monitoring strategies that have been applied in research on competitive swimmers. This knowledge can assist professionals in the field in choosing which method is appropriate in their particular setting. The results from this study showed that external training load was predominantly obtained through real‐life observation of the swimmers’ training volume. However, research has investigated a number of internal load monitoring tools, including blood lactate, training heart rate, and perceived effort of training. To date, blood lactate markers are still considered most accurate and especially recommended at higher levels of competitive swimming or for those at greater risk of injury. Further, mood state profiling has been suggested as an early indicator of overtraining and may be applied at the lower competitive levels of swimming. Professionals in the field should consider the individual, the aim of the current training phase, and additional logistical issues when determining the appropriate monitoring strategy in their setting.

Background Subacromial shoulder pain (SSP) is a frequently diagnosed shoulder complaint. Management often involves an exercise programme but may include many other interventions. The aim of this review is to update the systematic review published by Littlewood et al. in 2013, which focused on evaluating the effectiveness of interventions within the scope of physiotherapy including exercise, manual therapy, electrotherapy and combined or multimodal approaches. Methods An electronic search of Pubmed, Web of Science and CINAHL was undertaken. Methodological quality was assessed using the AMSTAR-checklist for systematic reviews. Results Sixteen systematic reviews were retrieved. Methodological quality was variable. A strong recommendation can be made for exercise therapy as first-line treatment to improve pain, mobility and function in patients with SSP. Manual therapy may be integrated, with strong recommendation, as additional therapy. Moderate evidence of no effect was found for other commonly prescribed interventions, such as laser therapy, extracorporeal shock wave therapy, pulsed electromagnetic and ultrasound. Conclusions Evidence for the use of exercise therapy as an intervention for SSP is increasing and strengthening. Ongoing research is required to provide guidance on exercise type, dose, duration and expected outcomes. A strong recommendation may be made regarding the inclusion of manual therapy in the initial treatment phase. J Orthop Sports Phys Ther, Epub 15 Nov 2019. doi:10.2519/jospt.2020.8498

Background: Knowledge of predictors for shoulder pain in swimmers can assist professionals working with the athlete in developing optimal prevention strategies. However, study methodology and limited available data have constrained a comprehensive understanding of which factors cause shoulder pain. Purpose: To investigate risk factors and develop and internally validate a multivariable prognostic model for the prediction of shoulder pain in swimmers. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 201 pain-free club- to international-level competitive swimmers were followed for 2 consecutive seasons. The cohort consisted of 96 male (mean ± SD age, 13.9 ± 2.2 years) and 105 female (13.9 ± 2.2 years) swimmers. Demographic, sport-specific, and musculoskeletal characteristics were assessed every 6 months. Swim-training exposure was observed prospectively. Shoulder pain interfering with training was the primary outcome. Multiple imputation was used to cope with missing data. The final model was estimated using multivariable logistic regression. We applied bootstrapping to internally validate the model and correct for overoptimism. Results: A total of 42 new cases of shoulder pain were recorded during the study. Average duration of follow-up was 1.1 years. Predictors included in the final model were acute:chronic workload ratio (odds ratio [OR], 4.31; 95% CI, 1.00-18.54), competitive level (OR, 0.19; 95% CI, 0.06-0.63), shoulder flexion range of motion, posterior shoulder muscle endurance (OR, 0.96; 95% CI, 0.92-0.99), and hand entry position error (OR, 0.37; 95% CI, 0.16-0.91). After internal validation, this model maintained good calibration and discriminative power (area under the receiver operating characteristic curve, 0.71; 95% CI, 0.60-0.94). Conclusion: Our model consists of parameters that are readily measurable in a swimming setting, allowing the identification of swimmers at risk for shoulder pain. Multivariable logistic regression showed the strongest predictors for shoulder pain were regional competitive swimming level, acute:chronic workload ratio, posterior shoulder muscle endurance, and hand entry error.

Context: Lateral ankle sprains (LAS) are among the most common injuries in sports, with a poor long – term prognosis due to high chronicity and recurrence rates. Chronic ankle instability (CAI) results up to 40% of people that endured a first – time LAS. Objective: The aim of this study was to compare ankle stability between groups characterised by the use of different types of footwear during their sport activities. Design: Cross-sectional study. Setting: Firm training surface, local sport clubs. Participants: Fifty - one male subjects were recruited, distributed in four groups based on the type of footwear they use during their sport activities. Main outcome measures: All subjects performed four clinical ankle stability tests, and completed the Dutch version of the Cumberland Ankle Instability Tool (CAIT) and Profile of Mood States (POMS). All clinical ankle stability tests were performed barefoot. Results: Subjects performing their sport activities barefoot scored better than subjects performing their sport with shoes at the multiple hop test (p= .002 to .047) and executed the figure–of–8 hop test significantly faster than subjects with submalleolar ankle support (AS) (p= .019). Subjects with submalleolar AS and studs showed significantly better results than subjects with supramalleolar AS on the CAIT– score (p= .024, p= .030) and the side– hop test (p= .050, p= .045). They also scored significantly better than subjects with submalleolar AS for the side – hop test (p= .032), foot – lift test (p= .019) and figure–of 8 hop test (p= .011). Conclusion: Barefoot sports performing subjects appear to have better ankle stability compared to subjects performing their sports with shoe support. Subjects performing sports with high AS appear to have worst ankle stability. LEVEL OF EVIDENCE Level III, Cross – sectional study. KEYWORDS Ankle Injuries; Ankle stability; Chronic Ankle Instability; Physiotherapy; Sports; Footwear

Chronicity and recurrence in musculoskeletal shoulder pain are highly prevalent and can possibly be attributed to the concept of central sensitization. Available studies suggest a role for central sensitization in explaining chronic shoulder pain, but so far a comprehensive quantitative sensory testing (QST) protocol has not been used. The aim of this study was to gain knowledge on sensory processing and central pain modulatory mechanisms in patients suffering from chronic shoulder pain using such a QST protocol. Fifty study participants, including chronic shoulder pain patients and healthy controls, underwent a standardized, comprehensive psychophysical testing procedure. A static adapted QST protocol (including pressure algometry, vibration and mechanical detection) was applied. Thereafter, all subjects underwent dynamic measures of temporal summation and conditioned pain modulation. Questionnaires assessing psychosocial factors were completed by each subject. No significant differences (P >= .05) were found between patients and controls based on pressure algometry, vibration detection, mechanical detection, temporal summation, and conditioned pain modulation. Moderate positive correlations (r = .5) were found between pressure pain thresholds (PPTs) and the amount of sports participation. Weak-to-moderate negative correlations (r = −.3 à −.5) were found between PPTs and psychosocial factors such as pain catastrophizing. Based on these findings, we can conclude that central sensitization is no characteristic feature in chronic musculo-skeletal shoulder pain but can be present in individual cases.

Highlights • Generalized hypersensitivity in post-cancer, sports-related and pediatric pain. • Rationale for pain education, stress management and cognition targeted exercises. • Need to change from a biomedical or psychosocial to an integrated approach., Background In the last decade, evidence regarding chronic pain has developed exponentially. Numerous studies show that many chronic pain populations show specific neuroplastic changes in the peripheral and central nervous system. These changes are reflected in clinical manifestations, like a generalized hypersensitivity of the somatosensory system. Besides a hypersensitivity of bottom-up nociceptive transmission, there is also evidence for top-down facilitation of pain due to malfunctioning of the endogenous descending nociceptive modulatory systems. These and other aspects of modern pain neuroscience are starting to be applied within daily clinical practice. However, currently the application of this knowledge is mostly limited to the general adult population with musculoskeletal problems, while evidence is getting stronger that also in other chronic pain populations these neuroplastic processes may contribute to the occurrence and persistence of the pain problem. Therefore, this masterclass article aims at giving an overview of the current modern pain neuroscience knowledge and its potential application in post-cancer, paediatric and sports-related pain problems.

Context: The latissimus dorsi plays a major role in generating the propulsive force during swimming. In addition, stiffness of this muscle may result in altered stroke biomechanics and predispose swimmers to shoulder pain. Measuring the flexibility of the latissimus dorsi can be of interest to reduce injury. However, the reliability of such measurement has not yet been investigated in competitive swimmers. Objective: To assess the within-session intrarater and interrater reliability of a passive shoulder flexion range of motion measurement for latissimus dorsi flexibility in competitive swimmers. Design: Within-session intrarater and interrater reliability. Setting: Competitive swimming clubs in Flanders, Belgium. Participants: Twenty-six competitive swimmers (15.46 [2.98] y; 16 men and 10 women). Intervention: Each rater performed 2 alternating (eg, left-right-left-right) measurements of passive shoulder flexion range of motion twice, with a 30-second rest period in between. Main Outcome Measures: The intraclass correlation coefficients were calculated to assess intrarater and interrater reliability. Results: Interrater intraclass correlation coefficient ranged from .54 (95% confidence interval [CI], −.16 to .81) to .57 (95% CI, −.24 to .85). Results for the intrarater reliability ranged from .91 (95% CI, .81 to .96) to .94 (95% CI, .87 to .97). Conclusion: Results of this study suggest that shoulder flexion range of motion in young competitive swimmers can be measured reliably by a single rater within the same session.

Background Competitive swimmers are exposed to enormous volumes of swim training that may overload the soft tissue structures and contribute to shoulder pain. An understanding of training factors associated with the injury is needed before practice guidelines can be developed. Objectives To investigate the relationship between swim-training volume and shoulder pain and to determine swim-training volume and shoulder pain prevalence across the life span of the competitive swimmer. Data Sources Relevant studies within PubMed, Web of Science, and MEDLINE. Study Selection Studies that assessed the relationship between a defined amount of swim training and shoulder pain in competitive swimmers. Data Extraction Twelve studies (N = 1460 participants) met the criteria. Swimmers were grouped by age for analysis: young ( Data Synthesis Adolescent swimmers showed the highest rates of shoulder pain (91.3%) compared with other age groups (range = 19.4%–70.3%). The greatest swim-training volumes were reported in adolescent (17.27 ± 5.25 h/wk) and adult (26.8 ± 4.8 h/wk) swimmers. Differences in exposure were present between swimmers with and those without shoulder pain in both the adolescent (P = .01) and masters (P = .02) groups. In adolescent swimmers, the weekly swim-training volume (P < .005, P = .01) and years active in competitive swimming (P < .01) correlated significantly with supraspinatus tendon thickness, and all swimmers with tendon thickening experienced shoulder pain. Conclusions Evidence suggests that swim-training volume was associated with shoulder pain in adolescent competitive swimmers (level II conclusion). Year-round monitoring of the athlete's swim training is encouraged to maintain a well-balanced program. Developing athletes should be aware of and avoid a sudden and large increase in swimming volume. However, additional high-quality studies are needed to determine cutoff values in order to make data-based decisions regarding the influence of swim training.

Objectives To investigate the association of pain sensitivity and endogenous analgesia capacity, and training volume in a group of competitive swimmers. Design An observational multi-center study. Setting Multiple competitive swimming clubs. Participants 102 healthy competitive swimmers. Main outcome measures Training volume was estimated using self-reported information. Static and dynamic measures of pain were assessed using pressure pain thresholds (PPTs) and conditioned pain modulation (CPM), the latter as a measure of endogenous pain inhibition. Selected demographic and psychosocial measures were considered as possible confounding factors. Results Moderate positive correlations (0.38 0.05). Conclusions Self-reported swim training volume is associated with pain sensitivity in competitive swimmers. Swimmers who train more show higher pressure pain thresholds, indicating lower pain sensitivity. Swim training volume is not associated with endogenous nociceptive inhibitory capacity as determined using CPM.

OBJECTIVES: Measuring thoracic spine mobility can be of interest to competitive swimmers as it has been associated with shoulder girdle function and scapular position in subjects with and without shoulder pain. At present, no reliability data of thoracic spine mobility measurements are available in the swimming population. This study aims to evaluate the within-session intra- and interrater reliability of the "lumbar-locked rotation test" for thoracic spine rotation in competitive swimmers aged 10 to 18 years. This reliability study is part of a larger prospective cohort study investigating potential risk factors for the development of shoulder pain in competitive swimmers. DESIGN: Within-session, intra- and inter-rater reliability. SETTING: Competitive swimming clubs in Belgium. PARTICIPANTS: 21 competitive swimmers. MAIN OUTCOME MEASURES: Intra- and inter-rater reliability of the lumbar-locked thoracic rotation test. RESULTS: Intraclass correlation coefficients (ICCs) ranged from 0.91 (95% CI 0.78 to 0.96) to 0.96 (0.89-0.98) for intra-rater reliability. Results for inter-rater reliability ranged from 0.89 (0.72-0.95) to 0.86 (0.65-0.94) respectively for right and left thoracic rotation. CONCLUSION: Results suggest good to excellent reliability of the lumbar-locked thoracic rotation test, indicating this test can be used reliably in clinical practice. ispartof: PHYSICAL THERAPY IN SPORT vol:32 pages:140-144 ispartof: location:England status: published

Shoulder pain is the most reported area of orthopaedic injury in swimmers. The so-called swimmers shoulder has been applied to a variety of complaints involving shoulder pain in swimmers without specific reference to contributing mechanisms or structures. Knowledge of dysfunctions associated with swimmers shoulder can assist clinicians in developing rehabilitation strategies. This literature review aims at providing clinicians insight into the musculoskeletal mechanisms and impairments associated with swimmers shoulder that could aid them in developing rehabilitation strategies. The following musculoskeletal dysfunctions will be discussed: muscle activity, strength, endurance, muscle control, range of motion, glenohumeral laxity, glenohumeral instability, shoulder posture and scapular dyskinesis. The findings in this review may have implications for swimmers, their coaches, and rehabilitation specialists working with swimmers.

Background: The awareness is growing that central sensitization is of prime importance for the assessment and management of chronic pain, but its classification is challenging clinically since no gold standard method of assessment exists. Objectives: Designing the first set of classification criteria for the classification of central sensitization pain. Methods: A body of evidence from original research papers was used by 18 pain experts from 7 different countries to design the first classification criteria for central sensitization pain. Results: It is proposed that the classification of central sensitization pain entails 2 major steps: the exclusion of neuropathic pain and the differential classification of nociceptive versus central sensitization pain. For the former, the International Association for the Study of Pain diagnostic criteria are available for diagnosing or excluding neuropathic pain. For the latter, clinicians are advised to screen their patients for 3 major classification criteria, and use them to complete the classification algorithm for each individual patient with chronic pain. The first and obligatory criterion entails disproportionate pain, implying that the severity of pain and related reported or perceived disability are disproportionate to the nature and extent of injury or pathology (i.e., tissue damage or structural impairments). The 2 remaining criteria are 1) the presence of diffuse pain distribution, allodynia, and hyperalgesia; and 2) hypersensitivity of senses unrelated to the musculoskeletal system (defined as a score of at least 40 on the Central Sensitization Inventory). Limitations: Although based on direct and indirect research findings, the classification algorithm requires experimental testing in future studies. Conclusion: Clinicians can use the proposed classification algorithm for differentiating neuropathic, nociceptive, and central sensitization pain. Key words: Chronic pain, diagnosis, hypersensitivity, classification, neuropathic pain

Background: In addition to fatigue, pain is the most frequent persistent symptom in cancer survivors. Clear guidelines for both the diagnosis and treatment of pain in cancer survivors are lacking. Classification of pain is important as it may facilitate more specific targeting of treatment. In this paper we present an overview of nociceptive, neuropathic and central sensitization pain following cancer treatment, as well as the rationale, criteria and process for stratifying pain classification. Material and methods: Recently, a clinical method for classifying any pain as either predominant central sensitization pain, neuropathic or nociceptive pain was developed, based on a large body of research evidence and international expert opinion. We, a team of 15 authors from 13 different centers, four countries and two continents have applied this classification algorithm to the cancer survivor population. Results: The classification of pain following cancer treatment entails two steps: (1) examining the presence of neuropathic pain; and (2) using an algorithm for differentiating predominant nociceptive and central sensitization pain. Step 1 builds on the established criteria for neuropathic pain diagnosis, while Step 2 applies a recently developed clinical method for classifying any pain as either predominant central sensitization pain, neuropathic or nociceptive pain to the cancer survivor population. Conclusion: The classification criteria allow identifying central sensitization pain following cancer treatment. The recognition of central sensitization pain in practice is an important development in the integration of pain neuroscience into the clinic, and one that is relevant for people undergoing and following cancer treatment.

PURPOSE: Despite the increasing evidence that illness perceptions should be addressed in patients, there is a lack of studies evaluating whether physiotherapists question illness perceptions. This study, using a mixed-methods design, investigates the integration of illness perceptions during the first consultation of physiotherapists treating patients with low back pain (LBP). METHODS: Thirty-four physiotherapists performed usual history taking in a patient with non-specific LBP. The interview was audiotaped and illness perceptions were indexed using an observational instrument, based on the domains of Leventhal's Common Sense Model. Patients were also asked to fill in the Illness Perception Questionnaire-Revised for LBP. RESULTS: Physiotherapists assessed the illness identity, also perceptions regarding the (physical) cause and controllability of LBP were evaluated. Illness perceptions, such as timeline, consequences, coherence and emotional representation, were poorly assessed. Results of the questionnaire reveal that LBP-patients report overuse, workload and bad posture as primary cause. Patients held positive beliefs about the controllability and have high illness coherence. CONCLUSION: Belgian physiotherapists mainly question bio-medically oriented illness perceptions, e.g. physical symptoms and causes, but do not sufficiently address psychosocially oriented illness perceptions as recommended in LBP guidelines. IMPLICATIONS FOR REHABILITATION: Belgian physiotherapists mainly question biomedical oriented illness perceptions (illness identity, provoking factors and treatment control) in patients with low back pain (LBP) during the history taking (i.e. the first consultation). From a bio-psycho-social view psychosocially oriented illness perceptions should be incorporated in the daily routine of physiotherapist's to comply with the bio-psycho-social treatment guidelines for LBP. Continuing education is mandatory in order to improve physiotherapists' knowledge regarding the use of all dimensions of illness perceptions in the assessment of patients with LBP.

Several questionnaires are available to evaluate illness perceptions in patients, such as the illness perception questionnaire revised (IPQ-R) and the brief version (Brief IPQ). This study aims to systematically review the literature concerning the clinimetric properties of the IPQ-R and the Brief IPQ in patients with musculoskeletal pain. The electronic databases Web of Sciences and Pubmed were searched. Studies were included when the clinimetric properties of the IPQ-R or Brief IPQ were assessed in adults with musculoskeletal pain. Methodological quality was determined using the COSMIN checklist. Eight articles were included and evaluated. The methodological quality was good for 3 COSMIN boxes, fair for 11 and poor for 3 boxes. None of the articles obtained an excellent methodological score. The results of this review suggest that the IPQ-R is a reliable questionnaire, except for illness coherence. Internal consistency is good, except for the causal domain. The IPQ-R has good construct validity, but the factor structure is unstable. Hence, the IPQ-R appears to be a useful instrument for assessing illness perceptions, but care must be taken when generalizing the results of adapted versions of the questionnaires. The Brief IPQ shows moderate overall test-retest reliability. No articles examining the validity of the Brief IPQ were found. Further research should therefore focus on the content and criterion validity of the IPQ-R and the clinimetric properties of the Brief IPQ.

Although dancing requires extensive physical exertion, dancers do not often train their physical fitness outside dance classes. Reduced aerobic capacity, lower muscle strength and altered motor control have been suggested as contributing factors for musculoskeletal injuries in dancers. This randomized controlled trial examined whether an intervention program improves aerobic capacity and explosive strength and reduces musculoskeletal injuries in dancers. Forty-four dancers were randomly allocated to a 4-month conditioning (i.e. endurance, strength and motor control training) or health promotion program (educational sessions). Outcome assessment was conducted by blinded assessors. When accounting for differences at baseline, no significant differences were observed between the groups following the intervention, except for the subscale "Pain" of the Short Form 36 Questionnaire ( p = 0.03). Injury incidence rate and the proportion of injured dancers were identical in both groups, but dancers following the conditioning program had significant less low back injuries ( p = 0.02). Supplementing regular dance training with a 4-month conditioning program does not lead to a significant increase in aerobic capacity or explosive strength in pre-professional dancers compared to a health promotion program without conditioning training, but leads to less reported pain. Further research should explore how additional training may be organized, taking into account the demanding dance schedule of pre-professional dancers. The trial is registered at ClinicalTrials.gov, number NCT01440153.

Background: Professional and pre-professional musicians are characterized by physical and psychological demands inherent to their musical activity, and therefore at risk for developing performance related musculoskeletal pain. Physical and psychological demands are known to influence human pain modulation. Objectives: In this study we compared the influence of a physically and emotionally stressful task on pain thresholds in musicians with and without shoulder pain. Study Design: A single-blinded randomized and controlled crossover study design was used to compare the effects of a physical versus emotional testing procedure on pressure pain thresholds (PPTs) in musicians with and without shoulder pain. Setting: All data were obtained in the field (e.g., at the physiotherapy accommodation in the Royal Conservatory). Methods: During the physical testing procedure, the subjects performed an isometric exercise of the glenohumeral external rotators. The emotional task comprised watching “unpleasant” images selected from the International Affective Picture System. The outcome was the assessment of change in PPTs before and after the physical and emotional task. Results: Our results indicate similar effects of both protocols in either group, i.e., musicians with and without shoulder pain (P > 0.05). All musicians showed elevated PPTs at local and remote areas after isometric exercise (P < 0.05). The emotional stress task increased PPTs at remote areas only (P < 0.05). Limitations: Despite the small sample size of musicians without shoulder pain, a power of 78.5% was achieved to detect the necessary effect size of Cohen’s d = 1. Furthermore, comparing these results with those of non-musicians (both healthy subjects and patients with shoulder pain) might reveal information regarding the specific adaptations. Finally a high variability was observed in shoulder disability (i.e., SDQ-scores) as typically seen in a population with shoulder pain. Conclusions: In musicians with and without regional shoulder pain, no significant differences were found with respect to pain modulation during a physically and an emotionally stressful task. Both interventions adequately activated central and widespread pain inhibitory mechanisms in both groups. Key words: Pressure pain threshold, PPT, exercise induced hypoalgesia, exercise induced analgesia, stress induced hypoalgesia, shoulder pain, musicians, regional pain