Functional Training for LBP


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In-service project for clinical affiliation with Southcoast Hospital Group in December of 2012. Presented by Doctoral Student of Physical Therapy, Amy Rosen

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Functional Training for LBP

  1. 1. Functional Training for LBP.Amy E. Rosén, SPT, CPT SPT: Student of Physical Therapy CPT: ACSM Certified Personal Trainer
  2. 2. Functional Training of the Inner and Outer Units
  3. 3. Muscle activity during functional coordination training:implications for strength gain and rehabilitation2• Evaluate if different types, body positions, and levels of progression of functional coordination exercises can provide sufficiently high level of muscle activity to improve strength of the neck, shoulders, and trunk muscles• 9 untrained women performed 7 exercises 12 times during 4weeks, 3 sessions of 20 mins/wk, before testing• EMG testing of Rectus Abdominus, Erector Spinae, External Oblique, & Trapezius during 2-4 levels of progression for each exercise• Maximal Voluntary Contractions (MVCs) were recorded for each subject for each muscle being investigated• >60% of MVC will indicate exercises for strength gain Exercises Bracing Bridge Prone Plank 4-pt. Kneeling Vertical Plank Horizontal Side Support Body Blade
  4. 4. Muscle activity during functional coordination training: implications for strength gain and rehabilitation2• Muscle activity above 60% MVC max ▫ Rectus Abdominus ▫ Upper Trapezius  Horizontal unilateral bodyblade: 73.9± 5.1%  Prone Plank Level 1: 87.7 ±10%  Horizontal bilateral bodyblade: 84.9± 7.5%  Horizontal side support: 70.1 ± 10.1%  Body positions had significant differences in ▫ Erector Spinae Prone Plank, Vert. Plank, & Bodyblade  4-pt. kneeling: 79.0± 11.7% ▫ External Oblique  Horizontal bilateral bodyblase: 77.7 ±8.1%  Prone Plank Level 1: 124.2± 24%  Verical bilateral bodyblade : 71.7 ±7.3%  Prone Plank Level 2: 88.9 ± 22.4%  Bridge: 76.3 ±6.3%  Horizontal side support: 64.9 ± 7.8%  Horizontal side support: 71.6 ±10.2%  Standing & Sideways exercises had higher activity than Prone & SupineConclusion: “…depending on type, body position, and level of progression,functional coordination training can be performed with a muscle activitysufficient for strength gain. Functional coordination training may therefore be agood choice for prevention or rehabilitation of musculoskeletal pain or injury…”
  5. 5. Motor training of the lumbar paraspinal muscles inducesimmediate changes in motor coordination in patients withrecurrent low back pain7• Chronic LBP is associated with altered motor coordination of lumbar paraspinal muscles• To understand if these muscles can be modified with motor training• 20 Participants with unilateral LBP randomly divided into 2 groups ▫ To cognitively activate lumbar multifidus independently from other low back muscles- skilled training ▫ To activate all paraspinal muscles with no attention to any specific muscles- extension training• EMGs of Deep & Superficial Multifidus, Superficial Abdominal & Back Muscles• Multifidus activity increased with slow trunk movements• Superficial trunk muscles activity was reduced only after skilled training.• There is potential to alter motor coordination with motor training.• Training-induced changes in motor coordination are not only related to muscle activation but are related to the TASK.
  6. 6. Functional movement training for recurrent low backpain: lessons from a pilot randomized controlled trail.5• 60% of Pt. have recurrence of LBP• “…to compare disability, physical functional capacity, and pain outcomes at 2, 6, & 12 months for 2 conventional & 1 novel P.T. intervention”• Randomized, controlled feasibility trial• 61 Participants into 3 groups ▫ G1: single session consisting of standard back pain education ▫ G2: 6 sessions in 8 wks of conventional P.T. ▫ G3: 6 sessions in 8 wks of a new method of functional movement training• Outcome Measures Used: ▫ Continuous Scale Physical Functional Performance Test (CS-PFP) ▫ A measure of actual physical functional capacity ▫ Oswestry Disability Index ▫ A measure of pain-related disability ▫ Roland Morris Disability Questionnaire ▫ Standard Visual Analogue Pain Scale
  7. 7. Functional movement training for recurrent low backpain: lessons from a pilot randomized controlled trail.5• Results ▫ 67% of participants provided data at 2 months; 44% at 12 months ▫ NO statistical significance was reached with any of the outcome measures ▫ Trends suggested little change for G1 ▫ Trends suggested greatest improvement for G3• Conclusion: ▫ “A large-scale randomized, controlled trial is warranted to determine whether an intervention based on functional movement training is superior to conventional, impairment-based intervention for individuals with recurrent LBP”
  8. 8. The effectiveness of a functional training programmefor patients with chronic low back pain- a pilot study8• Purpose: Investigate the effect of an individualized functional training program for Pt. with LBP• Randomized, controlled trail; single-blind design• Participants had to have non-specific LBP for at least 3 months ▫ 13 Training Group; 12 Control Group• Measures taken initially and at end of program: rating impairment due to pain-3 aspects with 0-10 scale, Oswestry Disability Index (ODI) and Functional Capacity Evaluation (FCE)• Both groups maintained their current rehabilitation program ▫ Training group underwent additional exercises  Warm-up (Jogging/walking), strengthening, work/activity sim, fitness/endurance training  Strengthening focused on trunk stabilization (TA & MF), Superficial & Deep with extremities.  Control TA & MF in static and dynamic before progressing with extremities , ROM and added weight.  Work/ Activity Simulation included push, pull and lifting  Total 100 hours of training over 2-3 months
  9. 9. The effectiveness of a functional training programme forpatients with chronic low back pain- a pilot study8• Results: ▫ FCE  12 items significantly improved with Training Group  1 in Control Group: 1-min walking distance ▫ Rating determining impairment associated with pain (0-10 Scale)  Severity of pain, activity limitation for pain and emotional disturbance by pain ALL significantly decreased in Training Group  No significant change in Control Group ▫ ODI  Significant reduction in Training Group  No significant change in Control Group• Conclusion ▫ “An individualized functional training programme benefits chronic LBP patients”
  10. 10. The Deep Trunk Muscles
  11. 11. The Anatomical Girdle• Local Activation1,6• Transverse Abdominus3 ▫ Prone Plank (Elbow-Toe)  Arm/Leg Lift ▫ Abdominal Isometric• Multifidus3 ▫ Bridge  Unilateral ▫ Planks ▫ Side planks ▫ Bird-Dog• Diaphragm ▫ “Belly Breathing”• Pelvic Floor ▫ Kegels ▫ Table Technique1
  12. 12. Global Muscle Activation- It’s all connected.
  13. 13. Anterior Oblique System1,6• Oblique Plane ▫ External Oblique ▫ Internal Oblique ▫ Anterior abdominal fascia ▫ Adductors ▫ Rectus Abdominus• Rotates the pelvis forward during the swing phase of ambulation, pulling the leg through. Files/file//CORE%20AND%20PELVIS%20HANDOUT%20Sample.pdf
  14. 14. Exercising Anterior Oblique SystemWhat we do now… Progress and Vary• Crunch • “Hula Crunch”• Tri crunch • Oblique crunch with ball• Forward T-Band Punch squeeze • Bicycle Crunch • Side Plank • Seated Ball Leg Transfer • Cross Half Clams ▫ on BOSU
  15. 15. Progress with more function• Torso Twist Against Wall1 • “Throwing” Standing Crunches1 ▫ Standing few inches from wall ▫ T-Band anchored on wall ▫ Knees bent ▫ Back to anchor  Can add ball squeeze ▫ Take T-Band in one hand ▫ Lean back (EXT) towards wall ▫ Arm EXT ▫ Rotate shoulder ▫ Bring forward across body ▫ Slowly return to NEU ▫ Slowly return back to start ▫ Repeat with other shoulder position ▫ Repeat• Standing Russian Twist ▫ Anterior rotation ▫ Medicine Ball, Kettlebell or Dumbbell ▫ Elbows bent or extended ▫ Lunge, Squat or Ball Squeeze
  16. 16. Posterior Oblique System1,6• Oblique Plane ▫ Latissimus Dorsi ▫ Gluteus Maximus ▫ Thoracodorsal Fascia• With ambulation, the Glut. Max contracts on foot strike simultaneously with contralateral Lat., creating a counter-rotation.• The countered contraction creates tension on the thoracolumbar fascia, stabilizing the sacroiliac joint (force- closure).• Spring System- stores energy in thoracolumbar fascia which is release in the next contraction ▫ Minimizes action & metabolic cost Files/file//CORE%20AND%20PELVIS%20HANDOUT%20Sample.pdf
  17. 17. Exercising Posterior Oblique SystemWhat we do now… Progress and Vary• T-Band Rows • Walk Outs with Physioball• Lat. Pull Down • Side Planks• Prone I, T, Ys • Prone Arm/Leg lifts• Bird-Dog ▫ Contralateral
  18. 18. Progress with more function• T-Band Squat & Row1 • T-Band Pull1 ▫ Anchor T-Band above waist ▫ Anchor T-Band low ▫ Facing anchor ▫ Facing anchor ▫ Stand with arms EXT ▫ Position for oblique pull ▫ Squat ▫ Pull up, across & over head ▫ Stand and Pull ▫ Add contralateral SLS ▫ Add  Static & Dynamic Arms • Dumbbell on Table1  Contralateral SLS ▫ Place DB on table ▫ Reach, Pick-up, Bring to self or overhead ▫ Return DB to table ▫ Return to standing ▫ Add contralateral SLS ▫ Lower placement table
  19. 19. Deep Longitudinal System1,6• Saggital Plane ▫ Erector Spinae ▫ Deep lamina of Thoracolumbar Fascia ▫ Sacrotuberous Ligament ▫ Hamstrings (BF) ▫ Peroneals• End of the swing phase: Hams. ecc. contract to control hip FLEX & knee EXT. BF contraction strains the sacrotuberous lig, assisting in stabilization of SIJ, force closure. KE is dispersed by the Erector Spinae through rotary action on the spinal column. Files/file//CORE%20AND%20PELVIS%20HANDOUT%20Sample.pdf
  20. 20. Exercising Deep Longitudinal SystemWhat we do now… Progress and Vary• Controlled Pick up • Unilateral Bird-Dog• Supermans (Trunk EXT) • Quadruped Arm EXT• Prone Arm/Leg Lifts • Quadruped Leg EXT• Bridge• Side Plank
  21. 21. Progression with more function• Toe Touch1 • T-Band Squat & Row1 ▫ Slowly reach to the floor ▫ Anchor T-Band above waist ▫ Touch ▫ Facing anchor ▫ Return to stance position ▫ Stand with arms EXT ▫ Squat ▫ Unilateral/Bilateral ▫ Stand and Pull ▫ Ipsilateral SLS ▫ Add  Static & Dynamic Arms• Dumbbell on Table1  Ipsilateral SLS ▫ Place DB on table • T-Band Pull1 ▫ Reach, Pick-up, Bring to self ▫ Anchor T-band low or overhead ▫ Facing anchor ▫ Return DB to table ▫ Position for straight pull ▫ Return to standing ▫ Add ipsilalateral SLS ▫ Pull up & over head ▫ Lower placement table ▫ Add ipsilalateral SLS
  22. 22. Lateral System1,6• Frontal Plane ▫ Gluteus Medius ▫ Gluteus Minimus ▫ Adductors ▫ Quadratus lumborum ▫ Sacroiliac Joint• SLS, hip ABD & ADD of the supporting leg work with the contralateral QL & ipsilateral Glut. Min. to stabilize the pelvis Files/file//CORE%20AND%20PELVIS%20HANDOUT%20Sample.pdf
  23. 23. Exercising Lateral SystemWhat we do now… Progress and Vary• Side-lying ABD • Bridge Unilat & Ball Squeeze• Monster Walks • Side-lying Bilateral Leg Lifts• Single Limb Stance • Side Plank ▫ Toe Taps ▫ Leg Lift• Wall Squats & Ball Squeeze• Bridge ▫ Unilateral ▫ Ball Squeeze ▫ T-Band ABD
  24. 24. Progression with more function• Grapevine • SLS with Other Hip at 90°1 ▫ a.k.a. Karaoke ▫ Stand as described ▫ Stand legs hip width apart ▫ Lift and drop hip that is at 90 ▫ Cross one leg in front of other ▫ Return to stance  Keeping hip at 90° of flexion ▫ Cross the same leg behind the ▫ Repeat with other side other ▫ Vary by changing hip’s ▫ Return to stance ▫ Repeat till desired distance is position traveled  ER, IR, etc. ▫ Repeat going the other way • Inch Worms1 ▫ Power –stance, squat position ▫ Small steps ▫ One way and then back ▫ ER, IR, and Staggered Stance
  25. 25. It’s All Connected• Gluteus Maximus works equally in ALL 3 planes1• Each system connects to the next• Importance of each in Gait/Ambulation & every day activities• Able to Muscle Test each system1 ▫ AS- Contralateral Shoulder & Hip ▫ PS- Contralateral Shoulder EXT & Hip EXT ▫ DLS- Ipsilateral Shouler EXT & Hip EXT ▫ LS- Ipsilateral ABD & ADD• Make sure trunk is held tight during ALL exercises• All exercises are to be performed pain-free• Have Pts. exhale during movement ▫ Don’t hold breath!• KEEP IN MIND: ▫ LBP/ Trunk Instability Pts. have long histories ▫ Education, description of their pain, varying types of pain, and understanding pain levels ▫ 4-6 weeks for muscle to build ▫ Not an easy fix• Pt. has to put in effort & be committed to feeling better (HEP)
  26. 26. HOW THE “CORE” AFFECTS THE WHOLERecent applicable patients seen at Southcoast RehabilitationService’s Truesdale Clinic
  27. 27. Case Pt. A: Initial Evaluation• 51 y.o. female with 6 mo. history of LE pain; R heel pain & L knee pain.• MD dx: R Plantar Fascitis• Pt. underwent bladder surgery for incontinence 1.5 years ago ▫ Hip & Back pain since & Incontinence con’t. ▫ Was seeing Women’s Health PT specialist but stopped bc of LE pain• Pain 0-8/10 ▫ Intermittent ▫ Better with anti-inflammatory meds and ice (both 2x/day) ▫ Has been wearing boot at night- better• Standing Tolerance: 15 mins Walking Tolerance: 40 feet• Hobbies: Has stopped Line Dancing. Been out for 2 mo. ▫ Prior status: 2-3 hrs Twice a week• LLE : All 5/5 and Full ROM• RLE: Pain with all Ankle MMT (3+ - 5-)/5 ▫ ROM: DF -5, PF 80, Ever 20, Inver 45• Increase Tissue Density R Plantar Surface• No increased discomfort with combine DF & Hallux EXT on R• Positive ASLR with R–sided weakness• LEFS: 55%
  28. 28. Pt. A• STGs: Pain, ROM, Strength, Standing & Walking Tolerance, Return 1day/wk to dancing, LEFS• Treatment ▫ US Right Plantar Surface Soft Tissue: Cross Friction ▫ Ankle T-Band Circuit Gastroc/Sol. Stretch ▫ SLS (with hip drop) Wall Squats with Pelvic Tilt ▫ T-Band Squat Rows• Pt. was seen for total of 6 visits.• Placed on hold Nov. 20th ▫ “My foot feels really good” ▫ ROM: DF 10 ▫ MMT: 5/5 No Pain ▫ Standing Tol: 15 mins Walking Tol: 2 blocks ▫ Went to dance class 11/19 but not 100% of participation ▫ Assuming she will return to Women’s Health P.T.
  29. 29. Case Pt. B• First seen 9/7/12-10/3/12• 20 y.o. female student with increasing L knee pain over the past year• MD dx: L patella pain• Pain surround knee that increases with activity: 1-10/10• MRI & X-Rays Neg.• L Knee ROM: 140-0-2• All MMT Hip & Knee 5/5, except L Hip ADD, 4-/5• Bilat. ITB tightness• Patella Mobs Bilat. even & painfree• Equal Bilat. Lateral Tracting. 10/3/12: NO CHANGE in• Treatment: Pain after 9 visits over 4 wks ▫ SLR, SAQ & LAQ ( Neu & ER) and HEP ▫ s/l Hip ADD Pain 4-10, All MMT 5/5 ▫ Bridge & Wall Squats with Ball Sqeeze ▫ Standing Hip ADD T-Band Pt.’s plan is to follow-up with ▫ Kick with Inseam a women’s sport specialist at ▫ Bilat. ITB Stretching Beth Israel in Boston ▫ 3 different KinesioTape Knee Techniques
  30. 30. Pt. B Returns• Return 10/31/12• Script from MD states: “quad. flexibility, lumbopelvic strengthening, hip rotational/abductor strengthening, ITB flexibility, alignment (decrease valgus thrust), hamstring strengthening, gym & HEP”• MD dx: Chondromalacia of Patella• Learned: Previous Gymnast & Cheerleader ▫ 3 years ago: 7 days/week training for 4-7 hours each day ROM L R• Also has 3 bulging disc in low back from cheering H Flex 125 135 accident in 2008 Ext 20 20• Initial Eval #2 ▫ Pain 4-11/10 Continuous and Getting worse ABD 70 60 ▫ Unable to maintain sitting/standing for 60 mins. ADD 35 30 ▫ Varying level of pain with walking, limiting distance ▫ Compensation for L with all activities, stairs very painful IR 35 41 ▫ Gait pattern unremarkable ER 40 35 ▫ No sign. TTP surrounding L knee; Patella tracking = Bilat. ▫ Increase flexibility through out SLR 93 94 ▫ Full bridge with pain in lumbar, Half bring is pain free K Flex 141 143 ▫ Q-Angle R: 23° L: 20° ▫ All MMT 5/5 Bilat, except SLR L 4+/5 with pain Ext +5 +4
  31. 31. Pt. B• STGs: Pain reduction, SLR strength, Ambulation and Stairs• Treatment Initially ▫ Bike Bridge with Leg EXT ▫ Curl Ups Prone Plank ▫ Side Planks SLS with other at 90 ▫ T-Band Squat & Row Torso Twist Against Wall• Pt. complaint of increase pain & discomfort in LE & back• Education & Descriptions of Pain ▫ How do you feel? When we start /end? Later that day? Does it resolve? ▫ Is it the same pain as before?• New Plan ▫ Bike/MHP Walk outs ▫ V-Ball Crunches Serratus Punch with Abdominal Isometric ▫ DB on Table- DLS Left Ball Squeeze with MB pick-up ▫ Quadruped Leg Ext ▫ REQUIRES CONTINUOUS CUEING and CONTROL REMINDERS
  32. 32. Case Pt. C: Initial Evaluation• 26 y.o. female student reports insidious onset of bilat. knee pain, increasing over past 6wks.• MD dx: Bilat. Knee Pain• Reports R-sided hip/LBP for past year• Pt. underwent gastric bypass surgery in April 2010 ▫ Has lost over 200#• Pain 3-8/10, Continuous & Unchanged• Pain after sitting, standing 30 mins, walking 10-15 mins, Non-recip. Up and down stairs and lifting/carry backpack (~30#) MMT L R• ROM ▫ PROM Hip Flex: L: 132 R: 110* H 5 4+ * ▫ PROM SLR: L: 100 R: 65* Flex ▫ AROM Knee: L: 0-150*R: 0-147* Ext 4 4+*• R Rectus Femoris Tightness ABD 5- 4*• No Pain with Bilat. Patella Mob.; L=R• Pain under R Patella with Quad. Set ADD 3+* 4+• Significant crepitus bilat. with supine movement SLR 5- 5-• Positive ASLR for TA weakness K Flex 4+ 4+• LEFS: 36.25% Ext 5* 5**
  33. 33. Pt. C• STGs: Pain, R Hip/SLR ROM, Strength, Standing & Walking Tolerance, Stair Climbing, School, LEFS• Treatment ▫ Bike Abdominal Isometrics ▫ Bridge Bridge with Ball Squeeze/T-Band ABD ▫ Tri- Crunches Plank Circuit ▫ T-Band Squat & Row Wall Squats & Ball Squeeze ▫ Inch Worms Side Squats ▫ Stretch: Quads, Piriformis, Hams, Gastro/Sol.• Start Pt. with trunk stabilizing exercises and progress to the more difficult with extremity involvement• Pt. has only been seen for one visit at this time.
  34. 34. Case Pt. D: Initial Evaluation• 35 y.o. obese female reports first injury back in 2009 when at work, performing slide board transfer of a large female who was slipping off the board & she stopped her but fell. Chronic LBP since• MD dx: L lumbar MPS, SIJ Dysfunction• Increased pain after having gastric bypass in July 2012 ▫ Has lost about 100# since.• Has tried 2 injections, Chiro., 3 PTs including Aqua PT and Spine Clinic• Pain 5-25/10, Continuous & Getting worse• Sitting & Standing 30 min, Walking 20 min (Treadmill 3.0-3.2 with incline), Restless sleep, Can Stair Climb Recip., 10-15# Lift/Carry limit from MD• Lumbar ROM all 75% of norm• SLR L: 85 with LBP R: 90• LEs MMT all 5/5, except L Hip Flex 5-/5• Able to bridge ▫ L Unilat. Bridge: discomfort L ▫ R Unilat. Bridge: instability & pain• Pain with AOS testing: R Shld & L Hip• Thigh Thrust: Relieve pain but uncomfortable Oswetry: 54%• Compression of SI: decreased pain Distraction: increased pain
  35. 35. Pt. D• STGs: Pain, Lumbar ROM, Core Strength, Sit & Stance Tolerance, Walking Tolerance, Oswetry• Treatment ▫ MHP lumbar SKC/LTR ▫ Pelvic Tilts with alt. hip flex, flys, SLR ▫ Bridge Unilateral and Marching ▫ Wall Pelvic Tilts Wall Squats ▫ T-Band Squat & Row SLS with other hip at 90• Pt. has been seen for 4 visits• Continues to report significantly high levels of pain and appears to be becoming discouraged• Did not show for last appt.• Plan: Education similar to that of Pt. B & Closely monitor any aberrant motions during exercises. Slow and controlled.
  36. 36. Bypass LiteratureRapid Changes in gait, Musculoskeletal pain in obese: a comparison with a generalmusculoskeletal pain, and population and long-term changesquality of life after bariatric after conventional and surgicalsurgery9 obesity treatment4• Examine whether participants • Compare the prevalence of work- who had undergone gastric bypass restricting musculoskeletal pain in an obese and general population & or gastric banding have investigate changes in the incidence improvements in joint pain, gait of and recovery from (7 parameters), mobility, and QOL musculoskeletal pain after bariatric by 3 month compared with sx or conventional obesity tx. nonsurgical controls • Conclusion: “Obese subjects have• Conclusion: “Improvements in more problems with work- restricting musculoskeletal pain some, but not all, gait than general population. Surgical parameters, walking speed, and obesity tx reduces the long-term risk QOL and of perceived functional of developing WRMSP & increase limitations occur by 3 months likelihood of recovering from such after a bariatric procedure.” pain.
  37. 37. References1. Austin GP, Control Exercise for the Patient with Lumbopelvic Pain: Current and Advanced Evidence-Based Concepts. Southcoast Hospital Group: Rehabilitation Services, P.T. In-service. October 25, 2012.2. Jørgensen M, Andersen L, Kirk N, Pedersen M, Søgaard K, Holtermann A. Muscle activity during functional coordination training: implications for strength gain and rehabilitation. Journal Of Strength & Conditioning Research (Lippincott Williams & Wilkins). July 2010;24(7):1732-1739.3. Okubo T, Kaneoka K, Imai A, Shiina I, et al. Electromyographic Analysis of Transversus Abdonimis and Lumbar Multifidus Using Wire Electrodes During Lumbar Stabilization Exercise. Journal of Orthop. Sports Phys. Ther. Novemeber 2010; 40(11): 743-750.4. Peltonen M, Lindroos AK, Torgerson JS. Musculoskeletal pain in the obese: a comparison with a general population and long-term changes after conventional and surgical obesity treatment. Pain. August 2003; 104(3): 549-57.5. Schenkman M, Jordan S, Backstrom K, et al. Functional movement training for recurrent low back pain: lessons from a pilot randomized controlled trial. PM & R: The Journal Of Injury, Function, And Rehabilitation. February 2009;1(2):137-146.6. Swinnen/Van Heddegem. Functional Resistance Training. and-outer-unit#outer-unit. Accessed November 15-24,2012.7. Tsao H, Druitt T, Schollum T, Hodges P. Motor Training of the lumbar paraspinal muscles induces immediate changes in motor coordination in patients with recurrent low back pain. Journal of Pain. November 2010; 11(11):1120-1128.8. Tsauo J, Chen W, Liang H, Jang Y. The effectiveness of a functional training programme for patients with chronic low back pain -- a pilot study. Disability & Rehabilitation. June 15, 2009;31(13):1100-1106.9. Vincent HK, Ben-David K, Conrad BP, Lamb KM, Vincent KR. Rapid changes in gait, musculoskeletal pain, and quality of life after bariatric surgery. Surgery for Obesity And Related Diseases: Official Journal of the American Society for Bariatric Surgery. May-Jun 2012; 8(3): 346-354.