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Neck pain is a significant contributor to worldwide disability and poses a considerable financial burden to its stakeholders. The prognosis for chronic neck pain is generally poor, and the associated disability seems to be more persistent than low back pain. It has been suggested that the goals of a rehabilitation program are to maximize return to function, limit progression of degenerative changes, and prevent further injury. The variety of treatment options can make it difficult for clinicians to agree on the most effective treatment intervention. This article reviews noninvasive treatment considerations for patients with neck pain. Exercise-based interventions, including aerobic conditioning, stretching, and strengthening, are addressed. Moreover, concepts related to education are covered, including the effects of posture and ergonomic counseling.
American Journal of Lifestyle Medicine
Mar • Apr 2010
The In uence of Education and
Exercise on Neck Pain
William J. Hanney, PT, DPT, ATC, CSCS,
Morey J. Kolber, PT, PhD, OCS, Cert MDT, CSCS,
Judi Schack-Dugre’, PT, DPT, MBA,
Rodney Negrete, PT, CSCS,
and Patrick Pabian, PT, DPT, OCS, CSCS
DOI: 10.1177/1559827609351134. Manuscript received February 4, 2009; revised April 7, 2009; accepted April 8, 2009. From the Department of Health Professions,
University of Central Florida, Orlando (WJH, JS-D, PP); Department of Physical Therapy, Nova Southeastern University, Ft Lauderdale, Florida (MJK); and Florida Hospital
Celebration Health, Celebration, Florida (RN). Address correspondence to William J. Hanney, PT, DPT, ATC, CSCS, University of Central Florida, Department of Health
Professions, 4000 Central Florida Blvd, HPA—1 Room 262, Orlando, FL 32816-2205; e-mail:
For reprints and permission queries visit SAGE’s Web site,
Copyright © 2010 The Author(s)
Abstract: Neck pain is a significant
contributor to worldwide disability and
poses a considerable financial bur-
den to its stakeholders. The prognosis
for chronic neck pain is generally poor,
and the associated disability seems to
be more persistent than low back pain.
It has been suggested that the goals of
a rehabilitation program are to max-
imize return to function, limit pro-
gression of degenerative changes, and
prevent further injury. The variety of
treatment options can make it difficult
for clinicians to agree on the most effec-
tive treatment intervention. This article
reviews noninvasive treatment consid-
erations for patients with neck pain.
Exercise-based interventions, includ-
ing aerobic conditioning, stretch-
ing, and strengthening, are addressed.
Moreover, concepts related to education
are covered, including the effects of
posture and ergonomic counseling.
Keywords: neck pain; disability; reha-
bilitation; treatment
eck pain is a significant contribu-
tor to worldwide disability.
Up to
70% of the population will expe-
rience an episode of neck pain at some
point in their lives,
and 15% of the popu-
lation will experience chronic neck pain.
Neck pain also poses a significant finan-
cial burden to its stakeholders, including
expenses related to the diagnostic process,
treatment costs, sick leave from work, and
premature retirement pensions.
The prog-
nosis for chronic neck pain is generally
poor, and the associated disability incurred
due to chronic neck pain seems to be
more persistent than low back pain.
It has been suggested that the goals
of a rehabilitation program are to max-
evidence to support various methods of
direct neck stretching and strengthening
for chronic neck disorders.
supportive literature is limited, expert
experience suggests that addressing
impairments related to postural and
ergonomic conditions is of benefit.
variety of treatment options can make
it difficult for clinicians to agree on the
most effective treatment intervention.
This article reviews noninvasive treat-
ment considerations for patients with
The interactions of pain, reduced activity
level, and emotion/stress all play a role
in the chronic pain process.
imize return to function, limit pro-
gression of degenerative changes,
and prevent further injury.
A sys-
tematic review illustrates multimodal
approaches to treating neck pain.
These approaches suggest that the
inclusion of stretching and strengthen-
ing exercises for subacute and chronic
mechanical neck disorders results in a
favorable response.
Another system-
atic review also demonstrated moderate
neck pain. Exercise-based interventions,
including aerobic conditioning, stretch-
ing, and strengthening, are addressed.
Moreover, concepts related to educa-
tion are covered, including the effects
of posture and ergonomic counseling.
This review of the literature also intends
to familiarize the reader with com-
mon impairments associated with each
of these interventions and the reported
effects of treatment.
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American Journal of Lifestyle Medicinevol. 4 • no. 2
Postural and Ergonomic
It has been proposed that ergonomic
and postural education is an integral part
of treating those patients with neck pain
likely to benefit from an exercise and
conditioning regimen.
Rempel et al
demonstrated decreased neck and shoul-
der pain in sewing machine operators
when improved postural support was
provided. It was also found that provid-
ing ergonomic training and altering work-
stations reduced neck/shoulder pain for
those working on computers in a call
Others do not support these
interventions. Grooten et al
that ergonomic interventions seem
to be ineffective for decreasing neck/
shoulder pain-related disability.
Systematic reviews are also not favor-
able for postural and ergonomic instruc-
tion. One literature review reported that
these types of educational interventions
have not been shown to be beneficial in
reducing pain associated with mechan-
ical neck disorders.
Some suggest that
poor results of given trials on ergonomics
may be due to single rather than multi-
modal programs.
Many studies involving
posture and ergonomic instruction do not
include other interventions. Therefore,
interventions such as ergonomic or pos-
tural instruction alone may not demon-
strate significant effectiveness because
of limitations in the external validity of
study design. These interventions in con-
junction with others, however, may be
valuable. Also, studies involving pos-
ture and ergonomic instruction gener-
ally include a heterogeneous sample.
Homogeneous subgroups may demon-
strate greater success.
Postural and Ergonomic
It has been suggested that prolonged
postural malalignment may contribute to
Alterations in skeletal align-
ment during interactions with the envi-
ronment may contribute to imbalances
between muscular agonists and antago-
nists, facilitating abnormal musculoskele-
tal changes.
These muscle imbalances
may lead to chronic strain, resulting in
pain and dysfunction.
An understanding
of how postural and ergonomic impair-
ments contribute to neck pain is nec-
essary to understand the mechanism
by which these dysfunctions persist.
By understanding the mechanical dys-
function within these patients, one can
understand the common impairments
associated with neck pain.
There are a variety of postural devi-
Postural dysfunction is often
referred to in the context of a forward
head position (FHP). One type of FHP is
demonstrated with the head resting well
in front of the vertical gravity line.
A second type of FHP occurs when the
chin leads and the head is angled slightly
upward, tilted caudally, while still being
within or slightly anterior to the verti-
cal gravity line.
Posture has been recog-
nized as a possible contributor to head
and neck pain.
Neck pain associated
with posture is generally due to static
loading positions.
This head position is
thought to increase the load on cervical
structures, which results in pain.
posture may also increase compressive
loading of the cervical spine, which is a
result of weight transfer from the upper
extremity through cervicoscapular muscle
Griegel-Morris et al
that those with severe postural abnor-
malities had a significantly increased
incidence of cervical, interscapular, and
headache pain.
that symptomatic women demonstrated
more rounded shoulders.
Although postural deviations can lead
to static loading positions, there may
also be influences on muscular func-
tion. The endurance capacity of the short
neck flexors is contributory to mainte-
nance of head posture.
It was found
that forward head posture is associated
with weak neck flexor muscles.
patients with neck pain demonstrated a
decreased ability to maintain an upright
posture when cognitively distracted.
Cagnie et al
found neck pain associated
with prolonged forward head posture, sit-
ting for an extended period of time, and
making repetitive cervical movements.
Some have found that suboccipital exten-
sion specifically may contribute to cervi-
cogenic headaches.
that habitual poor posture in a suboccip-
ital extended position can be a source of
posterior headaches. Also, smaller cran-
iovertebral angles are associated with a
high incidence of neck pain.
Many factors contribute to pain in the
upper quarter. Many of the contribu-
tors may be postural in nature, but there
is also a significant influence on how
individuals interact with their environ-
ment. Numerous ergonomic factors may
be a potential source of dysfunction and
pain. Marcus et al
reported that an opti-
mal desk height, armrests, and relaxed
neck postures are prognostic factors for
neck/shoulder symptoms and disorders.
Shikdar and Al-Kindi
reported that ergo-
nomic deficiencies are common in office
computer workstation design. Also, those
individuals who use notebook computers
tend to have a more flexed static posture
when compared to desktop computer
users, who generally have a more upright
posture and perform more neck move-
Wong et al
demonstrated that
certain ergonomic changes such as alter-
ations in chair back inclination influence
cervical repositioning errors in the sag-
ittal plan. Others found that ergonomic
changes decrease electromyographic
(EMG) activity of the upper trapezius and
pain in the shoulder and neck.
examples illustrate how the environment
influences performance of specific tasks.
The duration of static work postures also
influences symptoms. Kamwendo et al
reported that working with office machines
5 or more hours per day is associated with
a significantly increased risk for neck pain.
Mechanistic considerations of the environ-
ment also influence neck pain. Persons
who routinely use hand-transmitted vibra-
tion devices such as power tools are more
likely to complain of hand/wrist and neck
Also, men who report daily vibra-
tion exposure with a duration more than 1
hour have an increased risk of neck pain.
Alipour et al
found that risk indicators
for men include duration of employment,
high visual demands, repetitive work, sit-
ting position at work, awkward working
position, no regular exercise, monotonous
work, lack of encouraging organizational
culture, and anxiety concerning change.
Additional risk factors for women include
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repetitive work, sitting position at work,
and no support if there is work-related
It can be determined that a
wide variety of ergonomic factors can influ-
ence neck pain. The results of an investi-
gation by Krause et al
support the belief
that there is a causal role of physical work-
load and the development of back and
neck pain.
Effects of Postural and
Ergonomic Training
The effects of postural and ergonomic
interventions have generally been mixed.
Although many possible interventions
could be classified as postural and ergo-
nomic instruction, this review focuses on
the key components of patient education,
postural instruction, work environment,
and physical workload.
Patient/client education in one form or
another is a ubiquitous component of
treatment used by many physical ther-
apists. Research generally supports this
type of intervention, particularly as it
relates to neck pain. Brison et al
strated that postural education decreases
the severity of symptoms in patients
with whiplash-related disorders. A ran-
domized controlled trial showed that
a comprehensive ergonomic program
including education is significantly asso-
ciated with reduced discomfort scores in
the neck/shoulder.
Furthermore, Rempel
et al
demonstrated that providing ergo-
nomic training and altering workstations
reduce neck/shoulder pain for individu-
als working on computers in a call cen-
ter. Consistent with these and most other
studies, patient education is only one
component of a comprehensive treatment
regime. Therefore, it is difficult to differ-
entiate education as an independent vari-
able and its direct influence on neck pain.
Postural instruction can also have a
positive influence on neck pain. It has
been demonstrated that skilled pos-
tural instruction and facilitation results
in greater activation of the deep cervi-
cal flexor group and lumbar multifidus.
This suggests that training for proper pos-
ture is a dynamic process. Furthermore,
outcomes are enhanced when more than
verbal instruction is provided. These find-
ings are supported by a review that sug-
gests that ergonomic changes can be
made, which demonstrate a positive
influence on posture and pain.
Readjusting the workspace can also
help influence neck pain. Rempel et al
demonstrated that improved postural
support decreased neck and shoulder
pain in sewing machine operators. Also,
a randomized controlled trial showed that
a comprehensive ergonomics program
including workstation changes was signif-
icantly associated with reduced discom-
fort scores in the neck/shoulder.
et al
demonstrated that using two arm
supports instead of one decreased upper
trapezius activity and subjective discom-
fort. Interestingly, a significant reduc-
tion in shoulder and neck pain was also
reported after new lighting systems were
installed, workplaces were adjusted, and
optometric corrections were performed.
This illustrates the diverse type of inter-
ventions available for consideration
when adjusting the workspace environ-
ment. Although there are many different
ways by which one’s workspace could be
adjusted, each individual situation must
be thoroughly analyzed and changes
must be individually specific.
Adaptations of the actual physical work-
load may be necessary. Interventions
such as biofeedback demonstrated favor-
able outcomes in female computer work-
ers reporting neck-shoulder pain.
study demonstrated that taking regular
breaks revealed a decrease in the upper
trapezius activity and subjective discom-
Altering positions can also influence
pain levels. Keir et al
showed that alter-
nating positions and tasks with use of a
computer mouse may avoid excessive pres-
sure within the carpal tunnel. Kamwendo
et al
reported small correlations between
perceived fatigue, pain, and well-being
with the number of transitions from sit-
ting to standing and time spent typing. This
suggests factors that contribute to neck
pain can be somewhat individual. Another
study found that frequent breaks did
improve symptoms. van den Heuvel et al
found that computer software prompting
computer users to take regular breaks con-
tributes to perceived recovery from neck
or upper limb complaints. Others demon-
strated reduced EMG activity when operat-
ing an ergonomic microscope workstation
versus a standard microscope.
Aerobic Conditioning
and Physical Activity
Conditioning and physical activity are
components of a fitness program and
described as the ability to perform phys-
ical work.
This type of training gener-
ally includes repetitive dynamic activities
that incorporate large muscle groups.
Examples may consist of walking,
cycling, swimming, or upper body
ergometry. Physical activity has been
shown to reduce the risk of premature
mortality, improve functional capacity,
and help older adults maintain indepen-
Furthermore, aerobic condi-
tioning and physical activity have been
proposed to benefit certain patients with
neck pain.
Studies also suggest influ-
ences of exercise on maintenance of
proper posture. An exercise program that
targeted craniocervical flexor (deep neck
flexor) muscles in patients with neck
pain demonstrated an improved ability to
maintain a neutral cervical posture during
prolonged sitting.
Impairments Related to
Lack of Aerobic Conditioning
and Physical Activity
Many factors contribute to impairments
associated with conditioning and physical
activity. Fitness levels can be described
as ranging from poor to superior based
on energy expenditure during physical
Cardiovascular fitness and fear of
injury or movement have been identified
as impairments that have been related to
a lack of conditioning.
There are few studies that correlate neck
pain with fitness level. There is, however,
considerable information available regard-
ing the role that low back pain has on fit-
ness. Common physical characteristics
are shared by patients with neck and low
back pain.
An individual’s fitness level
seems to be influenced by the presence of
low back pain.
Patients who experience
low back pain typically have a decreased
level of physical activity.
Raven et al
found a decrease in max O
uptake in
patients with low back pain. Factors that
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influence oxygen consumption include
age, gender, heredity, inactivity, and dis-
Smeets et al
found that patients
with chronic low back pain seem to have
a reduced aerobic fitness level compared
with the normal population. Furthermore,
neck pain specifically has been associated
with cardiovascular disorders.
Injury can often cause increased lev-
els of concern or fear about movement.
These concerns in excess can contrib-
ute to higher levels of disability. Verbunt
et al
found that fear of injury is more
strongly associated with perceived dis-
ability than with aerobic fitness. Also,
patients with low physical activity had
significantly higher scores in fear avoid-
ance beliefs and pain catastrophizing.
Therefore, some feel that a perceived
decline in physical activity is important to
assess when evaluating low back disabil-
Ultimately, fear avoidance behaviors
may lead to a decrease in activity, per-
petuating increased disability in patients
with low back or neck pain.
Effects of an Aerobic
Conditioning and Physical
Activity Program
A conditioning program can have pro-
found physiological effects. Although
there is limited research regarding the
influence of aerobic exercise on neck
pain, much support exists for the influ-
ence on low back pain. The interactions
of pain, reduced activity level, and
emotion/stress all play a role in the
chronic pain process.
Unfortunately, individuals with chronic
pain often present with depressed mood
Several factors related to pain can
be influenced by exercise. Participating
in some type of exercise program seems
to have beneficial effects. Low to moder-
ate aerobic exercise improves mood states
and work status in patients with low back
Shepanski et al
found that individ-
uals participating in habitual exercises dem-
onstrated higher mood disturbance scores
compared to nonexercisers. Furthermore,
a narrative review illustrated strong sup-
port of acute mood benefits after exercise.
Although participation in an exercise pro-
gram seems to influence pain, other fac-
tors from an exercise program may also
have a positive effect. Some have stud-
ied the influence of exercise intensity on
mood. Thayer
found that short periods
of exercise at higher intensities offer mood
benefits. Moderate-intensity physical activ-
ity generally seems to positively influence
concluded that extremely
high or very low training intensities do
not appear to optimally improve mood.
Markoff et al
found that long periods
of exercise at lower intensities also pro-
vide benefit. It seems that the intensity and
duration are closely associated with influ-
encing mood state. Regardless of the level
of intensity or duration, the effects of
exercise-induced mood enhancement can
last up to 24 hours.
Exercise can alter one’s perception of
Janal et al
reported a reduction
in nociception after exercise. Another
investigation found decreased pain per-
ceptions after a 1-mile run.
One inves-
tigation reported the pain threshold to
be significantly higher along with signif-
icantly lower pain ratings immediately
after exercise.
One review illustrated
acute reduction of pain after aerobic
Some authors have suggested
that a certain level of exercise intensity
is required to increase pain tolerance.
Intensities as low as 50% maximal aerobic
capacity were not enough to show sta-
tistically significant changes in pain per-
Kemppainen et al
that intensities exceeding 70% max aero-
bic capacity are required to increase pain
thresholds. Another study also indicated
that higher levels of intensity are required
to alter pain tolerance. Hoffman et al
found that exercise for 30 minutes at 75%
maximal aerobic capacity was enough to
demonstrate exercise-induced analgesia
to a pressure pain stimulus. Furthermore,
individuals who exercise regularly have
higher pain tolerances than sedentary
Although levels of exercise intensity
required to alter pain tolerance may vary,
some researchers have studied how long
pain tolerance is altered after activity. Some
have found that exercise-induced analge-
sia is present for at least 30 minutes after
a bout of exercise.
Others have found
that exercise-induced analgesia is present
for as long as 50 minutes after exercise.
The effects of exercise-induced analgesia
in patients with low back pain have been
investigated. Hoffman et al
found that
those with chronic low back pain and
minimum to moderate disability dem-
onstrated exercise-induced analgesia to
pressure pain testing for over 30 minutes
after 20 minutes of aerobic exercise at
70% peak oxygen update. The effects of
aerobic exercise on mood and pain per-
ception are well documented in a popu-
lation with low back pain. However, to
our knowledge, these effects have not
been studied in patients with neck pain.
There are many benefits to implement-
ing a program of aerobic conditioning
and physical activity. Conditioning activ-
ities improve performance and allow the
same amount of work to be performed
at a lower physiological cost.
exercise has demonstrated health benefits
for various psychological conditions.
Furthermore, aerobic work improves
vigor while decreasing fatigue, tension,
and depression.
A multifactorial con-
ditioning program that included aerobic
conditioning was effective in reducing
the number of sick days for some work-
ers with chronic back pain.
Also, phys-
ical conditioning programs that included
a cognitive behavioral approach demon-
strated a reduction in the number of sick
days in patients with chronic back pain.
Lundblad et al
used general condition-
ing in addition to interventions focused
on proper movement for female work-
ers with neck and shoulder symptoms
who demonstrated decreased complaints
on neck and shoulder disability. Takala
et al
demonstrated improvement using
general conditioning with group gym-
nastics at the workplace to help with
neck pain. Although little research has
been performed on the effects of con-
ditioning on neck pain, this has been
studied extensively for low back pain.
Chatzitheodorou et al
found that high-
intensity aerobic exercise alleviated pain,
disability, and psychological strain in
people with chronic low back pain.
Some studies suggest that it is not nec-
essary to perform regimented condi-
tioning activities at a specific intensity.
Hildebrandt et al
found simply increas-
ing leisure-time physical activity may
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decrease musculoskeletal pain, particu-
larly in sedentary workers. Bernaards
et al
demonstrated that a change in life-
style and inclusion of physical activ-
ity decreased neck pain. Other lifestyle
modifications that complement a general
increase in physical activity have been
demonstrated to be effective. Mattila
et al
found that lifestyle interventions
to control hypertension had a favorable
effect on perceived disability of neck
pain. Also, people with an active lifestyle,
including participation in sporting events
during leisure time, reported fewer symp-
toms related to neck and upper limb
Myofascial Stretching
Myofascial stretching has been recom-
mended for patients with neck pain who
are likely to benefit from a program of
conditioning and exercise tolerance.
Stretching can be used for a variety of
purposes. DeVries
stretching as a method to reduce mus-
cle soreness following activity. Stretching
has also been recommended to prevent
Some authors have raised
questions regarding the effectiveness of
stretching in the prevention of injury.
Muscle Length Impairments
Implicated in Patients
With Neck Pain
Length-associated changes in mus-
cle are a problem commonly treated by
physical therapists.
Dysfunction can be
caused by immobilization, muscle imbal-
ance, postural malalignment, or a com-
bination of these mechanisms.
affected by improper alignment can
lead to specific alterations, which influ-
ence overall posture.
Gossman et al
described muscle length impairments
as having stretch weakness or tightness.
Stretch weakness is the effect on muscles
in an elongated position beyond neu-
tral that inhibits the ability of the muscles
to contract.
Shortness or tightness is
described as a decrease in muscle length
with limited movement in the direction
of elongation.
Both of these conditions
are of particular concern with regard to
development of a rehabilitation program.
In the context of myofascial stretching,
adaptive shortening becomes a particular
concern. A muscle fixed in a shortened
position can cause a decrease of up to
40% in the number of sarcomeres.
the amount of passive and active tension
created by a shortened muscle is less
than that compared to controls.
tension produced by shortened muscle
can lead to misinterpretations of muscle
strength testing when evaluating patients.
Shortened muscles might test strong
because of testing in their optimal short-
ened position.
In contrast, shortened
muscles that are tight may also be weak-
ened. This weakness limits their ability to
produce force and ultimately provide sta-
bility and mobility.
Muscle is extremely prone to struc-
tural change with either lengthening or
Clinically, specific mus-
cles are often stretched in a rehabilitation
program. McDonnell et al
published a
case report that included select muscle
lengthening, including that of the pecto-
ralis minor, pectoralis major, and poste-
rior cervical muscles, to improve posture
and decrease cervicogenic complaints.
Another study chose to perform stretches
for the upper trapezius, scalenes, and
posterior cervical musculature.
tendency for muscles to develop tight-
ness is generally not random, and typi-
cal muscle imbalance patterns have been
The cross-shoulder syn-
drome is a model describing the clinical
presentation of some muscles that have
a tendency to become tight.
The mus-
cles in the upper quarter, which gener-
ally become tight more often, are the
pectoralis major, pectoralis minor, upper
trapezius, levator scapulae, sternocleido-
mastoid, and suboccipital muscles.
Effects of Myofascial Stretching
There is a mechanical and neurophys-
iological premise for myofascial length-
ening. Although it is not clear which
stretching technique is most beneficial, it
is clear that stretching in any context will
improve muscle length. There are several
considerations when observing a mus-
cle’s response to a given stretch. The rate
of stretch is important when applying a
stretch. Greater peak tension and energy
absorption occur at faster stretch rates,
suggesting increased risk of injury with
increased stretch rate.
structures around muscle also affect a
muscle’s response to stretch and immobi-
Age influences tissue response
to stretch. As a person ages, the rate
of adaptation to stress slows, and max-
imum tensile strength and elastic rate
Several studies have looked at the
effects of myofascial stretching on cer-
vicogenic pain. Tsauo et al
reported a
reduction in neck and shoulder symp-
toms in sedentary workers through
the use of an intensive group exercise
stretching program. A systematic review
by Gross et al
found moderate evi-
dence of long-term benefit for improved
function favoring direct neck strength-
ening and stretching for mechanical
neck pain. Although stretching exer-
cises alone have demonstrated an ability
to decrease neck pain,
other studies
suggest a combination of strength train-
ing and stretching exercises for chronic
neck pain.
Although these stud-
ies used a variety of treatment options,
including muscle endurance training,
stretching was a component of treatment
that demonstrated the most significant
Muscular Performance
Muscle performance describes the
manner in which muscles function and
includes components of strength, endur-
ance, and motor control. Muscular
strength is defined as the maximal abil-
ity of a muscle to contract and generate
Muscular endurance is the abil-
ity of a muscle to resist fatigue or its abil-
ity to contract repeatedly over a period of
Motor control is the ability of a
muscle to perform coordinated contrac-
tions to control specific and purposeful
movements through the range of motion.
Each characteristic of muscular perfor-
mance lends itself to proper functioning of
the muscle. Muscular strength, endurance,
and motor control play an integral part in
facilitating movement of the cervical spine.
Rehabilitation programs will often incor-
porate components of each of these
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physical characteristics to improve muscu-
lar performance and function.
Muscle Performance
Impairments Implicated
in Neck Pain
If the musculature is not function-
ing properly, this may lead to an inabil-
ity to adequately stabilize, protect, and
functionally move in space. Performance
impairments are commonly found in pha-
sic muscles, which are generally weak
in nature.
Specific muscles that tend to
develop weakness and are prone to inhi-
bition in the cervicothoracic region are
the serratus anterior, rhomboids, mid-
dle trapezius, lower trapezius, deep
neck flexors, and posterior rotator cuff
McDonnell et al
a case report that addressed muscular
control impairments in the rhomboids,
middle and lower trapezius, and lower
abdominals. Other studies have impli-
cated deep neck flexor muscle weakness
in patients with cervicogenic pain.
The deep cervical flexors play an impor-
tant supporting role in the functioning of
the cervical region.
Jull et al
that individuals with cervicogenic head-
aches were more likely to present with
weakness of the deep neck flexors. In
addition, groups reporting monthly and
weekly neck pain were found to have
significantly decreased neck muscular
The tendency for muscles to develop
weakness is generally not random.
Typical muscle imbalance patterns have
been described.
The cross-shoulder
syndrome is a model that has been used
to describe the clinical presentation of
some muscles predisposed to weakness
and inhibition. The syndrome is charac-
terized by weakness of the deep neck
flexors, lower trapezius, middle trapezius,
serratus anterior, and posterior rotator
cuff muscles. In FHP, the serratus ante-
rior muscles are weakened. This weak-
ness results in a protracted position of
the shoulder complex, leading to gle-
nohumoral malalignment. The plane of
the glenoid becomes vertical, and main-
tenance of the humeral head in the fossa
may lengthen the posterior rotator cuff
muscles. This static lengthening leads to
additional weakness and instability of the
shoulder complex.
Effects of Muscular
Strength and Endurance
Training on Neck Pain
As discussed, there are many com-
ponents contributing to neck pain.
Additional contributors are the ability to
stabilize segmentally, perform controlled
movement, and be able to absorb out-
side forces.
If the musculature is
unable to perform these tasks adequately,
then complaints of neck pain may ensue.
Many studies support various methods
of direct neck strengthening and stretch-
ing exercises for chronic mechanical neck
In a recent review of
the literature, Gross et al
found moderate
evidence in support of various methods
of direct neck strengthening and stretch-
ing exercises for chronic neck pain.
There seems to be little consistency
with regard to the specific development
and implementation of training programs.
Although there is much variation in the
training programs, there does seem to
be some trends. Many studies used mus-
cle performance exercises as one compo-
nent of treatment. The positive outcomes
therefore may not be exclusively due
to training of the musculature. It seems,
however, that addressing muscle perfor-
mance is a critical component of treating
some patients with cervicogenic pain.
In conclusion, there are numerous con-
servative options for the treatment and
management of neck pain. Development
and implementation of these treatment
regimes also vary greatly and are often
dependent on who a patient sees rather
than their presentation. Etiological con-
siderations and presentation of the con-
dition are additional factors that must
be reviewed and considered before any
course of action is initiated when work-
ing with individuals with neck pain. It
has been demonstrated that not only
personal physical condition but psy-
chological and emotional states can
influence pain and pain perception.
Musculoskeletal and postural adaptations
also can affect the presence and severity
of neck pain.
The use of verbal instruction or edu-
cation alone is not sufficient as a treat-
ment intervention for cervicogenic pain.
Individuals learn and understand in dif-
ferent ways. This review of the literature
suggests that a combination of interven-
tions is best used to maximize outcomes
when an individual is in need of conser-
vative intervention to manage or reduce
cervical pain. Influences from education
and exercise on pain have been estab-
lished within this review. Conservative
treatment and its influences as discussed
here may not be the most appropriate
course of treatment for all individuals
suffering from neck pain. Where this is
not the case, invasive procedures would
need to be investigated.
The economic impact of the individual
as well as society was touched on briefly
but cannot be taken lightly. Its effects can
be far reaching when addressing cervi-
cal pain disability. With an epidemic-like
proportion of the population reporting
neck pain, understanding the influences
of education and exercise becomes para-
mount not only for an individual’s qual-
ity of life but for minimizing the financial
fallout of a society.
Summary of Findings
Based on the above stated findings,
the clinician must consider the follow-
ing. Education for neck pain is an impor-
tant component of overall treatment.
Although many educational modalities
can be used such as verbal communica-
tion, video, or booklets, the key is repe-
tition of the information given. Patients
who hear the same information in dif-
ferent forms are more likely to make
adaptive changes. Consider verbally
instructing the patient and reinforcing this
information with a booklet. Also, assum-
ing medical red flags have been cleared,
the practitioner should recommend an
active lifestyle within tolerance. Guided
exercise is also important for nonspecific
neck pain. Clinicians should consider a
course of supervised clinical exercises
that is reinforced to be performed
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at UNIV OF CENTRAL FLORIDA on March 15, 2010 http://ajl.sagepub.comDownloaded from
... The socio-economic system is seriously affected by chronic non-specific neck pain (CNSNP) due to direct costs affecting the health system (25% of visits to chiropractors, 15% to hospital physiotherapists, 2% to family physicians as well as 75% of musculoskeletal assessments by rheumatologists are related to neck pain [7] and indirect costs resulting from absences from work, lower productivity and even early retirement [1,8]. Due to the socio-economic burden of neck pain, it is important to maximise effective strategies to improve function, limit the progression of degenerative changes and prevent future neck pain relapses [8,9]. ...
... The socio-economic system is seriously affected by chronic non-specific neck pain (CNSNP) due to direct costs affecting the health system (25% of visits to chiropractors, 15% to hospital physiotherapists, 2% to family physicians as well as 75% of musculoskeletal assessments by rheumatologists are related to neck pain [7] and indirect costs resulting from absences from work, lower productivity and even early retirement [1,8]. Due to the socio-economic burden of neck pain, it is important to maximise effective strategies to improve function, limit the progression of degenerative changes and prevent future neck pain relapses [8,9]. ...
... Therapeutic exercise (TE) is a common treatment for CNP sufferers [2,[9][10][11]. Physical exercise is used to improve physical function and reduce the symptoms of pain and stiffness [1,2,7,8,10]. Intervention in water has been established as a therapeutic modality that uses the physical properties of water to produce physical and functional improvements in patients [12]. It has been demonstrated that TE in water is effective in improving functional capacity and symptoms in patients with CNP [1,2,9,13,14]. ...
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The aim of this study was to analyse the effect of an 8-week multimodal physiotherapy programme (MPP), integrating physical land-based therapeutic exercise (TE), adapted swimming and health education, as a treatment for patients with chronic non-specific neck pain (CNSNP), on disability, general health/mental states and quality of life. 175 CNSNP patients from a community-based centre were recruited to participate in this prospective study. 60-minute session (30 minutes of land-based exercise dedicated to improving mobility, motor control, resistance and strengthening of the neck muscles, and 30 minutes of adapted swimming with aerobic exercise keeping a neutral neck position using a snorkel). Health education was provided using a decalogue on CNSNP and constant repetition of brief advice by the physiotherapist during the supervision of the exercises in each session. primary: disability (Neck Disability Index); secondary: physical and mental health states and quality of life of patients (SF-12 and EuroQoL-5D respectively). Differences between baseline data and that at the 8-week follow-up were calculated for all outcome variables. Disability showed a significant improvement of 24.6% from a mean (SD) of 28.2 (13.08) at baseline to 16.88 (11.62) at the end of the 8-week intervention. All secondary outcome variables were observed to show significant, clinically relevant improvements with increase ranges between 13.0% and 16.3% from a mean of 0.70 (0.2) at baseline to 0.83 (0.2), for EuroQoL-5D, and from a mean of 40.6 (12.7) at baseline to 56.9 (9.5), for mental health state, at the end of the 8-week intervention. After 8 weeks of a MPP that integrated land-based physical TE, health education and adapted swimming, clinically-relevant and statistically-significant improvements were observed for disability, physical and mental health states and quality of life in patients who suffer CNSNP. The clinical efficacy requires verification using a randomised controlled study design. NCT02046876.
... Among the known contributing factors, clinical empathy is a primary theme for a successful clinician-patient relationship (3). Empathy is of importance because it allows the patient to feel valued and listened to, which encourages them to more fully communicate symptoms, ultimately improving the efficacy of prescribed treatments (3,24,37). Some factors that are highly important for certain patients may be less significant for others. ...
... As a result, between-day reliability values for EMG typically range from low to high, with fine-wire assessments having lower values (2). Isokinetic dynamometry measures torque production of muscle groups through voluntary contraction but clinical utility is limited because of the relative costliness and variability in setup of the machine parts according to the patient's physical characteristics (2,11,19,20). Hand-held dynamometry is a portable option that has been found to have moderate validity and reliability compared with isokinetic dynamometry (42). Apart from being easier to use in practice, TMG devices tend to be quite inexpensive and portable, making them ideal for clinical scenarios (13,21,27). ...
... O'Riordan et al. (2014) reported that resistance exercises and endurance training reduced pain and disability scores in office workers with chronic neck pain. Previous studies also revealed that office workers who received non-specific exercise, compared to receiving an educational pamphlet on ergonomics in the workplace, experienced a significant reduction in intensity and the duration of neck pain Hanney et al. 2010). ...
Background Non-specific neck pain is a common health problem of global concern for office workers. This systematic review ascertained the latest evidence for the effectiveness of therapeutic exercise versus no therapeutic exercise on reducing neck pain and improving quality of life (QoL) in office workers with non-specific neck pain. Method Seven electronic databases using keywords, that is, ‘office workers’, ‘non-specific neck pain’, ‘exercise’ and/or ‘exercise therapy’, ‘QoL’, ‘strengthening’, ‘stretching’, ‘endurance’, ‘physiotherapy’ and/or ‘physical therapy’, were searched from inception until March 2017. Heterogeneous data were reported in narrative format and comparable homogenous data were pooled using Revman. Results Eight randomised control trials were reviewed and scored on average 6.63/10 on the Physiotherapy Evidence Database (PEDro) scale. Five studies performed strengthening exercise, one study had a strengthening and an endurance exercise group, one study performed stretching exercise and one study had an endurance intervention group and a stretching intervention group. Five and four studies reported significant improvement in neck pain and QoL, respectively, when conducting strengthening exercise. When performing endurance exercises, one and two studies reported significant changes in neck pain and QoL, respectively. The one study incorporating stretching exercise reported significant improvement in neck pain. The meta-analysis revealed that there is a clinically significant difference favouring strengthening exercise over no exercise in pain reduction but not for QoL. Conclusion There is level II evidence recommending that clinicians include strengthening exercise to improve neck pain and QoL. However, the effect of endurance and stretching exercise needs to be explored further.
... Neck pain causes disability and hardly costs alot. Its prognosis is poor, and the disability persistent than low back pain [1]. Mechanical neck pain as reported as a disabling condition with a course marked by periods of remission and exacerbation [2]. ...
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Background: Neck pain is very common. It can negatively affect the patient's life and may result in disability.This study conducted to compare the effect of different Mulligan techniques which is more effective(Mulligan self-mobilizationorMulligan SNAGs)on cervical position sense, three groups pain and function. Methods: 87subjects with chronic mechanical three groups were randomly assignedtoGroup(1) 29 subjects received Mulligan self-mobilization and traditional treatment.Group(2) 29 subjects received Mulligan SNAGs and traditional treatment. Group(3) 29 subjects received traditional treatment only.Position sense measured by Joint reposition error, pain measured by visual analog scale and function by Functional Neck disability index.Measurements were taken pre and post the intervention period. Results: MANOVA test revealed thatthere was significant improvement in valuesof the post-treatmentin allGroupscompared with pre-treatment of JPE (pre:P=0.725, post:P
... MF sensitivity is a known contributor to neck pain, particularly when trigger points are present in the upper trapezius [5][6][7]. While there is debate on whether joint dysfunction of the cervical spine causes MF pain or if MF pain results in joint dysfunction of the cervical spine; they are likely interrelated [8]. ...
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Introduction: Myofascial pain is a common impairment treated with various manual interventions including spinal thrust manipulation and stretching; however, the comparative efficacy of each intervention is uncertain. Therefore, the purpose of this investigation was to evaluate thrust manipulation targeting the cervicothoracic junction compared to a manual stretch of the upper trapezius muscle on cervical range of motion and upper trapezius pressure pain thresholds (PPTs). Methods: Healthy participants with no significant history of neck pain were randomized into a thrust manipulation group, a stretching group, or a control group. Within group differences were evaluated via a dependent t-test, and group by time interactions were evaluated by a two-way repeated measures ANOVA. Results: One hundred and two participants were recruited to participate. Baseline demographics revealed no significant differences between groups. Significant group by time interactions were found for changes in PPTs for both the right and left upper trapezius. Also, significant differences were found for changes in cervical extension, as well as right and left cervical side bending favoring the treatment groups. Discussion: This study demonstrates the potential independent effectiveness of spinal thrust manipulation or stretching for reducing PPTs at the upper trapezius. Future research should further evaluate the limitation of PPTs as a measure of muscle sensitivity as well as factors that may contribute to variability in the measurements among individuals seeking care.
... 12 Recommendations for increased physical activity are common for many musculoskeletal disorders. [19][20][21][22] While there are many conditions treated in physical therapy such as shoulder disorders, 23-26 a recent study estimated that 29.7% of the patients receiving physical therapy had spinal disorders including LBP. 27 Adherence to an established clinical practice guideline for LBP treatment may have an influence on overall patient outcomes and treatment success. The studies analyzed in this review showed a general trend of reduced disability and improved patient outcomes when adhering to an active approach practice guideline. ...
Introduction. Low back pain (LBP) is one of the most common medical conditions in the United States. Clinical practice guidelines recommend active treatment approaches; however, there continues to be a significant disparity in how patients with LBP are treated. Therefore, the purpose of this systematic review is to evaluate the reported efficacy of active treatment approaches as recommended by clinical practice guidelines on LBP treatment on patient outcomes. Methods. Between the months of June and August 2015, a comprehensive search of the PubMed, Medline (EBSCO Host), and CINAHL (EBSCO Host) databases was performed. The search was restricted to articles that were published in a peer-reviewed journal, published in the English language, examined patient outcomes with a determined scale, determined the usage of an established clinical practice guideline for LBP treatment, reported at least one outcome measure, and specified either nonspecific or acute LBP. Results. Fifty-three articles were initially identified, with 4 articles ultimately meeting the criteria after screening. Articles scored between 17 and 20 points based on a maximum total score of 26 on the modified Downs and Black checklist. Conclusion. Studies identified in this review indicate that adherence to an active treatment approach as recommended by clinical practice guidelines may result in improved patient outcomes.
... Multiple forms of non-traditional therapy have been studied for effectiveness in the management of cLBP. Many studies have assessed the effects of aerobics, yoga, and Pilates in people with cLBP [7,[34][35][36][37]. The ...
Background: An alternative approach to facilitate movement and control through the trunk and pelvis is belly dancing. Investigations of belly dancing mechanics indicate similar muscular activation patterns of those known to influence chronic low back pain (cLBP). However, no documented studies have examined its effectiveness as a treatment for cLBP. Objective: The purpose of this study was to investigate the influence of a standardized belly dance program in women with cLBP. Methods: A single subject design was used to evaluate weekly outcomes during a three-week baseline period, six-week belly dance program, and again at a two-month follow-up. Outcome measures for pain, disability, function, and fear-avoidance beliefs were utilized. Results: Two subjects completed the program. No significant differences were noted during the baseline assessment period. At two months, subject one demonstrated change scores of -1.12, -1%, and 2.2 for pain, disability, and function respectively while subject two demonstrated change scores of 5.4, 5%, and 1.1 for pain, disability, and function, respectively. Subject one showed a clinically significant change score for both fear avoidance of work and physical activity, with score changes of 4 and 3.3, respectively. Conclusion: The results of this study suggest a standardized belly dance program may positively influence pain and function in women with cLBP.
... [20][21][22][23][24][25][26]. Guidelines have been adopted by several organizations for physical therapy and generally recommend an active treatment approach with the primary goal of educating patients to regain control over the condition [27][28][29]. Also, while the majority of physical therapists strongly agree with general recommendations for treatment of LBP [30][31][32], it seems their use of CPGs varies widely [33]. ...
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Background: Low back pain (LBP) is common and associated healthcare costs are significant. While clinical practice guidelines have been established in an attempt to reduce costs and healthcare utilization, it is unclear if adherence to physical therapy guidelines for those with LBP is efficacious. Therefore, the purpose of this study was to assess current evidence and evaluate the impact of physical therapy guideline adherence on subsequent healthcare costs and utilization for patients with LBP. Methods: An electronic search was conducted in PubMed, CINAHL (EBSCO Host), AMED (Ovid), and PEDro. Studies included in this review were published in peer reviewed journals and the primary mode of treatment was administered by a physical therapist. Also, the definition of adherence was clearly defined based on claims data and at least one measure of cost or utilization reported. Quality assessment was evaluated via a modified Downs and Black checklist. Due to the conceptual heterogeneity in variable measurements, data were qualitatively synthesized and stratified by reported utilization and cost measures. Results: A total of 256 results were identified and after omitting duplicates, 4 articles were retained, which were all retrospective in nature. Quality scores ranged between 19 and 21 points out of a possible 26 on the modified Downs and Black checklist. All identified studies used the same definition of guideline adherence, which focused on billing active codes and minimizing use of passive codes. The results demonstrated trends that, with a few exceptions, suggested those patients with LBP that were treated with an adherent guideline program demonstrated decreased healthcare utilization and an overall healthcare savings. Conclusion: Preliminary evidence suggests that adherence to established clinical practice guidelines may assist with decreasing healthcare utilization and costs. Additional research based on prospective randomized controlled trials are needed to provide high quality evidence regarding the impact of guideline adherence among patients with LBP.
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Change in the proper alignment of head on the body and subsequently in the cervical and glenohumeral joints is one of the risk factors reported in the previous studies. The purpose of this study was to investigate the influence of a 12-week corrective exercises program on forward head (FH) and forward shoulder (FSh) deformities. Forty subjects (20 males, 20 females) with excessive FH (>46º) and FSh (>52º) angles were chosen as samples using purposive sampling method. The average of age, weight and height of the samples were 21.08±1.67 years, 63.23±12.70 kg, and 170.21±10.21 cm respectively. The subjects were randomly divided into two groups of 20 experimental and control groups. Photogrammetric method technique was used to measure the angles of the FH and FSh. Data were analyzed using descriptive and comparative (Paired sample t test) statistical methods. The results demonstrated a significant decrease in the angles of forward head and shoulder in the experimental group. Also, the Cohen’s effect size of the exercise program was “large”. Therefore, using this program is recommended in subjects with these deformities.
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Poor posture has been suggested as one of the main factors contributing to the high prevalence of neck pain in video display unit (VDU) users, but no clear association between pain and any particular resting neck posture has been found. Postural awareness of the neck, as indicated by the repositioning accuracy, may therefore be an appropriate measure and potentially useful assessment tool. The objective of this study is to examine whether posture and fatigue affect the head repositioning ability in typical VDU usage. A group of 20 healthy participants reproduced a normal comfortable posture for forward, upright and backward chair back inclinations in random order both before and after fatigue of the upper trapezius muscles. Ten repetitions of the posture were recorded for 2 s each, and the angular and translational deviations from the original head position were measured with regard to the external environment (head in space repositioning) and with regard to the trunk (head on trunk repositioning). Analysis by repeated measures ANOVA showed significant effects and interactions of fatigue and chair back inclination on the repositioning errors in the sagittal plane, which typically showed systematic trends towards certain postures rather than random errors around a mean position. While further work is required to examine the ergonomic impact of impaired repositioning ability, head repositioning is sensitive to ergonomic factors such as seating configuration and fatigue, and may therefore be a useful tool for evaluation of static working postures.
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Previously, in a randomized study, we showed that women with chronic neck pain were able to perform intensive training for neck and shoulder muscles and that the increase in strength was accompanied by a reduction in pain and disability. The changes were significantly greater in the training groups compared with controls. The aim of the present study was to evaluate whether the controls would achieve similar results. Thus, 59 women in the control group initiated high-intensity strength training. Maximal isometric neck strength increased by 44% in both flexion and rotation and 27% in extension at the 2-year follow-up. Statistically and also clinically significant decreases in neck pain and disability indices occurred. Stretching and aerobic exercising during the first follow-up year produced only minor changes in both subjective and functional measures. Adding progressive strength training for the second year led to a significant improvement in neck strength and also to a considerable decrease in the pain and disability scores. Thus, to achieve effective rehabilitation in cases of chronic neck pain, a combination of strength training and stretching exercises are recommended.
It is likely that patients with neck pain are not a homogeneous group, but, instead, consist of a variety of subgroups, each of which may benefit from a specific intervention matched to the patient's signs and symptoms. Studies to date have largely failed to account for this possibility, which may compromise the statistical power of research and ultimately fail to provide guidance for clinical decision making. Classification provides a means of breaking down a larger entity into more homogeneous subgroups of patients, based on examination data. Classification can guide the determination of a patient's prognosis, and the selection of the most appropriate intervention strategy. Classification has received considerable attention in the management of patients with low back pain, and evidence is emerging regarding its benefits. There has been considerably less effort made towards examining classification as it pertains to patients with neck pain. The purpose of this clinical commentary is to examine the current literature and to propose a classification system for patients with neck pain, based on the overall goal of treatment. The approach is based on published evidence when possible and is also informed by clinical experience and expert opinion. Classification decisions are based on the integration of data from a variety of information from the history and physical examination. The end result of the classification process is to determine the treatment approach believed to be most likely to maximize the clinical outcome for an individual patient with neck pain.
Background. The authors reviewed studies to identify methods for dental operators to use to prevent the development of musculoskeletal disorders or MSDs. Types of Studies Reviewed. The authors reviewed studies that related to the prevention of MSDs among dental operators. Some studies investigated the relationship between the biomechanics of seated working postures and physiological damage or pain. Other studies suggested that repeated unidirectional twisting of the trunk can lead to low back pain, while yet other studies examined the detrimental effects of working in one position for prolonged periods. Additional studies confirmed the roles that operators' flexibility and core strength can play in balanced musculoskeletal health and the need for operators to know how to properly adjust ergonomic equipment. Results. This review indicates that strategies to prevent the multifactorial problem of dental operators' developing MSDs exist. These strategies address deficiencies in operator position, posture, flexibility, strength and ergonomics. Education and additional research are needed to promote an understanding of the complexity of the problem and to address the problem's multifactorial nature. Clinical Implications. A comprehensive approach to address the problem of MSDs in dentistry represents a paradigm shift in how operators work. New educational models that incorporate a multifactorial approach can be developed to help dental operators manage and prevent MSDs effectively.
MARKOFF, RICHARD A., PAUL RYAN, and TED YOUNG. Endorphins and mood changes in long-distance running. Med. Sci. Sports Exercise, Vol. 1-4, No. 1, pp. 11-15, 1982. Acute and chronic positive mood changes have been said to occur with running and jogging. It has been suggested that endogenous substances with opioid activity (endorphins) may serve as modulators of mood. The authors report experiments in which mood changes associated with long-distance running were measured by pre- and post-run difference-scores on a mood adjective checklist, the Profile of Mood States (POMS). Following this, the narcotic antagonist, naloxone, was given subcutaneously in double-blind fashion. The dose was 0.8 mg. The POMS was again presented 15 min later, and post-run/post-injection difference scores were obtained. No naloxone effect was found. The failure of naloxone to reverse the running-associated mood shift indicates that endorphins are not involved. The authors discuss the possible physiologic role of endorphins in light of these and other findings. (C)1982The American College of Sports Medicine
A four-minute standard exercise consisting of wrist hyperextension every two seconds with 9 1/2 pounds of resistance was administered to 17 subjects. The subjects then applied static stretching technique to the nondominant arm immediately after the exercise and 2, 6, 20, and 22 hours afterward. Observations of muscular distress were made on both arms during the exercise and at 4, 8, 24, 48, and 72 hours after the exercise. Significantly lesser magnitudes of muscular distress were found in the experimental arm at the 24- and 48-hour observations, at the .01 and .05 levels of confidence respectively. A lower level of muscular distress was also found in the experimental arm when all observations for each subject subsequent to the exercise bout were summed. This difference achieved significance at the .01 level of confidnce.
Objective: We hypothesized that change in pain threshold to pressure reflects a generalized change in the pain system affecting both tender and control points. Methods: We assessed 18 tender points and 4 control points using an algometer in 60 patients with generalized fibromyalgia/fibrositis syndrome, 60 patients with localized chronic pain syndromes, and in 60 pain-free subjects. Results: A significant correlation was found between myalgia scores at tender points and control points in these subjects. Conclusion: These results suggest that there is a diffuse change in pain modulation in fibromyalgia, as hypothesized, but the tender point is still clinically useful.
Study Design. A review of controlled trials. Objectives. To determine which interventions are used to prevent back and neck pain problems as well as what the evidence is for their utility. Summary of Background Data. Given the difficulty in successfully treating long-term back and neck pain problems, there has been a call for preventive interventions. Little is known, however, about the value of preventive efforts for nonpatients, e.g., in the general population or workplace. Methods. The literature was systematically searched to locate all investigations that were: 1) specifically designed as a preventive intervention; 2) randomized or nonrandomized controlled trials; and, 3) using subjects not seeking treatment. Outcome was evaluated on the key variables of reported pain, report of injury, dysfunction, time off work, health-care utilization, and cost. Conclusions were drawn using a grading system. Results. Twenty-seven investigations meeting the criteria were found for educational efforts, lumbar supports, exercises, ergonomics, and risk factor modification. For back schools, only one of the nine randomized trials reported a significant effect, and there was strong evidence that back schools are not effective in prevention. Because the randomized trials concerning lumbar supports were consistently negative, there is strong evidence that they are not effective in prevention. Exercises, conversely, showed stable positive results in randomized controlled trials, giving consistent evidence of relatively moderate utility in prevention. Because no properly controlled trials were found for ergonomic interventions or risk factor modification, there was not good quality evidence available to draw a conclusion. Conclusions. The results concerning prevention for subjects not seeking medical care are sobering. Only exercises provided sufficient evidence to conclude that they are an effective preventive intervention. There is a dire lack of controlled trials examining broad-based multidimensional programs. The need for high quality outcome studies is underscored.
Workers exposed to hand-transmitted vibration (HTV) often experience aches and pains in the upper limbs, but there have been few studies of the pattern and severity of symptoms, or their relationship to the estimated dose of vibration. As part of a wider survey of vibration, we mailed a questionnaire about exposures to HTV and pain in the neck and upper limbs to a sample of men selected at random from the registration lists of 34 British general practices and the pay records of the armed services. Analysis was confined to the 1856 male respondents who had been employed in manual occupations for a year or more and who reported the last week as being representative of their job. Inquiry was made about pain in the neck, shoulder, elbow and wrist/hand over the past week and past year (including pains that limited normal activity). Subjects were classed according to their lifetime exposure to HTV and their estimated average daily vibration dose [A(8) r.m.s.] in the previous week. A total of 283 men had a minimum estimated A(8) greater than a proposed action level of 2.8 m/s2, and in this group symptoms were about twice as prevalent as in manual workers who had never used vibratory tools. The excess risk was somewhat higher for distal sites than for proximal ones (e.g. the prevalence ratio for hand/wrist pain in the past week was 2.7 versus 1.8 for neck pain). This accords with the pattern of transmission of HTV to the upper limb, although a confounding effect from other ergonomic risk factors cannot be discounted.
It is generally accepted that increasing the flexibility of a muscle-tendon unit promotes better performances and decreases the number of injuries. Stretching exercises are regularly included in warm-up and cooling-down exercises; however, contradictory findings have been reported in the literature. Several authors have suggested that stretching has a beneficial effect on injury prevention. In contrast, clinical evidence suggesting that stretching before exercise does not prevent injuries has also been reported. Apparently, no scientifically based prescription for stretching exercises exists and no conclusive statements can be made about the relationship of stretching and athletic injuries. Stretching recommendations are clouded by misconceptions and conflicting research reports. We believe that part of these contradictions can be explained by considering the type of sports activity in which an individual is participating. Sports involving bouncing and jumping activities with a high intensity of stretch-shortening cycles (SSCs) [e.g. soccer and football] require a muscle-tendon unit that is compliant enough to store and release the high amount of elastic energy that benefits performance in such sports. If the participants of these sports have an insufficient compliant muscle-tendon unit, the demands in energy absorption and release may rapidly exceed the capacity of the muscle-tendon unit. This may lead to an increased risk for injury of this structure. Consequently, the rationale for injury prevention in these sports is to increase the compliance of the muscle-tendon unit. Recent studies have shown that stretching programmes can significantly influence the viscosity of the tendon and make it significantly more compliant, and when a sport demands SSCs of high intensity, stretching may be important for injury prevention. This conjecture is in agreement with the available scientific clinical evidence from these types of sports activities. In contrast, when the type of sports activity contains low-intensity, or limited SSCs (e.g. jogging, cycling and swimming) there is no need for a very compliant muscle-tendon unit since most of its power generation is a consequence of active (contractile) muscle work that needs to be directly transferred (by the tendon) to the articular system to generate motion. Therefore, stretching (and thus making the tendon more compliant) may not be advantageous. This conjecture is supported by the literature, where strong evidence exists that stretching has no beneficial effect on injury prevention in these sports. If this point of view is used when examining research findings concerning stretching and injuries, the reasons for the contrasting findings in the literature are in many instances resolved.