Neck and Scapula-Focused Exercise Training of Patients

With Nonspecific Neck Pain: A Randomized Controlled

Trial

TAHA IBRAHIM YILDIZ, ELIF

TURGUT, AND IREM DUZGUN
 Published in the Journal of Sport Rehabilitation,
2018

 it’s impact factor is 1.98

 ABSTRACT

 Objectives: The purpose of this study was to investigate the effects of

additional 6-week scapular stabilization training in patients with nonspecific
neck pain (NNP).
 Materials and Methods: A total of 30 patients with NNP were randomly
allocated to the study. Fifteen participants in the intervention group received
neck-focused exercise and scapular stabilization training, whereas 15
participants in the control group received neck-focused exercise training. All
groups were evaluated at baseline and after 6 weeks of rehabilitation. The pain
intensity on the neck was measured with the visual analog scale (VAS). The
self-reported disability status was measured with the neck disability index
(NDI). Three-dimensional scapular kinematics were recorded during dynamic
shoulder elevation trials using an electromagnetic tracking device, and data
were further analyzed at 30°, 60°, 90°, and 120° of humerothoracic elevations
 Results: Comparisons revealed that, regardless of the received treatment,
after 6 weeks of training both groups showed significant improvements in
VAS (P < .001) and NDI (P < .001) scores. Both VAS and NDI outcomes
have a large effect size (r = .618 and r = .619, respectively). For scapular
kinematics, there were no group differences, especially for scapular
upward–downward rotation and anterior–posterior tilt (P > .05). However,
in the intervention group, the scapula was more externally rotated at 120°
humerothoracic elevation (P = .04)

 Conclusion: Findings of this study showed that both manual therapy and
active interventions, including neck-focused exercise and scapular
stabilization training, are effective in decreasing pain and disability level in
patients with NNP. More comprehensive studies with longer follow-u
durations are needed to better understand the potential effects of scapular
stabilization training in patients with NNP.

 Keywords: rehabilitation, 3-dimensional kinematics, treatment,

scapulothoracic joint
 INTRODUCTION

 Nonspecific neck pain (NNP) is one of the most common

musculoskeletal disorders in the middle-aged group. The annual
incidence of NNP is between 30% and 50% of the population, and it is
increasing due to sedentary lifestyle and working conditions. Moreover,
most people in the population are expected to suffer from neck pain at
some stage of their lives.Because of the pain, the patient’s quality of life
and efficiency of work decrease, and with the health expenses, the
problem causes economic burden.
 The mechanism behind NNP is still not clearly understood. NNP occurs
without any systemic or specific problem being detected as the
underlying cause.Sedentary lifestyle, working conditions, previous
trauma to the neck region, postural abnormalities, and altered
neuromuscular control of cervical muscles are the main risk factors for
NNP stated in the literature
 Especially in recent years, the scapular region has attracted much
attention. Because of its close relationship with the cervical region,
scapular dyskinesia is thought to be one of the risk factors for NNP. So,
researchers have started to focus on the scapular region in patients with
neck problems.
 Alterations in dynamic scapular stabilization have been detected in
patients with NNP.Szeto et al reported more protracted acromion and
scapula on patients with neck pain.
 According to Helgadottir et al, there is less scapular posterior tilt on
patients with NNP compared with asymptomatic people. In another
study, researchers found decreased clavicular retraction and upward
rotation during upper limb tasks in patients suffering from neck pain
compared with asymptomatic people. In the literature tightness and
alterations in the activation strategies of axioscapular muscles, which
are secondary to pain, are thought to induce scapular dysfunction.
changes in the axioscapular muscle behavior result from neck pain and
aim to protect the region.
 AIM OF THE STUDY

 The aim of the present study was to investigate the effects of additional
6-week scapular stabilization training in patients with nonspecific neck
pain (NNP).
 HYPOTHESIS

 Experimental hypothesis (H1):

There will be significant effect of 6-week scapular stabilization training
in patients with nonspecific neck pain (NNP).

 Null hypothesis (H0):

There will be no significant effect of 6-week scapular stabilization
training in patients with nonspecific neck pain (NNP).
 METHODOLOGY

 Study design: randomized controlled trial

 Sample size total of 48 patients
 Study duration 6 months
 Study location Department of Physical Therapy and Rehabilitation,
from February 2016 to December 2016
Flow chart
 Inclusion criteria:
 Include 18 to 45 years of age,
 having a score between 10 and 40 points on the NDI,
 having scapular dyskinesia according to Kibler’s description,
 having no previous shoulder or neck surgery, and having no
accompanying shoulder problems.
 The inclusion criteria for the study were having neck pain that
had lasted at least 6 months,
 To eliminate the ceiling/floor effect, patients who scored
between 10 and 40 out of 50 points on the NDI were included in
the study.
 Exclusion criteria:

 The exclusion criteria for the study were symptoms of radicular pain
(positive sign of neck distraction test, Spurling’s neck compression test,
and Adson’s test),
 a score of below 10 or above 40 points out of 50 on the NDI,
 a previous neck or shoulder surgery, an accompanying shoulder
problem, or refusal to participate in the study..
 Ethical approval:-

The study was approved by the ethical committee of Hacettepe University.

 Outcome measures

 Pain. The pain-intensity level was measured using a scale of 10-cm

horizontal line visual analog scale (VAS).Patients were asked to place a
mark on the line ranging from 0 to 10 cm, in which 0 points referred to
“no pain” and 10 points referred to “worst pain.”
 Activities of Daily Living. Patient disability level was assessed with
the NDI, which is most commonly used as a self-reported questionnaire
in neck pain. It consists of 10 items, each of which comprise 6 potential
answers ranging from 0 (no disability) to 5 (full disability), and the
total of the NDI score varies between 0 and 50 points. It is
recommended that NDI scores should be interpreted as follows:
between 0-4 points, “no disability”; 5-14 points, “mild disability”;
points, “moderate disability”; 25-34 points, “severe disability”; and
more than 35 points “complete disability.”31 In this study, the patients
were instructed to fill in the NDI questionnaire before and after 6
weeks of treatment. The minimal detectable change was considered 5
points (10%) in the study
 Scapular Kinematics. Bilateral scapular kinematic data were
collected using 3D flock of birds electromagnetic tracking system
(Ascension Technology Corporation, Burlington, VT). The system
provides a direct recording of the local coordinate system, which
consists of an extended range transmitter, 5 wired receivers, 1 digitizer,
and a motion monitor hardware program (Innovative Sports Training
Inc, Chicago, IL). The flock of birds system gives reliable results with
orientation errors below 2°.
 During the procedure, 5 sensors were attached using 2-sided adhesive
tape on the patients’ skin. The thoracic sensor was placed on the
spinous process of the thoracic first vertebra, the scapular sensors were
placed on the flat surface of the acromion, and humeral sensors were
placed on the insertion of the deltoid muscles .
 Specific bony landmarks (on humerus; lateral and medial epicondyle,
on scapula; trigonum spine scapula, angulus inferior, angulus
acromialis, and coracoid process, on thorax; the spinous process of C7-
T8-T12 vertebras and xiphoid process) were palpated and marked on
the patients while they stood in a relaxed position. The protocol
proposed by the International Society of Biomechanics.
 During the testing procedure, patients were asked to elevate their arms
in the scapular plane, defined as 40° anterior to the frontal plane.
Leader sticks were positioned along the scapular plane to act as a guide
for patients while elevating the arm
 . Patients performed 3 repetitions of elevation trials during the tests,
and the mean values of all 3 repetitions were recorded at 30°, 60°, 90°,
and 120° of humerothoracic elevations. Because the scapular kinematic
data beyond 120° of humerothoracic elevations are not reliable, they
were not included in the study.
 During the testing procedure, patients were instructed to stay in a
relaxed position and not to straighten their posture or make any
compensatory movements. The assessor physiotherapist observed the
patients during the testing procedure, and if there was any deviation in
a patient’s posture, the test was repeated. Figure 3 — Grade 1 push-up
plus exercise. Figure 4 — Analysis of scapular kinematics. JSR Vol. 27,
No. 5, 2018 406 Yildiz, Turgut, and Duzgun Journal of
 PROCEDURE

 Exercise Training. Patients were randomized into 2 groups for

exercise interventions. CG conducted neck-focused training, and IG
conducted both neck-focused and scapular stabilization training. Both
exercise regimes were 6 weeks in duration and commenced with the
first manual therapy session. All patients received personal instruction
under the supervision of the therapist applying manual therapy once a
week and were checked by the therapist to see whether they were doing
the exercise properly.
 Neck-focused training consisted of cervical stretching, craniocervical
flexion, and cervical retraction exercises. Cervical stretching exercises,
which targeted the cervical extensor and lateral flexor muscles, were
performed every day for 3 sets of 5 repetitions. Craniocervical flexion
exercise targeting the deep cervical flexor (longus colli and longus
capitis) muscles was performed based on descriptions from Jull et al.
 Patients performed the exercise while supine. They were taught to
perform slow and controlled craniocervical flexion actions by feeling
the sliding motion of the head on the lying surface without having any
contraction on superficial sternocleidomastoideus muscles. All patients
performed the exercise twice a day for 2 sets of 10 repetitions
 In a standing position patients were instructed to perform a cervical
retraction, then apply resistance with an elastic band that was around
the head and hold the position against resistance for 5 seconds (Figure
2, grade 1). After the third week of the treatment, the exercise was
progressed and patients started to perform resistive cervical retraction
in combination with lunge exercises for more dynamic movement
(Figure 2, grade 2). The exercise was performed twice a day with 2 sets
of 10 repetitions
 Scapular stabilization training consisted of scapular retraction, lateral
pull-down, and push-up plus exercises. Patients practiced the scapular
retraction and lateral pull-down exercises with the elastic resistive
band.
 Push-up plus exercise was carried out with the support of a table in an
oblique position (Figure 3, grade 1). When the patients carried out the
exercise properly, it was progressed. After progression, the patients
started to perform the exercise on a horizontal plane (grade 2).
 All scapular stabilization exercises were performed once a day and 3
sets of 10 repetitions18 (Appendix). All scapular stabilization exercises
were conducted during the rehabilitation program (6 wk).
 Manual Therapy. Manual therapy was applied to the patients by the
same physiotherapist twice a week during the treatment at the clinic.
 Soft tissue mobilizations for right and left upper trapezius, levator
scapula scalenus, and cervical extensor muscles were performed.
Sustained compression technique, deep stroking massage, and
myofascial release techniques were practiced for each muscle group.
 Cervical lateral glides and cervical traction were performed after soft
tissue mobilizations. Both groups received the same manual therapy
program once a week for 6 weeks, and each manual therapy session
lasted for 15 to 20 minutes.
 Data analysis

 SPSS version 22.0 (IBM Corporation, Armonk, NY) was used for
statistical analysis
 An independent sample t test was used to analyze the difference
between the groups in physical characteristics
 Two-way repeated measures of analysis of variance (ANOVA) test was
used for the analysis of VAS and NDI scores and scapular kinematics
with the factors of rehabilitation groups and time.
 Level of significance was set at (p<0.05).
 RESULT

 There were no differences in patient demographics between the groups

(P > .05; Table 1).
 For pain intensity, there was no significant group interaction (F3.1, 73.2
= 0.180, P = .92), but there was a significant main effect of time (F3.1,
73.2 = 28.45, P < .001) (Figure 5).
 For NDI scores, 2-way ANOVA revealed no significant group
interaction (F1,23 = 2.9, P = .10). Yet, the main effect of time was
significant (F1,23 = 158.5, P < .001) in both groups.
 No significant angle-by-group interaction or main effect was observed
for external rotation at 30° (F1,23 = 0.0001, P = .99), 60° (F1,23 = 0.01,
P = .90), or 90° (F1,23 = 0.15, P = .67) humerothoracic elevations.
 Angle-by-group interaction was not significant for scapular upward
rotation at 30° (F1,23 = 2.76, P = .11), 60° (F1,23 = 2.26, P = .15), 90°
(F1,23 = 2.67, P = .12), or 120° (F1,23 = 2.77, P = .11) humerothoracic
elevations. Main effect for time was observed to be significant for
scapular upward rotation at 120° (F1,23 = 4.4, P = .04) of
humerothoracic elevation. Patients in IG showed significant
improvement in scapular upward rotation at 120° (P = .01) of
humerothoracic elevations.
 There was no significant angle-by-group interaction for scapular
posterior tilt at 30° (F1,23 = 1.3, P = .29), 60° (F1,23 = 1.37, P = .26),
90° (F1,23 = 1.34, P = .26), or 120° (F1,23 = 2.03, P = .17). All scapular
kinematics data are given in Table 2 and Figure
 DISCUSSION
 The results of the study showed that pain intensity and disability levels
decreased in cervical and cervical plus scapular exercises groups. However, we
could not support our hypothesis as there were no differences on scapular
kinematics, pain intensity, and NDI score between groups. Therefore, it can be
interpreted as scapular stabilization exercises had no extra effect in the short
term on patients with neck pain.
 combined therapy approaches are recommended due to better improvement in
pain severity and disability level than manual therapy or exercise alone.
Therefore, we integrated both manual therapy approaches and cervical exercise
in both groups. it was also shown that if the exercises are not maintained after
the pain decreases, the beneficial effects of the exercises are lost, andthe pain
might increase again.
 The primary aim of the treatment approaches is to decrease the pain severity in
patients with mechanical neck pain. In the study, similar improvement was
observed in both groups’ pain intensity severity after the rehabilitation
program. The decrease in neck pain was 3.5 points in CG and 3.4 points in IG.
Both groups showed clinically meaningful decreases in VAS scores after
treatment
 It was indicated that the correction of the scapular position may reduce
the tension in the axioscapular muscles and abnormal cervical loads,
and therefore the pain decreases. However, in this study, we observed
that there were no extra effects of 6 weeks of scapular stabilization
training on neck pain.
 Although there are studies investigating the effects of scapular
stabilization exercise on scapular kinematics in different pathologies,
there is still lack of information about the duration of rehabilitation
programs. On patients with shoulder problems, 4 weeks of scapular
stabilization exercises are stated to be insufficient, whereas 6 weeks of
stabilization exercises had better improvement in scapular
kinematics.However, it was shown that there is still not enough
correction on scapular kinematics after6 weeks of stabilization
exercises in patients with shoulder pathologies. likewise in shoulder
problems, 6 weeks of scapular stabilization exercises is not enough for
significant correction of scapular dyskinesiain NNP.
 In this study, the scapula underwent external rotation after 90° of
humerothoracic elevation in IG, whereas in CG it did not . From this result, it
may be thought that with the scapular stabilization training given in IG, the
altered neuromuscular control and activation pattern of the middle and lower
trapezius11 and serratus anterior muscles were improved.
 After the rehabilitation, the CG only showed 0.9° increase while IG showed 6.9°
increase in scapular upward rotation. Although it was not significant, IG had
better improvement in scapular upward rotation compared to with CG.
Thismight indicate that 6-week scapular stabilization exercises are not enough
to have a significant improvement on the scapular kinematics of patients with
NNP. Therefore, a longer duration of scapular stabilization exercises is needed
to investigate the effects on patients with NNP.
 CONCLUSION
 Both groups showed significant improvements in neck pain and
disability level after the treatment, yet no difference was observed
between groups. For scapular kinematics, the only difference was
observed in external rotation between the groups.
 It is concluded from the study that scapular stabilization exercise had
no extra effect on neck pain and quality of life in the short term..
Therefore, long-term studies with scapular stabilization training are
needed.
 LIMITATION

 We recruited the patients for 6 weeks. for scapular upward rotation

and posterior tilt, it may not enough for significant improvement,
 the patients had a different type of scapula, so they might not benefit
from the exercise at the same level.
 There is a variety of causes behind NNP (postural abnormalities, neck
trauma, smoking, psychological problems, etc) that might also affect
the results of the study.
 5 patients were excluded from the study for different reasons, and this
problem reduced the strength of this study.
 Studies investigating the scapular stabilization training with long-term
follow-up are recommended for future research. Also, an exercise
program that includes only scapular stabilization training is
recommended for future studies.
 In my view

 Large sample size can be taken

 Graphical representation of the results can be done.
 Data collection can be done at 6th week.
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