COMPARATIVE STUDY OF HANDS-ON THERAPY WITH

ACTIVE EXERCISES VS EDUCATION WITH ACTIVE

EXERCISES FOR THE MANAGEMENT OF UPPER BACK PAIN
Mary S. Pesco, MA,a Etsuo Chosa, MD, PhD,b and Naoya Tajima, MD, PhDc

ABSTRACT

Objective: The aim of this study was to compare hands-on therapy, including heat, massage, and active exercises with
postural education that emphasized increased self-efficacy and postural self-awareness along with education about the
physiology of the disorder, and prescribed daily active exercises.
Subjects: Twenty-four randomly selected women, 12 custodians and 12 students, with neck and shoulder pain
and stiffness.
Methods: All subjects received a medical examination and x-ray before the study to rule out any pre-existing neurologic
deficits and an evaluation that included history taking and self-reporting of pain according to a numeric pain scale. Student
participants received education and exercise instructions to be continued daily. The custodial workers received once-per-
week hands-on treatment.
Results: Data were compared using a nonparametric analysis (Wilcoxon signed rank test) and showed evidence of
statistically significant reductions in neck, shoulder, and back stiffness and shoulder muscle tension for most of the
study subjects.
Conclusion: Treatment of repetitive stress injuries that combines maintenance of daily active exercises prescribed and
modeled by a professional therapist, which emphasize postural awareness to correct poor posture and provide a basic
physiological understanding of the disorder, is as crucial to reducing upper back and neck pain and stiffness as hands-on
therapy with active exercise provided in a clinical setting. (J Manipulative Physiol Ther 2006;29:228- 235)
Key Indexing Terms: Musculoskeletal Manipulations; Cumulative Trauma Disorders; Exercise; Education

A
s industrialized societies advance technologically,
they place increasing demands for productivity
and speed on workers. Although jobs may require
less physical strength, they can require much greater
repetitiveness in job performance, which b. . .concentrates
the workload on fewer, smaller muscle groups,Q1 and can
lead to repetitive stress injury (RSI). The US Department of
Labor identified RSIs as bthe fastest growing workplace
injuries, and can result any time there is a mismatch between
a
Retired Professor, Department of Occupational Therapy,
Kyushu University of Health and Welfare, Nobeoka City, Kyushu,
Japan.
b
Director, Department of Orthopedic Surgery, Miyazaki Uni-
versity Hospital, Miyazaki, Japan.
c
Retired Head, Department of Orthopedic Surgery, Miyazaki
University Hospital, Miyazaki, Japan.
Submit requests for reprints to: Mary S. Pesco, MA, Retired
Professor, OTR, 507 123rd Ave NE, Bellevue, WA 98005
(e-mail: unkyo31@yahoo.com).
Paper submitted August 22, 2005; in revised form November 11,
2005.
0161-4754/$32.00
Copyright D 2006 by National University of Health Sciences.
doi:10.1016/j.jmpt.2006.02.001
the physical requirements of the job and the physical
capacity of the human body.Q 2
According to a 1993 Occupational Safety & Health
Administration document, employers reported 1 of 4 lost-
time injuries and illnesses due to RSIs to the Bureau of
Labor Statistics (6 150 000 cases in 1993 represented 32%
involving upper extremities).2 Consequently, there is a
growing need to treat people having RSIs but limited
research on how best to treat these disorders.
Treatment commonly consists of medication, physiother-
apy, muscle stretching and strengthening, and ergonomic
changes in the workplace, provided primarily by a
physician. However, the importance of patient education
and understanding of the perpetuation of an RSI is often
overlooked. We hypothesized that raising postural self-
awareness and increasing self-efficacy in performing pain
reduction exercises and providing a basic understanding of
the root causes of physiological disorders resulting from
repetitive stress, overwork, and poor posture could measur-
ably reduce pain and stiffness in the upper back and neck.
Furthermore, a comprehensive approach to treatment is
likely to enhance the effectiveness of clinical hands-on
therapy provided by a trained experienced therapist.

228
Journal of Manipulative and Physiological Therapeutics
Volume 29, Number 3
Fig 1. Therapist-administered massage.
Malposture of the head on the neck resulting from
muscle fatigue due to overwork or poor posture, among
other things, leads to aggravated tension in the trapezius
muscle and between the levator scapulae muscles and may
produce chronic neck and shoulder pain with stiffness. Pain
and stiffness occur because of accumulated catabolites from
steady contraction of the muscle-tendon unit or intraarticular
capsules due to musculoskeletal compensation for deviation
from normal orthostatic posture.3-5 Because the head
determines the body’s position, the body compensates for
the position of the head. Gravity tends to bring the head
forward, which means that the natural balance of the head
on the spine is thrown out of alignment and forces the
head’s supporting muscles to contract.3-5
This study, conducted from the beginning of May
through August 2003, compared the effectiveness of clinical
hands-on therapy along with prescribed daily active
exercises with treatment that provides a basic physiological
understanding of the causes of upper back and neck pain,
raises postural self-awareness, and emphasizes self-efficacy
in the maintenance of prescribed daily active exercises to
reduce pain and stiffness.
HANDS-ON THERAPY
Hands-on therapy is a specialized approach to relieving
spasms and pain and for decreasing stiffness. It includes
massage, manipulation, and passive range of motion of
joints. Stroking massage decreases edema and enhances
relaxation of muscle tissue.6 Stroking, kneading, and
stretching massage induce relaxation and releases tightened
fascia. Massage also helps to direct venous blood, lymph,
and catabolites into the main stream of circulation, thereby
normalizing muscle tissue levels.7
Melzack and Wall8 provide a brief explanation of how
hands-on therapy reduces pain. Specifically, their gate
control theory of pain offers some support for the hypothesis
that therapist-administered hands-on therapy could reduce
muscle pain and stiffness. The theory explains how the
bpain gateQ opens through activation of small diameter nerve
Pesco et al 229
Two Approaches for Reducing Upper Back Pain
Fig 2. Imoto Dynamic PEK-1 muscle meter.
fibers. This stimulates T cells, and impulses enter the
anterolateral system so that pain is felt. Activity in the large-
diameter nerve fibers that form the posterior column of
white matter in the spinal cord, known as the substantia
gelatinosa, inhibits the transmission of pain signals. This
means that signals cannot enter the anterolateral pathway
and no pain is felt; the gate is closed.
Consequently, massaging painful areas could reduce pain
because tactile stimulation increases the activity in large-
diameter nerve fibers and closes the pain gate. Pain impulse
transmission depends on the balance of activity in the first
order neurons of the medial lemniscus and the anterolateral
routes.9 Therapist-applied massage (Fig 1) is considered by
many health professionals to be a skill-dependent and
reliable therapeutic treatment, although evidence as to its
effectiveness is mixed.
According to Dr Mel Borins of the University of Toronto,
visits to massage therapists increased by 36% in the United
States from 1990 to 1997. In a 1998 US survey of patients
with neck or back pain within the previous year, 14% sought
massage therapy, and of those, 65% reported massage to be
bvery helpful.Q10 Although the medical value of massage
therapy is not universally accepted, there is some evidence
that it may be helpful under certain conditions, and research
will define these conditions. Furlan et al10 conducted a
systematic review of 8 studies examining the efficacy of
massage therapy compared with other therapies. A summary
of their findings suggests that massage therapy is,
b. . .beneficial for patients with subacute and chronic non-
specific low back pain (LBP) in terms of improving
symptoms and function.Q These beneficial effects on LBP
appear to be long-lasting (at least 1 year). Furthermore,
they report that massage is most effective when combined
in a comprehensive program with exercise and education
and when provided by a trained massage therapist with
extensive experience.11
Cherkin et al12 conducted a randomized trial compar-
ing traditional Chinese medical acupuncture, therapeutic
230 Pesco et al Journal of Manipulative and Physiological Therapeutics
Two Approaches for Reducing Upper Back Pain March/April 2006

Table 1. Daily active exercises for the neck and shoulders Table 2. Baseline variables from self-reported symptoms and NPS

Instructions Purpose Mean change,

pretest to
Breathe deeply for 5 min to warm up. Calming and relaxation Variable posttest (n = 24) SE Pa
While sitting up straight on a comfortable Prolonged stretching of
chair, tilt the head forward with the chin the frontal and Shoulder stiffness 1.33 0.12 .00044
touching the chest and count slowly to posterior supporting Hand numbness 0.17 0.08 .0464
5. Then, tilting the head backward, muscles of the neck Neck stiffness 0.79 0.12 .00044
count to 5, and return to the original Headache 0.79 0.08 .00044
position. Repeat 5 times slowly. Difficulty sleeping at night 0.58 0.13 .00144
Tilt the head to one side then to the other. Prolonged stretching of General irritation 0.75 0.11 .00044
Repeat 5 times slowly. the lateral supporting Treated by physician 0.13 0.07 .083
muscles of the neck NPS degree of pain 3.375 0.23 .00044
Tilt the head forward, roll the head slowly Prolonged stretching of a
Wilcoxon rank sum test used to test data.
to the left, and hold for 2 s. Roll the all of the muscles of 4 P b .05.
head to the back and hold for 2 s, then the neck and shoulders. 44 P b .005.
roll it to the right and hold for 2 s. Then,
roll the head forward and hold for 2 s
and return to the original position.
Repeat 5 times slowly.
the effects of sauna heat in 11 healthy women. They found
While sitting upright with both hands Prolonged stretching of that heat increased the women’s levels of B-endorphin and
joined behind the neck, bring the the pectoral, shoulder, reportedly produced a pleasant sensation afterward. Heat
elbows together pointing straight ahead and upper back also significantly increased prolactin and norepinephrine
and count to 5. Then point elbows out muscles secretion and contributed to pain reduction.13 Heat treatment
to the sides and count to 5. Repeat 5
times slowly.
decreases ischemia and enhances blood flow to striated
Sitting in a chair with the fingertips of Prolonged stretching of muscles. Warmed areas of tissue decrease tension partic-
both hands lightly touching the chest the upper back, chest, ularly in the area where pain originates, such as trigger
and elbows out to the sides at shoulder and supporting neck points.15,16 Physiological effects of heat treatment increase
level, abduct the elbows toward the muscles flexibility of collagenous tissues and decreases spasms
back as far as possible at shoulder level,
and tilt the head back. Hold for 5 s, then
through nociceptive nerve endings.6
adduct the elbows toward the front and
tilt the head forward. Hold for 5 s.
Repeat 5 times slowly. THERAPEUTIC ACTIVE EXERCISES
These exercise must be done while sitting on a chair as rolling or tilting These exercises stretch the muscles of the neck,
the head through the positions may make the subject dizzy. Subjects should
shoulders, upper back, chest, and upper arms. They promote
breathe deeply while engaging in these exercises to enhance cardiovascular
activity and relaxation. functional movement, enhance strength, and decrease stiff-
ness and pain. Active exercises enhance overall blood flow
massage, and self-care education for the treatment of and increase muscle relaxation thus decreasing stiffness.
chronic LBP. They reported positive long-term effects They are also easy to perform and take little time and can be
from therapeutic massage for the treatment of chronic LBP done almost anywhere.
and suggest that massage may even serve as an alternative
to conventional medical care for chronic LBP.12 Preyde13
compared comprehensive massage therapy (soft-tissue ma- EDUCATION
nipulation, remedial exercise, and postural education) with As noted earlier, prolonged malposture of the head on the
massage alone, remedial exercise alone, and a placebo neck may cause muscle fatigue, pain, and stiffness because
(sham laser) for the treatment of subacute LBP. He reported of steady contraction of the muscle-tendon unit and deviation
significantly improved function, reduced pain, and from normal body posture.3-5 Postural education promotes
decreased quality of pain for comprehensive massage well being by preventing malposture and raising postural
compared with the other 3 treatments.13 Unfortunately, awareness. Educating patients about the causes of their
the variability in types of massage therapy and in the skill particular condition is a critical component of a comprehen-
level of the practitioners as well as the cost of treatment sive treatment protocol. Knowing about the health risks and
limits its efficacy. benefits of particular behaviors, b. . .creates the precondition
for change.Q17 Increasing awareness of how one’s behaviors
may lead to harm, and how to modify those behaviors is the
HEAT TREATMENT first step to preventing future harm. Furthermore, any
Heat dilates blood vessels in the body, releases seratonin, comprehensive treatment should emphasize increased self-
and reduces headaches and pain. Loalikainen et al14 studied efficacy. Patients should be encouraged to model health
Journal of Manipulative and Physiological Therapeutics Pesco et al 231
Volume 29, Number 3 Two Approaches for Reducing Upper Back Pain

Table 3. Baseline variables from clinical tests: thermography and

tissue compliance

Mean change (8C),

pretest to posttest
Variable (n = 24) SE Pa

Thermography
Neck 0.1242 0.0177 .00044
Left shoulder 0.1133 0.0175 .00044
Right shoulder 0.1163 0.0197 .00044
Back 0.1242 0.0192 .0004
Tissue compliance
Left shoulder 2.1667 0.9221 .00344
Right shoulder 2.5417 0.6510 .00044
a
Wilcoxon rank sum test used to test data.
4 P b .05. Fig 3. Thermographic images of custodial worker before and after
44 P b .005. treatment.

promoting behavior and recognize that they, in fact, have at
least some control over their health-related habits and, thus,
their health consequences.
METHODS
Subjects
All procedures were approved by the Miyazaki Uni-
versity Hospital’s orthopedic department head, and
informed consent was obtained from each subject before
this study. Each person received an x-ray and was seen by
the same physician before the study to eliminate any
preexisting conditions.
All subjects complained of the same type of pain and
stiffness in the neck, shoulders, or both. Some complained
of headaches at times; however, none were treated with
medications to control their pain or stiffness during their
participation in the study. The student group consisted of
12 randomly selected female college students from the
Kyushu University of Health and Welfare. These subjects
experienced shoulder and/or neck pain and stiffness after
typing on the computer, reading, and preparing for tests.
The custodial worker group consisted of 12 randomly
selected women from Kyushu University of Health and
Welfare’s custodial staff and from Nomura Hospital in
Nobeoka City. These workers experienced shoulder, neck,
and/or back pain and stiffness after 6 to 10 hours of
repetitive demanding physical work, such as sweeping,
mopping floors, cleaning toilets, picking up rubbish, or
dusting ceilings in classrooms. The mean age of the
subjects was 24.12 years (range, 20-29 years). Two of the
custodial workers and one of the university students visited
a physician for shoulder stiffness and pain approximately
2 years before this study. No subjects had any serious
previous neck or shoulder injury. Clinical characteristics for
inclusion were persistent pain with stiffness, some hardened
tender spots, difficulty sleeping, or unsatisfactory sleep and
feelings of discomfort.
Education Group
Each of the student participants was informed about their
condition by the therapist through a verbal explanation and a
printed illustration that included a flow diagram of the
disease process. These subjects also received printed
illustrations and verbal instructions for active exercises to
be continued on a daily basis. This exercise program
consisted of stretching exercises for the neck, shoulders,
forearm, and back, which the therapist showed, and each
participant rehearsed to show proper technique to the
therapist. Each student was then reevaluated once per
month and encouraged to continue exercising. Postural
reeducation exercises were also provided with the following
aims: (1) teach subjects awareness of correct posture; (2)
correct stressful, incorrect posture during work and study
activities; (3) strengthen posture-supporting muscle groups;
and (4) teach subjects to rest periodically during work and
learn to relax by engaging in stretching exercises.
Hands-On Therapy Group
Hands-on therapy, consisting of focal touch, deep friction
massage, and passive stretching, was given to each custodial
worker–participant once a week in an air-conditioned
(approximately 248C-268C; 758F-798F) occupational ther-
apy department room. The therapy included an initial
10 minutes of rest. Tissue compliance was tested with a
PEK meter (Imoto, Tokyo, Japan) before and immediately
after therapy (Fig 2). After the initial tissue compliance
reading, we applied a hot pack (688C-708C; 1548F-1588F)
wrapped with 8 layers of large towels to each subject’s neck
and shoulders for 15 minutes. Next, 5 minutes of gentle
massage was applied to the neck and shoulder areas
beginning with focal touch, especially around painful and
stiff areas such as trigger points, gradually transitioning to
deep friction massage. Focal touch is a form of hands-on
therapy applied particularly to tender or dense spots and can
be used to decrease pain and reduce tension.18 Subjects
engaged in active stretching exercises for the neck,
232 Pesco et al
Two Approaches for Reducing Upper Back Pain
Fig 4. Thermographic images of student participant before and
after prescribed exercises.
shoulders, arms, forearms, and hands (Table 1) for
approximately 15 minutes while sitting in a comfortable
chair; these stretching exercises correspond with those given
to the students. The therapists showed the proper form for
each exercise and encouraged each participant to rehearse
these exercises until they were performed correctly. Verbal
guidance was given to each study subject by the therapist,
along with printed step-by-step illustrations for each
exercise. This was followed by 5 minutes of rest, after
which, the subjects returned to their jobs.
Baseline Measures
Self-reported symptoms. All 24 subjects received a question-
naire at the beginning of the first day of the study and at the
end of the last day of the study, asking them to report any
symptoms of shoulder or neck stiffness, hand numbness,
headache, difficulty sleeping at night, general irritation, or if
they had been treated by a physician for any of these
particular ailments (Table 2).
Numeric pain scale. All 24 subjects received a Numeric Pain
Scale (NPS) questionnaire at the beginning and again at the
end of this study. This questionnaire asked subjects to report
the degree of pain they felt at that time on a scale from 0 to
10 (0 representing no pain and 10 representing extreme
pain) (Table 2).
Tissue compliance. Each subject’s muscle tissue stiffness was
tested before and after the fourth month of treatment using
the Imoto Dynamic PEK-1 muscle meter (Fig 2)19 in an air-
conditioned therapy room (258C-268C; 778F-798F). The
muscle meter was used to test each subject’s trigger point
tissue density (Table 3).
Thermography. Thermography is a noninvasive and safe
procedure using infrared imaging to evaluate muscle
condition.20 Thermographic images were taken after the
fourth month of the study to determine each of the custodial
subject’s temperature distribution change over painful
trigger points and stiff areas15 before and after hands-on
therapy and tissue compliance measure tests (Fig 3). The
student subjects were also evaluated at the end of the fourth
Journal of Manipulative and Physiological Therapeutics
March/April 2006
Fig 5. Numeric pain scale and self-reported degree of pain
(change, P = .000, n = 24).
month of the study before and after exercising (Fig 4).
Thermographic imaging serves as a useful way of compar-
ing skin temperature change before and after treatment,
which reflects the change in blood flow in painful areas.
Increased surface temperature is the result of increased
blood flow from deeper tissue to the superficial tissue
layers.20,21 Thermography, in this study, is used as an
assessment measure and not as a diagnostic tool. Clearly,
controversy exists about the use of thermography as a
diagnostic tool (for breast cancer and other diseases), but
that is not its purpose here. The researchers acknowledge the
limitations of thermographic imaging but do recognize its
usefulness under limited conditions by trained health
professionals (by a physician and occupational therapist in
this study) under controlled standardized clinical conditions.
Statistical Analysis
The data collected during this study were summarized,
and results were analyzed with a nonparametric test
(Wilcoxon signed rank test) using SPSS software version
11.0 for Windows (SPSS Inc, Chicago, Ill) to compare pre-
and posttreatment measures (tissue density or compliance,
thermography, numeric pain scale, and self-reported pain
symptoms) between the custodial workers and the students.
All results are reported as mean change pre- to posttreat-
ment with standard errors. P b .05 was considered
statistically significant.
Statistically significant results are desirable but do not
necessarily reflect clinical significance. Although statistical
significance is well defined, clinical significance is based on
subjective judgments relevant to a particular profession.
Occupational therapists define clinical significance as
improved functioning in activities of daily living, decreased
pain and stiffness, and improved quality of life. Occupa-
tional therapists and other therapists routinely collect self-
reported responses, conduct timed observations of function
and performance, and quantify physical ability to make
Journal of Manipulative and Physiological Therapeutics Pesco et al 233
Volume 29, Number 3 Two Approaches for Reducing Upper Back Pain

Fig 6. Average change in self-reported symptoms pre- and

posttreatment (shoulder stiffness, P = .000; hand numbness, P = Fig 7. Average changes in thermography (neck, P = .000;
.046; neck stiffness, P = .000; headache, P = .000; difficulty right shoulder, P = .000; left shoulder, P = .000; back,
sleeping, P = .001; general irritation, P = .000; treatment by P = .000).
physician, P = .083).

judgments regarding clinical efficacy of treatments. Meas-

ures such as thermographic imaging and tissue compliance,
although not routinely done because of cost and access to
equipment, help to further quantify functional ability.
Interpretation of these measures and responses still depends
on the skill and expertise of the therapist. Jacobson and
Truax22 developed one method, called the Reliable Change
(RC) Index, of quantifying clinical significance that could
theoretically apply to any clinical disorder and would satisfy
the requirements of both lay and professional outcome
expectations. This method classifies patients as clinically
bchangedQ or bunchangedQ according to a calculated cutoff
point, bounded by a CI, on a distribution of change scores. Fig 8. Average changes in tissue compliance (left shoulder P =
The RC score is calculated by dividing the change measure .003, right shoulder P = .003).
(posttest pretest) by the standard error of the difference.
Any RC score greater than 1.96 (which represents 1.96 SDs
and 95% of the distribution) would indicate that clinically 2 treatments during the study (Figs 7 and 8). According to
significant change had occurred.22 the results from the thermographic measures, a majority of
the subjects showed statistically significant improvement in
neck, both shoulders, and back measurements ( P b .000).
RESULTS
All 24 subjects completed the study. Two questionnaires,
the self reported symptom questionnaire and the NPS
DISCUSSION
(Fig 5), showed statistically significant findings of reduced Findings published in a 2001 report on musculoskeletal
pain after treatment. Nearly all subjects appeared to disorders of the low back and upper extremities in the
experience significant reductions in perceived shoulder workplace by the National Research Council and the
stiffness ( P b .000) and neck stiffness ( P b .000), headache Institute of Medicine illustrate the magnitude of the cost
( P b .000), and general irritation ( P b .000) (Fig 6). of these disorders in lost wages, lost productivity, and
Half of the subjects perceived less difficulty sleeping compensation payments in the United States each year.23
after either treatment or exercising ( P b .001). In no instance According to the report, musculoskeletal disorders of the
did any subjects report increased stiffness or pain of any low back and upper extremities in the workplace cost at
kind asked about in the questionnaire. At worst, some least $45 to $54 billion each year, although this estimate
subjects reported no perceived improvement after hands-on may actually be somewhat low because many cases go
therapy or exercising. Results from 2 clinical tests, unreported. These costs do not account for the psycholog-
thermography and tissue compliance, show significant ical costs paid by those that suffer continually from
improvement for most participants because of either of the these disorders. The report stresses the importance of
234 Pesco et al
Two Approaches for Reducing Upper Back Pain
musculoskeletal disorders of the low back and upper
extremities as an bimportant national health problem.Q23
Clearly, this is an important health problem for all nations
whose citizens engage in stressful or repetitive physical
labor or work long hours at computers. It is unlikely that
chronic upper back and neck pain due to repetitive stress
will resolve without either treatment or changes in the work
or study environments because the natural progression of
this disorder is to worsen over time and may eventually lead
to permanent disability.1 In a 1993 US Department of Labor
report, 1 of every 3 dollars of workers’ compensation is paid
for RSI; 2.73 million workers’ compensation claims were
filed for RSIs and directly cost employers more than $20
billion dollars with indirect costs estimated at $100 billion.2
Preventing RSIs in the workplace is preferable; however,
from a therapist’s perspective, treatment is the most practical
solution to diminishing the associated pain and stiffness for
those already having these disorders. This treatment should
stress personal responsibility for self-awareness while
working in situations that may cause disorders and actively
avoiding such stressful situations if possible. Treatment
should also encourage participation through continued
prescribed exercises away from the treatment setting.
Specifically, postural reeducation, eliminating poor work
habits, hands-on therapy, and engaging in intermittent
stretching exercises during the workday are effective means
for resolving these disorders.
Finally, the report recommends expanding research into
the causes and prevention of musculoskeletal disorders
and encourages researchers to collect and share scientific
findings regarding interventions, including outcome mea-
sures. This study attempts to provide such outcome mea-
sures for therapist-prescribed personalized active exercises,
education, and hands-on therapy as ways to alleviate
musculoskeletal disorders of the upper extremities. Thera-
pist-administered hands-on therapy reduces pain and stiff-
ness, allowing those suffering musculoskeletal disorders of
the neck and shoulders to engage in exercises beyond the
treatment setting. Otherwise, pain and stiffness may
ultimately act as a deterrent to exercising. Moreover, as
noted earlier, it is comprehensive therapy—including
massage, exercises and education—that appears to be most
effective for treating chronic muscular pain long term.11,13
Positive findings from this study are encouraging but must
be evaluated within the context of the study’s limitations,
including a small sample size, no control group, and a
relatively short study period with no follow-up. Under these
circumstances, the results may be questionable. However,
when viewed within the growing body of peer-reviewed
literature that offers similar findings to those from this study,
these results become less questionable, and should, at least,
encourage further research into this potentially effective
means for treating a growing national problem. The RC
formula was applied to the data from this study and produced
RC scores greater than 1.96 for those measures that were
Journal of Manipulative and Physiological Therapeutics
March/April 2006
found originally to be statistically significant. Unfortunately,
because of the small sample size, the CIs around the RC
scores were quite large, and the clinical significance could not
be confirmed according to this method. Nevertheless, the
results obtained from this study appear encouraging and
should inspire further research on this subject, perhaps
including RC score calculations.
Although this study period was short (4 months), most
participants experienced improvement in reduced shoulder
and neck stiffness and pain. Furthermore, it is difficult to
know how well, or whether, the university student partic-
ipants performed their prescribed exercises outside those
observed once each month by this therapist. Nevertheless,
and most importantly, even these individuals experienced
significantly reduced pain and stiffness. Thus, if even a
minimum of regular active exercise has a positive effect,
then it appears logical to assume that even greater benefit,
including improved postural awareness, may be obtained
from a comprehensive hands-on therapy protocol. The
suggestion that the data show equally good results from
both hands-on therapy with active exercises and education
with active exercise is particularly significant because one
would expect hands-on therapy to produce superior results
to self-administered exercises.
CONCLUSION
The data generated by this study offer encouraging
results suggesting support of the hypothesis that compre-
hensive hands-on therapy that includes individually tail-
ored active daily stretching exercises and education
emphasizing increased postural self-awareness and self-
efficacy offer a potentially useful means for reducing upper
back and neck pain due to repetitive stress, overwork, and
poor posture.
ACKNOWLEDGMENT
The authors thank Glen E Leverson, PhD, biostatistician,
Department of Surgery, University of Wisconsin Hospital
and Clinics, for his assistance with this manuscript.
REFERENCES
1. Stock RS. Workplace ergonomic factors and the development
of musculoskeletal disorders of the neck and upper limbs: a
meta-analysis. Am J Ind Med 1991;19:87-107.
2. Reich RB. Preventing repetitive stress injuries. U.S. Depart-
ment of Labor. OSHA Archive Report. 199. Available from:
www.osha.gov/pls/oshaweb.
3. Gelb H. Craniocervical mandibular disorders. In: Kraus H,
editor. Diagnosis and treatment of muscle pain. 2nd ed.
Chicago7 Quintessence Publishing Co; 1988. p. 67-76.
4. Ishmael W, Shorbe H. Care of the neck. 2nd ed. Baltimore7
Lippincott Williams and Wilkins; 1985. p. 1-30.
5. Han SC, Harrison P. Myofascial pain and trigger-point
management. Reg Anesth 1997;22:89-101.
Journal of Manipulative and Physiological Therapeutics
Volume 29, Number 3
6. Vasudevan SV. Physical rehabilitation in managing pain.
Pain: Clinical Updates; 1997 Nov. V.
7. Zohn DA. Musculoskeletal pain. Diagnosis and physical
treatment. 2nd ed. Boston7 Little Brown and Company; 1988.
p. 137-9.
8. Melzack R, Wall PD. Pain mechanisms: a new theory. Science
1965;150:971-9.
9. Tyldesley B, Grieve JI. Muscle, nerve and movement:
kinesiology in daily living, vols 11,2,3. 2nd ed. Oxford7
Blackwell Scientific Publications; 1996. p. 277-8.
10. Borins M. Massage therapy. A universal alternative. Can J
Diagn 2005;38-9.
11. Furlan AD, Brosseau L, Imamura M, Irvin E. Massage for low-
back pain: a systematic review within the framework of the
Cochrane Collaboration Back Review Group. Spine 2002;27:
1896-910.
12. Cherkin D, Eisenberg D, Sherman KJ, Barlow W, Kaptchuk
TJ, Street J, et al. Randomized trial comparing traditional
Chinese medical acupuncture, therapeutic massage, and self-
care education for chronic low-back pain. Arch Intern Med
2001;161:1081-8.
13. Preyde M. Effectiveness of massage therapy for Subacute low-
back pain: a randomized controlled trial. CMAJ 2000;162:
1815-20.
14. Loalikainen T, Saliminen K, Kohvakka A, Petterson J.
Response of plasma endorphins, prolactin and catecholamines
in women to intense heat in a sauna. Eur J Appl Physiol
1988;57:102.
Pesco et al 235
Two Approaches for Reducing Upper Back Pain
15. Takagi K, Ushishima F. The cause and symptoms of shoulder
stiffness. Seikei Geka Kango 2001;6:20 - 4.
16. Chosa E, Tajima N. Low back pain, shoulder stiffness,
cervico-omobrachial syndrome. Mon Book Orthop (Jpn)
2000;13:170-6.
17. Bandura A. Health promotion by social cognitive means.
Health Educ Behav 2004;31:143-64.
18. McCormack GL, Weiner RS. Specific pain-reduction strategies
and techniques for therapy or home use. Pain Manag
1993;11:207-9.
19. Yono T, Arima Y, Inomoto J. Development of digital
palmometer. Jpn J Hand Perform Study 1998;9:1.
20. Kim Y-C, Bohk J-H, Lee S-C, Lee Y-W. Infrared
thermographic imaging in the assessment of successful block
on lumbar sympathetic ganglion. Yonsei Med J 2003;44:1.
21. Fischer A. Documentation of muscle pain and soft tissue
pathology. In: Kraus H, editor. Diagnosis and treatment of
muscle pain. 2nd ed. Chicago7 Quintessence Publishing Co;
1988. p. 55-65.
22. Jacobson NS, Truax P. Clinical significance: a statistical
approach to finding meaningful change in psychotherapy
research. J Consul Clin Psychol 1991;59:12-9.
23. Barondess JA, Cullen MR, de Lateur BJ, et al. Panel on
Musculoskeletal Disorders and the Workplace Commission On
Behavioral And Social Sciences Education National Research
Council and Institute of Medicine. Musculoskeletal disorders
and the workplace. Low back and upper extremities. Wash-
ington (DC): National Academy Press; 2001;1-17, 364.