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1Medical University of Sofia, Bulgaria.
2Bulgarian Academy of Sciences, Laboratory of Telematics – Sofia, Bulgaria.
3Medical Faculty of Sofia University, Bulgaria.
*Corresponding author: E-mail: yvette@cc.bas.bg, dr.yvette.5@gmail.com;
Chapter 10
Print ISBN: 978-93-91215-01-9, eBook ISBN: 978-93-90888-94-8
Complex Physical Prevention and Rehabilitation of
Cervical Myofascial Pain and Headache, Due to
Spine Malposition in Users (Abusers) of Smart
Phones
Ivet B. Koleva1*, Radoslav D. Yoshinov2 and Borislav R. Yoshinov3
DOI: 10.9734/bpi/hmmr/v12/1675F
ABSTRACT
Introduction: The introduction of portable devices in the everyday life imposed the necessity to
evaluate the possible consequences (of the abuse) on the spine and on the central nervous system,
respectively to create programs for the prevention of these consequences. The goal of current article
is to evaluate the impact of different physical modalities (including physiotherapy, ergotherapy,
manual therapy, deep oscillation, lasertherapy, magnetic field) in the prevention and the complex
rehabilitation of the onset of cervical myofascial pain and headache, due to spinal malposition in users
(abusers) of smart phones.
Material and Methods: We observed a total of 165 patients with cervical myofascial pain and
headache, divided into 5 groups (of 33 patients each). The age of the patients was between 19 and
50 years, with posture (position) alterations of the cervical spine, but without significant cervical
pathology. All patients used a mobile device in their everyday activities (minimum 2 hours daily) for at
least 6 months. Functional evaluation was effectuated before, during and after treatment, and one
month after the end of the rehabilitation. In all patients we applied a complex physical-therapeutic
program (PT), including analytic exercises for paravertebral muscles and soft tissue techniques
[massages, post-isometric relaxation (PIR) for the respective upper trapezius and sterno-cleido-
mastoideus muscle] and stimulation of patients’ active participation in the process of prevention
(education in principles of back-school, self-massage, auto-PIR). The patients in the first group
effectuated only these procedures. In the second group, we added elements of manual therapy (MT -
tractions, mobilizations, manipulations; and auto-mobilizations). In patients of the next groups, a
paravertebral application of a preformed modality was added to the PT and the MT: in group 3 – Deep
Oscillation (DO); in group 4 – lasertherapy (LT); in group 5 - magnetic field (MF). Statistical evaluation
was performed by SPSS programme, version 17; using t-test (analysis of variances ANOVA) and
Wilcoxon rank test (non-parametrical correlation analysis).
Results and Analysis: All patients reported a significant decrease of the intensity of cervical pain and
headache (evaluated by Visual analogue scale of pain and by pressure dolorimetry). In all patients we
observed amelioration of the static position of the cervical spine, reduced amount of paravertebral
muscle spasm and of the sensibility of trigger and tender points; and augmentation of range of active
motion of the cervical region of the spine. During the rehabilitation period the results were most
important in the second group (with manual therapy), but one month later there is not statistical
differences between both groups.
Discussion and Conclusion: Techniques of PT and MT are very useful for the prevention and the
rehabilitation processus of cervical myofascial pain and headache. The program of care includes
active (analytic) exercises, PIR and stretching techniques, tractions and mobilizations, education of
the patient, and (in some cases) manipulations. The inclusion of preformed modalities (DO, LT, MF) in
the complex prevention and rehabilitation program accelerates the effects on pain and spine mobility
Highlights on Medicine and Medical Research Vol. 12
Complex Physical Prevention and Rehabilitation of Cervical Myofascial Pain and Headache, Due to Spine Malposition in Users
(Abusers) of Smart Phones
81
and ameliorate the stabilization of the results. We consider that every medical doctor - specialist in
Physical and rehabilitation medicine, every physiotherapist and ergotherapist must adapt the general
algorithm for the needs of the concrete patient.
Keywords: Physical modality; physiotherapy; manual therapy; lasertherapy, magnetic field;
myofascial pain; cervicogenic headache; tension type headache; kinesiological analysis.
1. INTRODUCTION
Ultimately, the introduction of portable devices in the everyday life imposed the necessity to evaluate
the possible consequences (of the abuse) - on the position of the spine and on the central nervous
system, respectively to create programs for prevention of these consequences. Cervical myofascial
pain, cervicogenic and tension-type headache are between the top 10 causes for the reduction of the
quality of life of the modern ‘healthy’ citizen. These conditions are situated in the field of interest of
different specialists – medical doctors (general practitioners or specialists in Neurology,
Rheumatology, Orthopedics and Traumatology, Physical and Rehabilitation medicine /PRM/); manual
therapists, ergotherapists, physiotherapists, psychologists, etc [1,2,3]. Many authors consider that the
origin is located in the malposition or the static alteration of the cervical spine (especially the first
levels – atlanto-occipital and the atlanto-axial joints and the surrounding structures).
1.1 Objective
The goal of current article is to evaluate the impact of different physical modalities (including
physiotherapy, ergotherapy, manual therapy, deep oscillation, lasertherapy, magnetic field) in the
prevention and the complex rehabilitation of the onset of cervical myofascial pain and headache, due
to spinal malposition in users (abusers) of smart phones.
1.2 Design of the Study
Current randomized study was performed during the last five years in 165 out-patients of an
ambulatory medical center in Sofia (in the PRM department). After a signed informed consent all
patients received a rehabilitation complex of 3 weeks (15 procedures, 5 times weekly) with
correspondent examinations and evaluations before (before Th), during (week 2) and at the end of
rehabilitation (after Therapy), with control of the stability of results one month later.
2. MATERIALS
We observed a total of 165 patients with cervical myofascial pain and headache, divided into 5 groups
(of 33 patients each).
The distribution of patients M: F is presented in Fig. 1.
The age of patients was between 19 and 50 years (Fig. 2).
All patients use a mobile device in everyday activities (minimum 2 hours daily) for at least 6 months.
Fig. 1. Distribution of patients (M:W)
86
47
Women
Men
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Complex Physical Prevention and Rehabilitation of Cervical Myofascial Pain and Headache, Due to Spine Malposition in Users
(Abusers) of Smart Phones
82
Fig. 2. Distribution of patients (age)
All patients presented an important vertebral syndrome with paravertebral muscular spasm,
paravertebral and pericranial tenderness, with posture (position) alterations of the cervical spine
(cervical hypo-lordosis), reduction of the range of motion of the cervical spine (predominantly of the
extension and rotation, in some cases – adding the latero-flexion) and functional blockages (level 2 of
Stoddart) in the cervical intervertebral joints and at the cervico-thoracal transition level (C7-Th1); but
without significant cervical pathology (radiologically proved – X-ray), and without radiculopathy
(clinical exam and EMG investigation).
Before rehabilitation, our patients received a neurological diagnosis of headache, according the
International Classification of Headache disorders (3rd edition, beta version, 2013) [4]:
tension-type headache (2.TTH, associated with pericranial tenderness: 2.1.infrequent or
2.2.frequent episodic TTH, or 2.3.chronic TTH) or
cervico-genic headache (11.2.1.); with appendix diagnosis headache, attributed to cervical
myofascial pain ((A 11.2.5.).
The distribution TTH versus cervicogenic headache (64 patients TTH : 69 patients with cervicogenic)
is presented in Fig. 3.
Fig. 3. Distribution of the headache of patients: tension-type headache or cervicogenic
headache
3. METHODS
The rehabilitation programme was performed by 15 procedures, distributed in three weeks (5 times
weekly, 60 minutes per day).
In all patients we applied a complex physical-therapeutic and ergotherapeutic program, including
analytic exercises for paravertebral muscles and soft tissue techniques [massages, post-isometric
relaxation (PIR) for the respective upper trapezius and sterno-cleido-mastoideus muscle], and
stimulation of patients’ active participation in the process of prevention (education in principles of
back-school, prevention of stato-dynamic alterations of the spine; self-massage, auto-PIR).
The patients of the first group (gr-1) effectuated only these procedures.
15
25
54
39
under 21 y
21 - 30 y
31 - 40 y
41 - 50 y
TTH
48%
Cervicogenic
52%
Type of the headache
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Complex Physical Prevention and Rehabilitation of Cervical Myofascial Pain and Headache, Due to Spine Malposition in Users
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In the second group (gr-2) we added elements of manual therapy (tractions, mobilizations,
manipulations; and auto-mobilizations).
In patients of the next groups, a paravertebral application of a preformed modality was added to the
PT and the MT:
in group 3 (gr-3) – Deep Oscillation (DO); or rehabilitation program PT+MT+DO;
in group 4 (gr-4) – lasertherapy (LT); or rehabilitation program PT+MT+LT;
in group 5 (gr-5) - low intensity low frequency magnetic field (MF); or rehabilitation program
PT+MT+MF.
We realized periodical exams and functional evaluation of patients: before, during and after treatment,
and one month after the end of the rehabilitation.
Statistical evaluation was performed by statistical package SPSS, version 17; using options of two
samples comparison; with parametrical analysis of variances (ANOVA) and non-parametrical
correlation analysis: t-test (t-criterion, p-value); Signed test, Signed rank test, Mann-Whitney
(Wilcoxon) test (W median). We consider values of p under 0.05 as statistically significant; in some
cases we receive p<0.01.
4. RESULTS AND ANALYSIS
All patients reported a significant decrease of intensity of cervical pain and headache (evaluated by
Visual analogue scale of pain 0-10 and dolorimetry – Figs. 4 & 5). In all patients we observed
amelioration of the static position of the cervical spine, reduction of the paravertebral muscle spasm
and of the sensibility of trigger and tender points; and augmentation of the range of active motion of
the cervical region of the spine (Figs. 6 & 7).
Fig. 4 presents the results of the assessment of pain (using Visual analogue scale 0-10).
The analgesic effect of physical modalities is significant in all cases with application of manual therapy
and preformed physical modality, but the reduction is significant in MF and DO.
Fig. 4. Visual analogue scale of pain (0-10)
0
1
2
3
4
5
6
7
8
9
Gr-1 (PT) Gr-2 (PT+MT) Gr-3
(PT+MT+DO)
Gr-4
(PT+MT+LT)
Gr-5
(PT+MT+MF)
Before Th
Week 2
After Th
1 month later
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Next Fig. 5 presents the results of the evaluation using dolorimetry.
The reduction of the paravertebral and pericranial tenderness (dolorimetric evaluation) is most
relevant in case of application of manual therapy with preformed modality (the MF is the most
effective, after that – DO, and finally – LT).
Fig. 5. Dolorimetry - paravertebral and pericranial tenderness (0-3)
The results of the goniometric evaluation of the range of motion (ROM) of the cervical spine before,
during and after rehabilitation were relevant. We observed significant ROM-amelioration in all groups
with manual therapy and we present our results in extension (Fig. 6) and in rotation (Fig. 7). The
inclusion of DO and MF is effective only in extension, but not in rotations. No significant effect on
ROM from the inclusion of LT.
Fig. 6. Goniometry of cervical spine - Extension
0
0.5
1
1.5
2
2.5
3
Before Th
Week 2
After Th
1 month later
Before Th
Week 2
After Th
1 mo later
0
10
20
30
40
50
60
70
Group 1 Group 2 Group 3 Group 4 Group 5
Before Th
Week 2
After Th
1 mo later
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Complex Physical Prevention and Rehabilitation of Cervical Myofascial Pain and Headache, Due to Spine Malposition in Users
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Fig. 7. Goniometry of cervical spine – Rotation of the altered side
5. DISCUSSION
5.1 Interpretation of Our Results
Our work categorically proves the necessity of application of physical prevention and rehabilitation in
cases with cervical myofascial pain and headache, due to static alterations. Our results demonstrate
the positive effect of several physical modalities and techniques (physical and manual therapy, deep
oscillation, laser, magnetic field) on paravertebral and pericranial pain, on muscular tenderness, and
on the range of motion of cervical part of the spine.
During the rehabilitation period, the anti-pain effect was most important after inclusion of manual
therapy (in the second group – better than in the first group) and even most significant in the groups
with preformed modalities (gr-3-DO, gr-4-Laser, gr-5-MF). The inclusion of the preformed modalities
DO and MF is effective on the range of motion in extension (but without significance in rotations).
One month later, there is not statistical differences between the first and the second groups. The
inclusion of preformed modality is effective on the stabilization of the results, concerning pain and
muscle spasm.
We consider, that the stabilization of the effect one month after the end of rehabilitation is due
principally to the efficacy of patients’ education.
5.2 The Role of the Upper Cervical Spine
The influence of techniques ameliorating the static and dynamic alterations of the upper levels of the
cervical region proves the dominant role of the upper cervical spine in the generation of this type of
back pain and headache [5,6,7]. We consider that the impact of the upper cervical region is
determining factor not only for the generation of the so called cervicogenic headache, but too - for the
initiation and the intensification of tension-type headache.
Our opinion is that the upper cervical region is significant for the support and the static of the whole
spine, for the body posture, for the balance and the gait.
Before Th
Week 2
After Th
One month later
0
10
20
30
40
50
60
70
Gr-1 Gr-2 Gr-3 Gr-4 Gr-5
Before Th
Week 2
After Th
One month later
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5.3 The Mechanism of Action of the Applied Preformed Modalities
Deep Oscillation is a relatively new physical factor, consisting of application of an electrostatic electric
field on tissues in profundity, explained with the effect, named after Danish engineers F. A. Johnsen
and K. Rahbek [8]. The Johnsen–Rahbek effect occurs when an electric potential is applied across
the boundary between a metallic surface and the surface of a semiconducting material. Under these
conditions an attractive force appears, whose magnitude depends on the voltage and the specific
materials involved. Practically, the device produces a micro-massage therapy, based on the action of
a pulsating, low-frequency, two-phase alternating electrostatic field generated between the
practitioner’s hands and the patient’s skin [9]. At the level of the connective tissue this intermittent
electrostatic field produces an intense resonant vibration and the repetition of this phenomenon in
rapid succession generates rhythmic deformations of the tissue (skin, connective, and muscular). The
resulting effect includes improvement in microcirculation, better tissue nourishment, enhancement of
cellular metabolism, promotion of faster healing even on open wounds), anti-oedema, lymph drainage,
anti-fibrosis and detoxifying properties, alleviation of pain and swelling, stimulation of collagen
production and tissue regeneration.
LASER is a contemporaneous physical modality, based on light (photo-therapy). LASER is an
acronym of: Light (L) Amplification (A) by Stimulated (S) Emission (E) of Radiation (R). Laser is an
intense, highly directional beam of light; with some specific properties. The light released is
monochromatic; coherent (monophasic); very directional, with minimal divergence. The theoretical
foundation of the Laser is the photoionization, established by Albert Einstein in 1917.
In the field of medicine, Laser is useful for diagnostics or therapy. In physical medicine we apply
therapeutic laser class III, called low power laser, soft laser or low level laser therapy (LLLT). Some
authors prefer the terms: Bio-stimulating laser, bio-regulating laser and photo-bio-modulating laser
[10]. Many authors consider that effects and mechanisms of action of LTh depend from the pathologic
processus (disease or condition), from the character and parameters of the Laser radiation [11,12]. In
current study, we applied a semi-conducting diode Laser, infra-red (wavelength λ 905 nm). So, our
hypothesis concerns the mechanisms of action of these types of LLLT (low doses). The clinical effects
of the lasertherapy include: analgesic, anti-inflammatory, anti-edema, regenerative (soft-tissue
healing), immuno-modulation. In current study we used the analgesic and the anti-inflammatory
effects.
The low frequency low intensity magnetic field (MF) is a traditional physical modality, with an
important inhibitory effect on the increased neuro-irritability, respectively analgesic and anti-
inflammatory effect [10]. MF provokes a relaxation of muscular spasm in profundity, this explain the
augmentation of the range of motion in extension after its application. MF provokes changes in the
orientation of the big molecules, decrease of the velocity of biochemical reactions, changes of the
angle of chemical connection in the water molecule, changes of the capacities of the molecule of the
water. The most important biological effects of the MF consist in the non-specific influence on the
permeability and the potential of cellular membranes: stimulation of the diffusion and the osmosis
through the membrane and depolarization of the water molecules in the cell (transition from a
polarized state to a non-polarized state). MF provokes metabolic changes on the oxidative
phosphorylation in mitochondria, with reduction of the free oxidation) [13].
6. CONCLUSION
Techniques of physical therapy and manual therapy are very useful for the prevention and the
rehabilitation processus of cervical myofascial pain and headache. The program of care includes
active (analytic) exercises, PIR and stretching techniques, tractions and mobilizations, education of
the patient, and (in some cases) manipulations.
The inclusion of preformed modalities (deep oscillation, laser and magnetic field) in the complex
prevention and rehabilitation program accelerates the effects on pain and spine mobility and
ameliorate the stabilization of the results.
Highlights on Medicine and Medical Research Vol. 12
Complex Physical Prevention and Rehabilitation of Cervical Myofascial Pain and Headache, Due to Spine Malposition in Users
(Abusers) of Smart Phones
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All applied preformed agents are useful for the anti-pain effect, Deep Oscillation and magnetic field
have too positive influence on the range of motion.
We consider that every medical doctor - specialist in Physical and rehabilitation medicine and every
health professional (physical therapist and occupational therapist) must adapt the general algorithm
for the needs of the concrete patient.
CONSENT
All authors declare that written informed consent was obtained from every patient before any
examination or procedure.
ETHICAL APPROVAL
All authors hereby declare that the investigations and treatment of patients have been approved by
the appropriate ethics committee and have therefore been performed in accordance with the ethical
standards laid down in the 1964 declaration of Helsinki.
COMPETING INTERESTS
Authors have declared that no competing interests exist.
REFERENCES
1. Cambier J, M.Masson, Dehen H. Neurologie. Paris: Masson; 1989.
2. Mumenthaler M. Neurology. – Stuttgart – New York: Georg Thieme Verlag; 1990.
3. Cyriax J, Russell G. Textbook of Orthopedic Medicine. – London, Chirchill-Livingstone; 1981.
4. Headache Classification Committee of the International Headache Society. The International
Classification of Headache disorders. 3rd Edition, beta version. Cephalalgia. 2013;33(9):629-
808.
5. Evans R, Bronfort G, Nelson B, Ch. GoldsmIth. Two-year follow-up of a randomized clinical trial
of spinal manipulation and two types of rehabilitative exercise for Patients with Chronic Neck
Pain. – Spine. 2002;27(21):2383-2389. Ed.Lippincott Williams & Wilkins.
6. Marcus D, Scharff L, Mercer S, Turk D. Nonpharmacological treatment for migraine:
Incremental utility of physical therapy with relaxation and thermal biofeedback. Cephalalgia.
1998;18(5):266-72.
7. Wheeler A. Botulinum toxin A, adjunctive therapy for refractory headaches associated with
pericranial muscle tension. Headache. 1998;38(6):468-471.
8. Aliyev R, Mikus EWJ, Reinhold JG. Hochsignifikante Therapieerfolge mit DEEP
OSCILLATION® in der orthopеdischen rehabilitation. Orthopadische Praxis. 2008;44(9):448-
453.
9. Atkinson R. A simple theory of the Johnsen-Rahbek effect. Journal of Physics D: Applied
Physics. 1969;2(3):325.
10. Коleva I. Repetitorium physio-therapeuticum (basic principles of the modern physical and
rehabilitation medicine). Book for English Speaking Students of Pleven Medical University.
Sofia: SIMEL. 2006;95.
11. Gam AN, Thorsen H, Lonnberg F. The effect of low-level laser therapy on musculoskeletal pain:
a meta-analysis. Pain 52. 1993;63–66.
12. Fulop AM, Dhimmer S, Deluca JR, Johanson DD, Lenz RV, Patel KB, et al. A meta-analysis of
the efficacy of laser phototherapy on pain relief. Clin. J. Pain 26. 2010;729–736.
13. Koleva I, Yoshinov R, Yoshinov B. Physical Analgesia. Edited by prof. Ivet Koleva. Saint-Denis
(France): Connaissances et Savoirs - Sciences Sante. 2018;146
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Biography of author(s)
Ivet B. Koleva
Medical University of Sofia, Bulgaria.
She is professor at the Medical University of Sofia, Bulgaria. She is a medical doctor as well as Philosophy Doctor, specialist in
Physical and Rehabilitation Medicine (PRM) and in Neurology. She obtained Doctor Degree in Medical Sciences and Professor
in PRM. She has many research publication in the national and International Journals.
Radoslav D. Yoshinov
Bulgarian Academy of Sciences, Laboratory of Telematics – Sofia, Bulgaria.
He is an engineer, Philosophy Doctor and Professor in Informatics. Presently, he is working as a professor at the Bulgarian
Academy of Sciences (BAS), Bulgaria. He is the Director of the Laboratory of Telematics at BAS, Bulgaria. He has published
many research in the national and International Journals.
Mr. Borislav R. Yoshinov
Medical Faculty of Sofia University, Bulgaria.
He is associated with Medical Faculty of Sofia University, Bulgaria. He obtained a Bachelor degree in Physiotherapy. Presently,
Mr. Yoshinov is a student in Medicine. He has published many research in the national and International Journals.
_________________________________________________________________________________
© Copyright (2021): Author(s). The licensee is the publisher (B P International).
DISCLAIMER
This chapter is an extended version of the article published by the same author(s) in the following journal.
Journal of Yoga & Physical Therapy, 7(2), 2017.
