Diploma in Osteopathic Manual Practice (DOMP) student, Justine Teng, explores the benefits of osteopathic manual treatment on aerobic group exercise instructors.

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Benefits of OMT on Aerobic Group Exercise Instructors
Justine Teng Hui Ling
Thesis Submission in accordance with requirements for DIPLOMA in
OSTEOPATHY MANUAL PRACTICE (DOMP) by London College of Osteopathy
and Health Sciences
May 2021

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Contents
A. Introduction: How does Chronic Pain and Overtraining affect Group Exercise
Instructors (GXIs), and can Osteopathic Manipulative Treatment (OMT) help
improve the performance of GXIs?
B. Chronic Pain and Aerobic Group Exercise Instructors (GXIs)
I. Issues faced by Aerobic Group Exercise Instructors (GXIs)
II. Search for treatment
III. Case Studies: How can Osteopathic Manipulative Treatment (OMT)
help with improving the performance and quality of daily life
movements for Aerobic Group Exercise Instructors (GXIs)?
C. Conclusion: Benefits of Osteopathic Manipulative Treatment (OMT) on
Aerobic Group Exercise Instructors (GXIs)
D. Bibliography

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Introduction: How does Chronic Pain and Overtraining affect Aerobic Group
Exercise Instructors (GXIs), and can Osteopathic Manipulative Treatment (OMT)
help improve the performance and quality of life for GXIs?
What is pain, and what is chronic pain? The International Association for the Study of
Pain defines it as “An unpleasant sensory and emotional experience associated with
actual or, potential tissue damage, or described in terms of such damage” (Merskey,
Nogduk, Classification of Chronic Pain) and any pain that lasted for more than 3
months can be considered as chronic pain (Andrews, Steultjens, Riskowski, “Chronic
widespread pain prevalence in the general population”, 5). Treatment methods for
pain are also widely varied. Some individuals may choose to get a massage from a
masseur to relief the sore and aches on their body, while others may have to visit a
general practitioner (GP) for prescriptions of painkillers, and to obtain medical
certificates for rest and/or referrals to a physiotherapist, and there are also some who
seek alternative treatments such as Traditional Chinese Medicine (TCM). In more
serious cases, invasive procedures ranging from steroid injections to hip or knee joint
replacement, be it total or partial, may be required to elevate the pain one is
experiencing.
Pain is not just experienced by the average Joe; it is also no stranger to amateur
sports participants and professional athletes too. Chronic leg pain is a common
complain amongst athletes. Although the sources of their pain may differ, the more
commonly encountered conditions are medial tibial stress syndrome, chronic
exertional compartment syndrome, stress fracture (Burrus, Werner, Starman,
Gwathmey, Carson, Wilder, Diduch, “Chronic Leg Pain in Athletes”, 1538). Most of
the painful conditions listed are caused by repetitive strain to their muscles and
overworking of their legs during training practices.
So, what is overtraining, and how does it affect group exercise instructors (GXIs)?
Overtraining can be defined as a stress – recovery imbalance, or in other words, too
much stress and too little time for the body to recuperate (Lehmann, Foster,
Gastmann, Keizer, Steinacker, Overload, Performance Incompetence, and
Regeneration, 1-6). In GXIs, overtraining mostly comes in the form of teaching

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multiple classes a week, sometimes with many back-to-back classes per day. This
may overwork their bodies if insufficient rest periods are given. In particular, those
who conduct aerobic classes are likely to have a higher amount of forces loaded
repeatedly onto their muscles and joints over long periods of time. Coupled with
insufficient recovery time, the amount of stress within the body tissue builds up, and
this may also increase the chances of sustaining injuries, gradually causing chronic
pain as experienced by many GXIs. Other than repeatedly overloading and
overtraining their body, daily activities like poor posture and other lifestyle habits can
also be some of the causes of chronic pain. One example would be low back pain
(LBP), with the lifetime prevalence of non-specific (common) low back pain is
estimated at 60% to 70% in industrialized countries, and a one-year prevalence of
15% to 45%, and adult incidence of 5% per year (Duthey, “Low Back Pain”, 4). A
systematic review of 28 studies showed that the prevalence of chronic low back pain
was 4.2% in individuals aged between 24 and 39 years old and 19.6% in those aged
between 20 and 59. Of the nine studies that included individuals aged 18 and above,
six reported a chronic low back pain prevalence between 3.9% and 10.2% and the
other three studies showed a prevalence between 13.1% and 20.3% (Meucci, Fassa,
Faria, “Prevalence of Chronic Low Back Pain”, 1). Pain changes the quality of life and
affects daily movement (Brumagne, Janssens, Janssens, Goddyn, “Altered Postural
Control”, 660), and studies have also showed that chronic pain has physiological &
psychological effects on people (Crofford, “Chronic Pain”, 170).
Osteopathic Manipulative Treatment (OMT) consists of techniques that can be used
to diagnose, treat, and prevent illness or injury. Techniques such as myofascial
release, Instrument Assisted Soft Tissue Mobilization (IASTM) and Muscle Energy
Technique (MET) can be used alone or in combination by the therapist to achieve the
desired session goals.
In this thesis, we aim to:
1) Understand if chronic pain experienced by GXIs who teaches aerobic classes
are caused by overtraining, and

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2) Explore if the usage of OMT techniques on GXIs can help them to minimize or
resolve their chronic pain, thereby improving their performance during class
and their quality of life in their day-to-day activities.

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I. Chronic Pain and Aerobic Group Exercise Instructors (GXIs): Issues
faced by GXIs
Chronic pain is a common issue faced by many (Dahlhamer, Lucas, Zelaya, Nahin,
Mackey, DeBar, Kerns, Von Korff, Porter, Helmick, “Prevalence of Chronic Pain”,
1003), and one of the most difficult chronic pain to manage would be chronic
musculoskeletal pain (Crofford, “Chronic Pain”, 167).
The causes of chronic pain are widely varied, ranging from childhood trauma, bad
posture and habits, repetitive use. etc., to in-born physical limitations or disorders
such as scoliosis. Regardless the cause of chronic pain, chronic pain transforms the
way we behave, both physiologically & psychologically (Crofford, “Chronic Pain”, 167).
The following figure shows the bio-psychosocial model of pain, and how it interacts
with osteopathic philosophy.
Figure 1. The Biopsychosocial Model of Pain and Osteopathic Philosophy
Adapted from: J. N. Penney, The biopsychosocial model of pain and contemporary osteopathic
practice, International Journal of Osteopathic Medicine. Elsevier, 2010. Volume 13, Issue 2, June
2010, Pages 42-47

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In a separate study conducted by Loannis Delimaris, it has been shown that
overtraining can lead to physiological problems such as musculoskeletal (MSK)
injuries, adverse cardiovascular effects, exercise-induced muscle damage and
exercise related alterations of immunity among many others (Delimaris, “Potential
Adverse Biological Effects of Excessive Exercise and Overtraining”, 7-10). This
makes exercise a double-edged sword; too little exercise or not moving at all, one
might have health and chronic pain issues related to living a sedentary lifestyle, while
over exercising, on the other hand, brings on a different spectrum of issues (Citko,
Górski,Marcinowicz, Górsk, “Sedentary Lifestyle and Nonspecific Low Back Pain”, 6).
GXIs, especially those who teach multiple aerobic classes a week, experience a high
amount of load repeatedly to the muscles and joints. As time passes, when they start
to experience chronic pain issues as a result from the excessive use of their body,
the way they move in class and in their daily lives might be affected. In return, their
mood may be negatively affected due to poor teaching performance in class, and that
might make it hard for them to get quality rest, which is essential for recovery. In the
long run, they might end up getting trapped in the cycle of chronic pain, where quality
of rest, level of activity and mood are compromised due to chronic pain. Figure 2
illustrates the pain cycle.
Figure 2. The Pain Cycle

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To establish and understand the relationship between chronic pain and GXIs, it is
important to determine if the GXIs have chronic pain and, if so, identify the common
areas of pain experienced by them and the reasons why they have chronic pain. In a
research highlighting the benefits of exercise & chronic pain, it has shown that chronic
pain can be reduced with exercise and, exercising can also help to improve physical
and mental wellness (Geneen, Moore, Clarke, Martin, Colvin, Smith, “Physical Activity
and Exercise for Chronic Pain in Adults”, 4).
Among the clients I worked with, a number of them are GXIs with chronic MSK pain.
Due to the nature of the job (i.e., repetitive stress on body tissue and insufficient
recovery time) and/or overtraining, stress induced fatigue resulting in MSK injuries or
pain are quite common among the GXIs who visit the clinic for treatment. In some of
the cases, their condition also has a direct impact on their daily lives, for example, a
decrease in joint range of motion (ROM) which inconveniences daily life, or simply
the inability to move normally with no pain.
I did an online survey to find out about the relationship between GXIs and chronic
pain, and a total of 113 GXIs from Singapore and Malaysia responded. For the
purpose of this thesis, the survey did not include details of why some GXIs experience
chronic pain while others do not, or the program mixes of the GXIs who experience
pain as compared to the others. From the data collected, 49.6% of all GXIs
experience chronic pain (Figure 3), 41.6% of all respondents feels that chronic pain
has affected their quality of life (Figure 4), and 50.4% of all GXIs thinks that chronic
pain will affect their performance in class (Figure 5). The demographics of GXIs who
participated in the survey are shown in Figure 6.

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Figure 3. Percentage of GXIs Who Experience Chronic Pain
Figure 4. Percentage of GXIs Who Feels That Chronic Pain Has Affected Their Quality of Life
49.60%
50.40%
Do you experience chronic pain?
Yes No
41.60%
58.40%
Do you think that chronic pain will affect your
lifestyle?
Yes No

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Figure 5. Percentage of GXIs Who Feels That Chronic Pain Has Affected Their Performance in
Class
Figure 6. Number of Year Participants Have Been A GXI
Data collected amongst the GXIs who responded that they have chronic pain also
indicates that the top 3 common areas GXIs experience chronic pain are the lower
limbs, such as the knee and ankle (27.74%), low back pain (LBP) (24.52%), and
shoulder pain (14.84%). The chart below (Figure 7) shows all the areas that GXIs
experience chronic pain. Participants that do not have chronic pain are not included
in this chart.
50.40%
49.60%
Do you think that chronic pain will affect your
performance in class?
Yes No
5.30%
5.30%
9.70%
4.40%
15%
13.30%
8%
9.70%
0.90%
28.30%
0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00%
1
2
3
4
5
6
7
8
9
10
Percentage of Total Particpants
Number
of
Years
as
GXI
How many years have you been a GXI?

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Figure 7. Areas Affected by Chronic Pain in GXIs
From the survey data collected, the percentage of GXIs who experience chronic pain
(49.6%) is higher than the general population (8.7%) based on a study done in
Singapore in 2009 (Yeo, Tay, “Pain prevalence in Singapore”, 941). It is also higher
than 20.4% of the general population based on the research by the Centers for
Disease Control and Prevention (CDC) in the United States (Dahlhamer, Lucas,
Zelaya, Nahin, Mackey, DeBar, Kerns, Von Korff, Porter, Helmick, “Prevalence of
Chronic Pain”, 1002). Although limited cross-sectional studies are done to directly
compare the chronic pain experiences between Western and Asian population, and
how the possibility of a difference in genetic makeup between the Western and Asian
population may pre-dispose and increase the likelihood of certain groups getting
chronic pain, we can safely infer that GXIs are still at higher risks of experiencing
chronic pain as compared to the general population.
0.00%
7.10%
14.84%
9.03%
24.52%
4.52%
27.74%
11.61%
0.65%
0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00%
Head
Neck
Shoulders
Upper Back
Lower Back
Upper Limbs
Lower Limbs
Hips or Pelvic
Internal Organs
Where do you experience chronic pain?

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II. Pain and Aerobic Group Exercise Instructors (GXIs): Search for
treatment
From the survey, 45.1% of GXIs sought treatment for their chronic pain, while 35.4%
did not, and 19.5% felt that it was not applicable. Additionally, 50.4% of all the GXIs
who participated agreed that chronic pain affected their performance in class (Figure
5) and 41.6% of all who participated felt that chronic pain affected their quality of life
(Figure 4).
Figure 8. Percentage of GXIs Who Seek Treatment for Chronic Pain
Regardless, whether they experienced chronic pain or not, 72.6% of all GXIs were
keen to learn more about how OMT can help with their chronic pain issues. This
indicates that a majority of GXIs are open to different treatment methods to help them
cope with chronic pain.
45.10%
35.40%
19.50%
Do you seek treatment for your chronic pain
issues?
Yes No Not Applicable

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Figure 9. Percentage of GXIs Keen to Learn More on How OMT Can Help with Chronic Pain
In Singapore, there are many different treatments for pain, and some of these
methods are readily available for anyone who can afford the price tag. From the
survey, majority of the GXIs (21.14%) opted to go for body massage, while others
chose to go for TCM (14.23%), physiotherapy (14.23%), pain relief rubs and/or
plasters (14.23%). Figure 10 further illustrates the preference for treatment among
GXIs for their chronic pain. Participants without pain have been excluded from this
chart.
Figure 10. Types of Treatments Seek by GXIs For Chronic Pain
72.60%
27.40%
Would you like to learn about chronic pain
management and how osteopathic treatment
can help with chronic pain?
Yes No
14.23%
2.03%
8.54%
11.38%
14.23%
7.72%
21.14%
14.23%
1.22%
3.25%
2.03%
0.00% 5.00% 10.00% 15.00% 20.00% 25.00%
TCM
GP
Self-medication (Eg. Painkillers)
Chiropractor
Physiotherapy
Manual therapy or Osteopathy
Massage (Eg. Spa, Thai Massage, Sports…
Pain relief rubs or plasters
Surgery or other invasive treatments
Did not seek any treatment
Others
What kind of treatment do you seek?

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III. Case Studies: How can Osteopathic Manipulative Treatment (OMT) help
with improving the performance and quality of daily life movements for
Aerobic Group Exercise Instructors (GXIs)?
To find out how OMT can help in improving the performance and quality of life for
GXIs, I did 3 case studies and analysed the GXIs who experience chronic pain.
• Case Study 1
Name: SM
Age: Early 30s
Number of years as GXI: 1.5 years
Issue: Loss of strength in left arm
• Case Study 2
Name: MW
Age: Early 50s
Number of years as GXI: 8 years
Issues: Achilles tendonitis, Infraspinatus and Supraspinatus tendinosis,
degenerative changes of the Acromioclavicular Joint (ACJ)
• Case Study 3
Name: EZ
Age: Late 20s
Number of years as GXI: Less than 1 year
Issues: Left Anterior Cruciate Ligament (ACL) reconstruction, right ankle pain

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Case Study 1
Name: SM
Age: Early 30s
Number of years as GXI: 1.5 years
Issue: Loss of strength in left arm
SM is a part-time GXI who works in a bank as his main job, and spends four of his
week days evenings teaching high-intensity aerobic classes. He first came into the
clinic presenting a lack of strength in his left arm, trouble carrying heavy weights
during his own training, thus affecting his performance when teaching his classes.
Subjective assessment revealed that the problem started off with pain in his left arm
which did not diminish even when he reduced the weight carried during training. Over
a period of 6 months, not only did the pain persisted, it had also gradually evolved
into weakness. This gotten SM concerned, and that was when he decided to seek
treatment.
Upon objective assessment, SM presented no noticeable imbalances in his posture,
no reduction in his ROM for his arms, but complaints of pain and loss of strength
when doing bicep curls. During the palpation of structural symmetry and tissue texture,
the tissue around his left deltoids lacked bounce as compared to his right arm. A
particularly “knotty” area in the fascia towards the anterior deltoid was also noted
during palpation. Tissues were unable to glide much when moved, but have no pain
during normal flexion and extension of his arm. SM also has tightness in his trapezius,
pectoral muscles, calves and glutes. Soft tissues techniques, such as myofascial
release, were used on SM’s left deltoid to release the tension around his left arm.
After the first session, SM saw an improvement in his grip strength when doing bicep
curls and lesser pain when teaching classes. In subsequent sessions, I continued to
use soft tissues techniques as well as Instrument Assisted Soft Tissue Mobilization
(IASTM) on SM’s left arm. IASTM seemed to be effective on releasing the ‘knotty’

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fascia around his deltoid. Following that, I moved up the kinetic chain by releasing his
left pectoral muscles, which also presented tightness during the initial assessment,
using myofascial release and around tendons near the attachment points of the
humerus to his clavicle.
SM’s left arm pain showed significant improvement during the few IASTM sessions.
He reported no pain in his left arm during class or when doing bicep curls, and also
mentioned that he has a better grip when holding barbells during weight training. SM
is currently getting back to his previous training weights and continues to attend
myofascial release sessions for other parts of his body (e.g. Glutes, pectorals and
calves to minimize any risk of injury due to his lifestyle and work schedule.

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Case Study 2
Name: MW
Age: Early 50s
Number of years as GXI: 8 years
Issues: Achilles tendonitis, Infraspinatus and Supraspinatus tendinosis,
degenerative changes of the Acromioclavicular Joint (ACJ)
MW is a full-time GXI who teaches approximately 11 aerobic classes a week, and
has been actively teaching aerobic classes for 8 years. She has been suffering from
Achilles tendonitis for the past 3 years and has seeked treatments such as massage,
physiotherapy and shock wave therapy. Despite the treatments, her Achilles
tendonitis never fully resolved, and she still has pain in her right heel when she
overexerts herself during classes. MW has also been experiencing a reduction in her
right shoulder ROM, and the pain in her shoulder caused her discomfort while
teaching her classes. The pain and discomfort in her shoulder also caused her to not
enjoy attending other group classes as much as before. 3 months prior to her visit,
MW went for an MRI for her shoulder, and the result showed tendinosis of the
infraspinatus and supraspinatus tendon, and degenerative changes of the ACJ.
Upon physical assessment, MW presented with lesser shoulder abduction ROM on
her right (approximately 110 degrees) as compared to her left (full ROM 180 degrees),
and was unwilling to move her right shoulder into more abduction due to pain. She
also had a noticeable tighter left trapezius muscle compared to her right when asked
to tilt her head sideways.
During palpation, MW reported tenderness around her right heel and right shoulder.
There was an increase in muscle tone around her right deltoids and biceps, which felt
hard and ‘knotty’ with little give.

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OMT such as myofascial release, IASTM, soft tissue mobilisation and muscle energy,
were used during MW’s first session, to release and mobilise the stuck fascia around
her right ACJ, deltoids and biceps. By doing so, it helped reduce the tension in the
arm muscles and mobilise the joint. In subsequent sessions, I incorporated
myofascial release and other soft tissue mobilisation around her right shoulder,
targeting the subscapular, pectoral and triceps muscles.
After approximately 6 weeks of treatment, MW started to have an improvement in her
right shoulder ROM and could abduct her right arm without pain or discomfort. While
working on the right arm, we also managed to integrate myofascial release on her
right calf and heel. By releasing the muscle tension in her right soleus, gastrocnemius,
heel and plantar area, it has helped to reduce the stress on her Achilles tendon during
movements such as jumping, heel lifts in her classes, making it more comfortable for
MW.

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Case Study 3
Name: EZ
Age: Late 20s
Number of years as GXI: Less than 1 year
Issues: Left Anterior Cruciate Ligament (ACL) reconstruction, right ankle pain
EZ is a full-time student, and has recently started out as a part-time GXI. She teaches
1 high intensity aerobics class per week, and has soccer practices 2-3 times a week
at school. 3 years ago, EZ had a complete tear in her ACL during one of her soccer
matches. She had undergone ACL reconstruction surgery and had metal implants in
her left knee. She completed rehabilitation and recovered with full knee ROM. Post-
surgery and rehabilitation, EZ had no pain in her left knee during soccer games.
However, she started to experience tightness and pain in her right ankle when she
overexerts herself during soccer games, and recently, while teaching her aerobic
classes.
During physical examination, EZ had no significant differences in bilateral knee ROM.
Although her left calf appears to be slightly smaller, she has no restrictions in her
ankle ROM. Upon palpation, tightness can be felt around the sides and back of the
left knee, and there is a palpable difference in muscle tone in her right calf as
compared to her left. There is also fascia tightness felt underneath and around the
surgical scar on her left knee, despite EZ not having any discomfort around the area.
Based on the above assessment, it seemed likely that the pain in EZ’s right ankle
was caused by her left knee injury and scar tissue, as her body likely compensated
by weightbearing more onto her right side to stabilise the body and allowed the left
side to recover from her ACL surgery. Hence, session goals focused on breaking
down and remodelling of surgery scar tissue, mobilising the fascia and muscles
around her left knee, and reducing the tightness in her right calf to minimise the pain
in her right ankle during soccer practices and aerobic classes.

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Over the course of 3 months, OMT such as myofascial release, IASTM, soft tissue
mobilisation was used, and the pain in EZ’s right ankle has reduced greatly. She has
not been experiencing pain in her ankles, the tightness behind the knee have reduced,
and the surgery scar on the top of her knee has soften and flatten. Even though her
calf muscles will still become tense after over-exertion through the week, they are
now more receptive to myofascial release and soft tissue mobilisation as compared
to her first session. In addition to her manual therapy sessions, EZ has also been
diligent with doing self-myofascial release with a foam roller as part of her own
maintenance regime, and as such, ha not reported pain in her right ankle.

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Conclusion: Benefits of Osteopathic Manipulative Treatment (OMT) on Aerobic
Group Exercise Instructors (GXIs)
Based on the 3 case studies above, we can conclude that chronic pain in GXIs is not
just a result of teaching multiple aerobic classes; it could also be caused by the
accumulation of stress from other activities and/or lifestyle of individual GXIs.
Regardless of the cause of chronic pain, there are a few points that are common for
all 3 GXIs presented in my case studies:
1. Myofascial release, IASTM and soft tissue mobilisation are the most effective
OMT treat and relief chronic pain for GXIs
2. The site where the GXIs experience chronic pain may be a referred pain from
other areas
3. Overtraining, long hours of physical or making repetitive moves during aerobic
classes can be the cause of chronic pain experienced by GXIs
4. ‘Knots’ in fascia can cause it to glide less smoothly, hence causing restrictions
in joint ROM and chronic pain if left untreated
In conclusion, the usage of OMT techniques on GXIs can help them to improve their
performance during class and also their quality of life for their daily activities. OMT
can also be used to provide a holistic maintenance program for GXIs, in addition to
their own self-maintenance regime (i.e., regular stretching, self-myofascial release)
to maintain the longevity of their fitness career.

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Bibliography
1. Andrews, P, Steultjens, M, Riskowski, J. “Chronic widespread pain prevalence
in the general population: A systematic review” European Journal of Pain 22
(2018)
2. Brumagne, Simon, Janssens, Lotte, Janssens, Evelien, Goddyn, Lieselotte.
“Altered Postural Control in Anticipation of Postural Instability in Persons with
Recurrent Low Back Pain” Gait & Posture 28 (2008)
3. Burrus, M Tyrrell, Werner, Brian C, Starman, Jim S, Gwathmey, F Winston,
Carson, Eric W, Wilder, Robert P, Diduch, David R. “Chronic Leg Pain in
Athletes” The American Journal of Sports Medicine Vol. 43, No. 6 (2015)
4. Citko, Anna, Górski, StanisBaw, Marcinowicz, LudmiBa, Górsk, Anna.
“Sedentary Lifestyle and Nonspecific Low Back Pain in Medical Personnel in
North-East Poland” BioMed Research International Vol 2018, Article ID
1965807
5. Crofford, Leslie J. “Chronic Pain: Where Body Meets the Brain” Transactions
of The American Clinical and Climatological Association Vol. 126 (2015)
6. Dahlhamer, James, Lucas, Jacqueline, Zelaya, Carla, Nahin, Richard,
Mackey, Sean, DeBar, Lynn, Kerns, Robert, Von Korff, Michael, Porter, Linda,
Helmick, Charles. “Prevalence of Chronic Pain and High-Impact Chronic Pain
Among Adults” US Department of Health and Human Services/Centers for
Disease Control and Prevention Morbidity and Mortality Weekly Report Vol. 67
No. 36 (2018)
7. Delimaris, Loannis. “Potential Adverse Biological Effects of Excessive
Exercise and Overtraining Among Healthy Individuals” Acta Medica Martiniana
2014, 14/3 (2014)
8. Duthey, Béatrice. “A Public Health Approach to Innovation, Update on 2004
Background Paper, BP6.24 Low Back Pain” Priority Medicines for Europe and
the World (2013)
9. Geneen, LJ, Moore, RA, Clarke, C, Martin, D, Colvin, LA, Smith, BH. “Physical
Activity and Exercise for Chronic Pain in Adults: An overview of Cochrane
Reviews” Cochrane Database of Systematic Reviews 2017, Issue 4. Art. No.:
CD011279. (2017)

23. 23
10.Lehmann, Manfred, Foster, Carl, Gastmann, Uwe, Keizer, Hans, Steinacker,
Jiirgen M. Overload, Performance Incompetence, and Regeneration. Kluwer
Academic / Plenum Publishers, New York (1999)
11.Merskey H, Bogduk N. Classification of Chronic Pain: Descriptions of Chronic
Pain Syndromes and Definitions of Pain Terms. Seattle, Washington:
International Association for the Study of Pain (1994)
12.Meucci, RD, Fassa, AG, Faria, NMX. “Prevalence of Chronic Low Back Pain:
Systematic Review” Rev Saúde Pública (2015)
13.Penney, J. Nicholas. “The biopsychosocial model of pain and contemporary
osteopathic practice” International Journal of Osteopathic Medicine 13 (2010)
42–47
14.Sow Nam, Yeo, Kwang Hui, Tay. “Pain prevalence in Singapore” Annals of the
Academy of Medicine, Singapore (2009) 38(11):937-42