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Long-term effect of direction-movement control training on female patients with chronic neck pain
Accepted Manuscript Long-term effect of direction-movement control training on female patients with chronic neck pain Zohreh Khosrokiani, Amir Letafatkar, Yahya Sokhangoie PII:
S1360-8592(17)30128-6
DOI:
10.1016/j.jbmt.2017.06.004
Reference:
YJBMT 1551
To appear in:
Journal of Bodywork & Movement Therapies
Please cite this article as: Khosrokiani, Z., Letafatkar, A., Sokhangoie, Y., Long-term effect of directionmovement control training on female patients with chronic neck pain, Journal of Bodywork & Movement Therapies (2017), doi: 10.1016/j.jbmt.2017.06.004. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Long-term effect of direction- movement control training on female patients with chronic neck pain Zohreh Khosrokiani 1, Amir Letafatkar2, Yahya Sokhangoie3 Department of Biomechanics and Sports Injuries, Faculty of Physical Education and Sport Science, Kharazmi University, Tehran, Iran.
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Abstract Background: Treatment of movement faults in the neck is known as an important factor in treatment of chronic neck pain. Along with the identification of site and direction of the faults, direction-movement control intervention retrains the control of the movement faults. Purpose: This study was designed to investigate long-term effects of a direction- movement control training on pain, disability, head repositioning accuracy, function, cervical flexor endurance, and range of motion in female patients with chronic nonspecific neck pain. Material and Methods: Thirty women (36.5 ± 5.7 years) with chronic nonspecific neck pain were randomly allocated into two groups, i.e., an experimental group (n = 15) and a control group (n = 15). The experimental group performed the direction- movement control training for 30 min/day, three days per week for six months. All subjects were evaluated using the visual analog scale (VAS), range of motion (TOM), progressive iso-inertial lifting evaluation (PILE), neck disability Index (NDI), helmet attached with laser pointer using for head repositioning accuracy (HRA), and Trott's test (deep neck flexor endurance), in pre- and six-months posttreatment intervention. Results: Significant differences were observed for the pain, neck disability Index, function endurance, head repositioning accuracy, range of motion, and cervical flexor endurance in the experimental group compared to that of control group. Conclusion: Direction- movement control training is likely to be an effective training program to enhance body functionality through improvement of pain, function, endurance, head repositioning accuracy, range of motion, and cervical flexor endurance. Due to the high reported effect size for direction- movement control exercises, the application of the training is suggested as a supplementary method to improve chronic nonspecific neck pain in females. Keywords: Chronic neck pain, head repositioning accuracy, function.
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Highlights • The effects of direction-movement control exercises in the treatment of neck pain were examined. • It is observed that the exercises that are categorized with site and direction of uncontrolled movements will improve functionality in patients with neck pain. • High effect size of the direction-movement control training was reported in chronic nonspecific neck pain.
1*. Ms. (Corresponding author), Department of Biomechanics and Sport Injuries, Faculty of Physical Education and Sport Sciences, Kharazmi University, Mirdamad, Shahid Mofateh, Tehran, Iran. Email: [email protected]. 2 . Assistant professor, Department of Biomechanics and Sport Injuries, Faculty of Physical Education and Sport Sciences, Kharazmi University. 3. Assistant professor, physical therapist, Shahid beheshti University of Tehran, Tehran- Iran. 1
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1. Introduction Neck pain is one of the most common pain disorders, leading to considerable stress on healthcare systems. It is estimated that 67% of the population will experience neck pain at some point in their life (Yun et al., 2015). Neck pain is now second to back pain, the most common musculoskeletal disorder (Ferrari and Russell, 2003). More than 50% of adults have experienced neck pain within the past 6 months; the one-year incidence of neck pain was between 10.4% and 21.3%, and the one-year prevalence ranged from 4.8% to 79.5% (mean, 25.8%) (Cheng et al., 2015). Women are more likely to experience persistent neck pain than men (DeokJu et al., 2015). The prevalence in women, 27.2%, is higher than in men, 17.4% (Cheng et al., 2015). Nonspecific neck pain induced by nonspecific musculoskeletal disorders may occur repeatedly, resulting in a vicious cycle of chronic pain (pain persisting for more than three months) (Lafond et al., 2008; Childs et al., 2009; Kim et al., 2013; Cheng et al., 2015).
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Neck muscles are required to generate, sustain, and maintain precision of neck activities. Changes in neck muscles have potentially disastrous consequences for the neck because the neck relies on muscles for mechanical stability (Roijezon, 2009).
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Identifying and classifying movement faults is fast becoming the key of recent neuromusculoskeletal rehabilitation (Sahrmann 2002). In recent years clinicians and researchers have described movement faults and used many terms to describe these abnormal patterns. Some terms include substitution strategies (Jull et al 2008), muscle imbalance ( Sahrmann 2002), faulty movement (Sahrmann 2002), abnormal dominance of the mobiliser synergists ( Jull et al 2008), and movement impairments (Sahrmann 2002). All of these terms describe aspects of movement dysfunction, many of which are linked to UCM. Uncontrolled movement (UCM), contributing to neck pain symptoms, can cause compression or impingement on one side of joints while developing tensile strain on the other side. If UCM is not managed, and the related tissue stress and strain are sustained or repeated beyond the limits of tissue tolerance, multiple tissue pathology may develop eventually and a combination of symptoms may occur (Comerford & Mottram, 2012). The management of neck pain, a significant factor in musculoskeletal disorders, is still poorly described, utilized and researched (Jull et al., 2008). A common feature of movement control faults is reduced control of active movements, or movement control dysfunction (Luomajoki et al, 2007). The distinctive features of the exercise start with the positioning of the spine or segment in its ‘neutral position’ by the therapist, which is then actively controlled by the patient while they move the joint region either above or below the joint system. The direction- movement control training is based on identifying, firstly, a consistent pattern of movement which is associated with the patient’s symptoms and, secondly, a decrease in pain when the uncontrolled movement is corrected. The suggestion is that uncontrolled movement links to the pattern of movement during everyday activities and relates to neck pain. The hypothesis here is that early movement during everyday activities suggests an increase in frequency of movement of a specific region which may contribute to increased stress on tissue resulting in pain (Mueller & Maluf 2002). Patients with neck pain present diverse clinical findings, courses of disease and prognoses. They therefore make up a heterogeneous group of patients, which may explain why treatment effects in numerous studies looking at specific physiotherapy treatments in the chronic neck pain group are often discouraging. There is low level evidence that cervical interventions are effective on pain and range of motion at the immediate follow up, but no evidence on the effectiveness of the direction movement control intervention especially on the effectiveness of long term follow up. In addition, results from previous studies remain controversial because most of the studies on the effects of chronic neck painxercises for reducing neck pain are cross-sectional studies with no control group for comparison(Jeong & Hee, 2011). For this reason, exercise 2
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treatments for neck pain patients tend to be based on the subjective judgment of the therapist, rather than on scientific evidence (Sarig-Bahat, Weiss, Laufer, 2010). Different therapeutic exercises have been evidently proved beneficial for many groups of patients. The development of rehabilitation strategies directed at correcting the UCM, identified by evidence, is gaining recognition and acceptance because patients may present with a similar diagnosis of pathology but different kinematic mechanisms (Comerford & Mottram, 2012). Moreover, active movement therapy can effectively improve short- and medium-term pain and disabilities of patients with chronic nonspecific neck pain (Jull et al., 2008). However, the long-term (six months or longer) effectiveness of movement therapy remains unknown. Thus, this study was designed to investigate the long-term effects of direction-movement control training on pain, disability, head repositioning accuracy, function endurance, deep neck flexor endurance, and range of motion in females with chronic nonspecific neck pain.
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2. Methods 2.1. Participants: The subjects were recruited from hospital patients presented with neck pain during the period April 2016–May 2016. The first step included a reply to a questionnaire sent out to 100 female computer worker patients with neck pain, age 25–45 years. The following inclusion criteria had to be fulfilled: 1) Pain between three and eight using VAS. 2) Neck disability index (NDI) score over 25. 3) Neck pain at least within the last 3 months. 4) Female administrative staffs that had similar number of work hours and more than four hours of computer usage per day. The following exclusion criteria had to be fulfilled as well: 1) Acute neck pain, lasting less than three months. 2) A previous history of neck surgery, presence of other neurological or orthopedic disorders affecting the neck. 3) Receiving muscle relaxant treatment. Each Patient was independently examined by two physicians, to determine any neurological or orthopedic disorders. Two experienced physiotherapists assessed the subjects based on clinical history, mechanism of injury, and symptom responses to active movements. The physiotherapists also controlled the operation of whole protocol. For preliminary and baseline data, the assessors were blinded to group allocation. Only the data analyst was blinded to treatment allocation. The physiotherapists and two trainers oversaw the training. A total of 60 women fulfilled the inclusion criteria, 30 were excluded due to the above exclusion criteria or due to unavailability during the intervention. The participants were randomized at the cluster level to 1 of the 2 groups in a balanced design accounting for similar age, body mass index, and VAS on neck pain. Finally, a total of 30 subjects participated in the study. The participants were randomly assigned to the control (n = 15) and intervention groups (n = 15) (age 36.5 ± 5.7 years, height 160.6 ± 6.83 cm). Based on the formula below the sample size was calculated to be about 12 but to overcome the loss of some subjects during the training period, 15 subjects were considered in each group.
M1: mean of NDI for experimental group in post- test. M2: mean of NDI for control group in post-test. S1: standard deviation of NDI for experimental group in post-test. S2: standard deviation of NDI for control group in post-test.
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Uncontrolled criteria were sleep, nutrition, environmental, psychosocial, and physiological factors of the subjects. The experiment was conducted with the approval of the Institutional Review Board of Kharazmi University. All subjects were provided with written informed consent prior to study enrollment. The experimental group practiced direction-movement control training for six months, 30 minutes per day, three days per week for eight weeks and was also allocated two training and one home sessions per week for the remaining time. The control group was allocated only a total of 3 hour per week home exercise program described postural correction on daily activities explained in the digital video disk but met more irregularly for lectures giving information on activities promoting general health. All the subjects could take medications to reduce pain if needed. The experimental group did not report use of any pills. Outcomes were obtained three times in each group, and participants were supplied with self-report questionnaires, VAS and NDI, before intervention and 48 hours after the 8-week, and six-month intervention. The other assessments of subjects in both groups were performed before, 48 hours after the 8-week, and sixmonth intervention. The measurements performed included: 1) Cervical range of motion (ROM), 2) Head Repositioning Accuracy (HRA) test, 3) The deep neck flexor endurance test (Trott's test), and 4) progressive isoinertial lifting evaluation (PILE) test.
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2.2. Instrumentation 2.2.1. Range of motions All subjects sat on a chair with backrest so that their lumbosacral spine filled the gap between the seat and the backrest. Their feet were positioned flat on the floor, and their arms rested freely at their sides. As instructed by the tester, each subject performed three repetitions of neck active range of motion (ARM) in each direction within a designated cardinal plane to increase compliance of the neck's soft tissues (warm-ups). The tester then measured the subject's cervical active range of motion, in both directions within a cardinal plane, by goniometer, providing two sets of six measurements. Alignment of the goniometer to measure active range of motion was performed according to the instructions in the procedure for measuring cervical flexion and extension. The examiner positioned the center of the goniometer (A) at the center of the subject's external auditory meatus. The fixed arm (B) was vertical and the movable arm (C) was aligned parallel to the imaginary line between the external auditory meatus and the base of the nose. The patient was then asked to move down her chin. The recorder wrote down both start and end points of the cervical active range of motion. For the extension, following the procedure as said above, the subject was then asked to move her chin up. The recorder wrote down both start and end points of the cervical AROM. In the procedure for measuring cervical lateral flexion, the examiner positioned the goniometer center (A) over the center of the subject's sternal notch. The fixed arm (B) was aligned parallel to an imaginary line between the subject's acromion processes; the movable arm (C) was aligned with the center of the subject's nose. The recorder wrote down both start and end points of the cervical AROM. For the reverse side, same procedure was followed. The examiner positioned the axis (A) over the center of the subject's head. The fixed arm (B) of goniometer was aligned with an imaginary line between the subject's acromion processes; the movable arm (C) was aligned with the tip of the subject's nose. The recorder wrote down both start and end points of the cervical AROM. For the reverse side, same measurements were taken as well (Youdas et al., 1991). 2.2.2. Pain intensity
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The initial and post-program evaluations of pain were performed using the visual analog scale; each participant marked neck pain levels on an 11-point scale. After explaining the pain scale, the participants indicated their current pain level by choosing a number from 0 (no pain at all) to 10 (unbearable pain), which were displayed along a horizontal line. This scale is widely used in clinical settings as it best reflects the pain level and has been utilized as an important tool to assess the effectiveness of pain treatment (Wewers et al., 2001; DeokJu et al., 2015). SCORING: Using a ruler, the score is determined by measuring the distance (mm) on the 10-cm line between the “no pain” anchor and the patient's mark, providing a range of scores from 0–100 (Jensen, Karoly, Braver, 1986).
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2.2.3. Functional endurance Functional endurance was measured by PILE test. PILE test or lifting weights, is recommended as a functional test to measure muscle endurance (Mayer et al., 1988; Koning et al., 2008). Women began with an eight-pound load (five-pound iron bar plus container weight). Weight was increased at a rate equal to the initial free weight (8, 13, 18, 23, 28 pounds) every 20 seconds. Four lifting movements were performed at 20-second intervals. The PILE protocol involved the lifting of weights in a plastic box, in a cervical test lifting capacity from waist to shoulder height (30-54 inches). The test end-point also established when aerobic capacity or neuromuscular fatigue was felt (Mayer et al., 1988; Koning et al., 2008).
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2.2.4. Neck Disability Index (NDI) This questionnaire has been designed to give the researchers information about how the subject's neck pain has affected their everyday life. 1. The patients were instructed to put a mark next to each appropriate statement. 2. The total number of marked statements was added by the clinician. 3. Clinical improvement over time could be graded based on the analysis of serial questionnaire scores. For each section, the total score was 5: if the first statement was marked, the section score is 0, if the last statement was marked, it equals 5. If all ten sections were completed the score was calculated as follows: 16 (total score)/ 50 (total possible score) x 100 = 32%. If one section was missed or not applicable the score was calculated as 16 (total score)/ 45 (total possible score) x 100 = 35.5%. Minimum detectable change (90% confidence) is 5 points or 10% points. With this system, 28-10% of the score was a sign of mild physical disability, 45-30% a sign of average disability, 68-50 % a sign of severe disability and 72% score or more sign of disability (Vernon & Mior, 1992).
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2.2.5. Head Repositioning Accuracy (HRA) To measure HRA, a helmet attached with a laser pointer was used. In order to measure HRA, a 1 m × 1 m graph paper was attached on the wall that was 2 m away from the subject. The subject was asked to sit upright on a chair put in line with the central line of a graduated ruler. After wearing a helmet with a laser pointer attached on it, the subject was asked to move her head and aim the beam at the center of the graph paper. And then the subject was asked to carry out a preliminary training five times. After completing the preliminary training, the experimenter asked the subject to aim the beam at the center of graph paper after turning the subject’s head to the right. The experimenter measured the distance between spot where the beam was shot and the center of the graph paper. The test was performed three times, and the average value was used as the head repositioning accuracy. Less deviation implied that the head repositioning accuracy has improved. The experimenter asked the subject to stare forward naturally, and marked the point on the graph paper, which was in accordance with the laser beam. And the subject was instructed to stare forward naturally again after carrying out left-right 5
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2.2.6. Endurance of the cervical flexor muscle Isometric endurance of the deep flexors was measured by Trott's (1988) test. In this protocol, subjects lay supine on a plinth, retracted their chin and lifted their head a short distance from a pillow placed under the head. The proposed method of cervical short flexor muscle endurance was measured in three steps: (l) No pillow was used. (2) A distance of 2 cm from the back of the head to the plinth was arbitrarily chosen to standardize the lift from the plinth. The 2-cm lift was confirmed visually by the examiner, using a vertical ruler placed by the side of the plinth. Since head weight differs from subject to subject, the same amount of head lift on test and retest ensured the same load was placed on individual cervical short flexor muscles. (3) The time between assuming the test position until the chin began to thrust was measured in seconds with a stop watch. Chin thrust was determined in two ways: by light finger pressure over the point of the subject's chin, and by observation (Grimmer, 1994).
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2.2.7. Direction-movement control training: Establishment of the neutral region is a key requirement of the training process. The “anatomical or postural ideal” joint position or “loose pack” joint position is often arbitrarily chosen as the reference for “neutral" (Panjabi, 1992). Retraining in control of the site and direction of UCM is instructed as follows: 1- The site of UCM was positioned within its neutral training region and the patient was demonstrated how to recruit the appropriate muscles to control a specific direction of movement at this site, while concurrently moving an adjacent joint (above or below) in the same direction independent of the UCM. Control can be maintained at the site of the UCM, and joint or myofascial restrictions were permitted. 2-The retraining emphasis is focused on the joint and in the direction of movement that is isometrically controlled (not where the movement is actively performed). 3- A variety of feedback tools (tactile, visual, adhesive tape and skin tension or verbal cueing) can be employed to teach and facilitate the required retraining movement. These can involve visual, palpation, and kinaesthetic feedbacks (with adhesive tape and skin tension); visualization, verbal instruction and correction; 4- Slow, low effort repetitions are required to change motor control patterns; 5-The focus is on the quality of control; 6-The efficiency of control at the UCM is more important initially than the range of motion at the adjacent joint; 7- Each movement is practiced until it feels familiar and natural; 8-The aim of this retraining is to facilitate the active and eventually automatic recruitment of the local and global stability muscle systems to control movement and by restoring the appropriate use of stiff muscles. The directionmovement control training consists of many strategies, employed in the retraining of movement. Through the intervention, ratio between the maintenance of each exercise and the intervals between movements was 1:1, and ratio between the maintenance of each exercise and intervals between sets was 1:2. The overload principle was considered by adding weekly exercises and repetitions. The experimental group practiced the directionmovement control training three days a week for eight weeks. Slow repetitions for each move were performed for duration of 10 seconds up to two minutes. Some examples of moves are: 1- Nodding, while the lower and upper cervical spine, the scapula and TMJ are positioned in the neutral training region, the patient sits tall with their feet unsupported and the pelvis in neutral position. Then, the patient performs the occiput lift exercise, nodding, actively dissociates and controls low cervical flexion and moves the upper cervical spine into flexion. 2In the overhead arm lift exercise, the patient actively performs shoulder flexion to the overhead position while concurrently keeping low cervical spine and head in neutral position. The subject stands with the arms resting by the side in neutral rotation (palm in) and with the scapula, the low and upper cervical spine, and TMJ in a neutral position. The plane of the face should be vertical. The patient is instructed to keep the low cervical spine and the head in the neutral position and lift both arms over the head and lower them back to the side. 36
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Thoracic flexion dissociation assesses the ability to actively dissociate and control low cervical flexion and move the thoracic spine into flexion. Overhead arm lift dissociation retrains the ability to actively dissociate and control low cervical flexion and move the shoulders through overhead flexion. 4- Forward head lean dissociation retrains the ability to actively dissociate and control upper cervical flexion and moves the low cervical spine into flexion. The subject needs to learn the concept of movement retraining and the importance of cognitive input into the retraining process. This promoted a concept of “mindful” movement. Awareness and concentration were essential in these exercises. The focus was on retraining the coordination of movement patterns, not the range of movement or the strength of muscle activation. The Direction-movement control training used for this research is included the following exercises: 1) Thoracic flexion exercise (Figure 1, Exercise 1); 2) Horizontal retraction (Figure 1, Exercise 2); 3) Arm extension exercise(Figure 1, Exercise 3); 4) Lift exercise(Figure 1, Exercise 4); 5) Occiput lift exercise, nodding(Figure 1, Exercise 5); 6) Forward head lean exercise(Figure 1, Exercise 6); 7) Cervical extension control (Figure 1, Exercise 7); 8) Lower neck tilt(Figure 1, Exercise 8); 9) Upper neck tilt (Figure 1, Exercise 9); 10) Head turn(Figure 1, Exercise 10); 11) Reading text on a cellphone; 12) Writing at a desk; 13) Typing text on a cellphone.
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Figure 1. Exercises that were used in the Direction-movement control training: 1) Thoracic flexion exercise; 2) Horizontal retraction; 3) Arm extension exercise; 4) Lift exercise; 5) Occiput lift exercise, nodding; 6) Forward head lean exercise; 7) Cervical extension control; 8) Lower neck tilt; 9) Upper neck tilt; 10) Head turn The subjects in the experimental group underwent the Direction-movement control training. (Table 1)
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3. Statistical analysis All statistical analyses were performed using SPSS version 20 statistical software (SPSS Inc., Chicago, IL, USA). Results are presented as mean ± standard deviation (SD). Prior to the training, the normality of the data was assessed by Shapiro-Wilk test. Sample and paired t-tests were used to examine the significance of differences for variables. The paired t-test was used to assess pain, function, movement accuracy, range of motion, and endurance before and after the treatments. The independent t-test was performed to identify differences between groups. For all tests, statistical significance threshold was set at p < 0.05.
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4. Results A total of 30 subjects participated in this study, with 15 subjects in the experimental group and 15 in the control group. The general characteristics of the study subjects are summarized in Table 2. There were no significant differences in the baseline values between the experimental and control groups (Skelly 2011). Table 2. The subjects’ characteristics Please insert Table 2 here. Values are expressed as mean ± SD.
VAS, NDI and HRA scores decreased significantly in the experimental group (p< 0.05), with significant differences in the score changes of the two groups (p< 0.05) (Table 3). 7
ACCEPTED MANUSCRIPT The Endurance and Function scores increased significantly in the experimental group (p< 0.05), with a significant difference in the score changes of the two groups (p< 0.05) (Table 3). Table3. Visual analogue scale (VAS), Neck Disability Index (NDI), function, Head repositioning accuracy (HRA) , and endurance scores at pre- and post-training Please insert Table 3 here.
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Values are expressed as mean ± SD. *, A significant change between the pre- and post- Direction-movement control intervention; #, a significant difference between the experimental and control groups (p < 0.05).
The Cervical range of motion scores increased significantly in the experimental group (p< 0.05), with a significant difference in the score changes of the two groups (p< 0.05) (Table 4).
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Table 4. Cervical range of motion scores at pre- and post-training Please insert Table 4 here.
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Values are expressed as mean ± SD. *, A significant change between the pre- and post- Direction-movement control intervention; #, a significant difference between the experimental and control groups (p< 0.05).
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5. Discussion: This study was performed to determine the long-term effects of the direction-movement control training, an active therapeutic intervention; focusing on retraining the normal movement of the neck spine. This study showed that the six-month training had significant effects on pain and disability in the experimental group. However, the control group showed no marked difference in dependent variables compared with the experimental group, which may be explained by the fact that the patients did not have the supervision and guidance of the clinician (they only had an audio-visual and manual material). This observation highlights the importance of the presence of the physiotherapist and the trainer during treatment sessions. Yun et al. (2015) and DeokJu et al. (2015) reported that therapeutic training was effective to reduce pain and disability in people with chronic neck pain. Our results were consistent with these studies as well as with those of the previous studies, demonstrating that active treatment could help to reduce subjective symptoms in patients with chronic neck pain. Literature indicates how alteration in the cervical motion seen at segmental levels in neck leads to pain. People with neck pain have altered movement control strategies and these changes are associated with pain and disability (Roijezon, 2009). These altered strategies often will influence the control of movement that lead to compensation, dysfunction, and pain. Insufficient active control (UCM) shows dysfunction in dynamic stability and has potential to accumulate micro-traumas in different tissues. If this accumulation exceeds tissue tolerance it can contribute to dysfunction and pain (Comerford & Mottram, 2012). Along with the identification and the correction of impaired movement control, it is also possible to manage environmental changes (psychosocial and physiological factors although mentioned as uncontrolled factors), which influenced disability (Jull et al., 2008) by this treatment. Changes in pain were considered clinically significant when a statistically significant change of at least one was observed (Powell et al., 2001). The experimental group showed a decrease of 3.60 ±0.21 in pain and a decrease of 18.14 ±2.32 in disability six months after exercise, which is considered to be clinically significant. Due to the significant reduction of pain in the experimental group after the intervention, it could be inferred that the direction-movement control training could cause reduction in the mechanical stimulation and damages to sensitive structures. Such training may resolve the pain through retraining the normal and controlled movements of the neck segments, probably with coordination of the co-contraction of muscles, management of 8
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the symptoms, and changing in the sensorimotor recruitment strategies triggering pain. After reduction in pain level, the NDI reduction could be also expected. The six-month intervention also resulted in significant improvement of HRA. Perez et al. (2015) reported significant differences in HRA after the therapeutic exercise. Kang et al. (2015), however, could not identify any significant changes in HRA after the exercise, probably due to the short-term exercise program employed. In neck disorders, dysfunction of the receptors can change afferent data and consequently change integrity, timing and regulation of the sensorimotor control (Treleaven, 2008). The HRA is one of the factors frequently used to evaluate the sensory-motor control (Treleaven, 2008). The training is primarily directed towards changing recruitment patterns and active control of site and direction dysfunction in movements associated with muscle instability. The training process aims at the reprogramming of the movement control. During pain, the options to control movements available to the CNS become limited. However, research indicates that in the pain-free state, the brain and the central nervous system (CNS) can utilize a variety of movement control strategies to maintain joint stability. Considering the observed reduction in pain scale, improvement of HRA in the experimental group can be also expected (Hodges, 2003). Significant changes in HRA of the experimental group is possibly the result of control gain on the direction of motion and the abnormal movements, sensation of easy effort in low load exercise, and reestablishment of the uncontrolled movement and sensorimotor program after the intervention. Functionality was increased significantly after the intervention. Our results were consistent with Perez et al. (2015) and Yun et al. (2015) demonstrating that active treatment helps to improve function in patients with chronic neck pain. Grimby and Hannerz (1976) reported when proprioception is diminished, the sense of effort necessary for efficient activation of slow motor units is increased i.e. during low load activity, the subject feels, she must try harder (even if it feels like maximum effort) to achieve tonic recruitment of slow motor units (Comerford and Mottram, 2012). The pain related changes in the patterns or the thresholds of recruitment between one joint stabilizer and their multipoint mobiliser synergists can only be demonstrated during unloaded or low threshold function (Sahrmann 2002; Kang et al 2015). One-joint muscles that should be dominant in non-fatiguing function and postural control demonstrate downregulation of activation and are less active in experimental subjects compared to controls with no pain. When a low load exercise feels, or looks like hard work this usually indicates a motor control recruitment dysfunction (not weakness) and needs specific low threshold retraining. When maximum or high sensation of effort is needed to perform a low load activity or movement then it is most likely there is inefficient facilitation of slow motor unit recruitment and dysfunction of normal spindle responses (Comerford and Mottram, 2012). For the same reasons though, when less sensation of effort was needed to perform that same low load activity or movement (and it feels easier) in the functional PILE post-test in the experimental group, then it is likely there is better facilitation of slow motor unit recruitment in the pain free state. The results showed significant changes in the neck short flexor endurance after the intervention in the experimental group. This can be explained by the fact that some exercises were more focused on the deep neck flexors. This result is in accordance with Perez et al. (2015), suggesting that active treatment helps to improve function in patients with chronic neck pain. Damages to muscles or joints may bring about a dysfunction on muscle spindle. If there is damage to the proprioception, it will be difficult to make a proper response based on the collaboration of related muscles (Roijezon, 2009). The changes in the neck short flexor endurance, have positive effects on proprioception, and further resulted in activation of the neck deep flexor muscles which have a high volume of afferent spindles. One of the factors contributed to the change in deep cervical flexor activity after training is likely associated with the degree of pain reduction caused with the training in patients with chronic neck pain (Falla et al., 2012).
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Recruitment altered in the presence of pain, and the resultant muscle spasm and guarding also contribute to inhibition of SMU recruitment and the dysfunctional compensatory movement patterns (Comerford and Mottram, 2012). Through the training, efficiently controlled compensation does not appear to contribute to the development of altered SMU recruitment. The exercises are categorized by the site and direction of uncontrolled movements. In the low cervical flexion, one of the exercises, ability to actively dissociate and control low cervical flexion and move the upper cervical spine into flexion are retrained. Retraining actively to flex low cervical spine can likely be considered as a mechanism to activate the neck deep flexor afferents. Furthermore, this study showed that after the six-month direction-movement control training, range of motion of the neck in experimental group was significantly improved. The development and maintenance of cervical pain influence the management. If the UCM is range related, it may be associated with elongation or a change in recruitment sequencing of global muscles resulting in a lack of myofascial coordination or a lack of force. During UCM, direction specific hypermobility is re-enforced and if repetitively loaded, tissue pathology can develop (Comerford and Mottram, 2012). The direction-movement control training could reprogram restrictions and direction specific hypermobility which influence both uncontrolled translatory movement and uncontrolled range or physiological motion. These restrictions can be due to muscle spasm or guarding in response to the pain, tenderness/stiffness related to altered recruitment strategies between co-contraction muscles or tension response to the psychosocial and physiological factors (Dvorak et al., 1988). Direction-movement control training does not change the peripheral muscle structure to any great extent, but instead improves the central nervous recruitment system of muscles to fine-tune muscle coordination and improve the efficiency of movement. The direction-movement control training most likely brings about reduction in tension and restrictions of physiological motion related to the altered recruitments through decreasing pain and retraining the normal and ideal movements in the neck spine. The sample consists of only female subjects which is a limitation of our study. However, the fact that chronic neck pain incidence affects mostly women can partly justify this limitation. Also, the fact that the therapy was performed from two different therapists and trainers indicates the possibility that maybe one therapist or trainer outperformed the other one.
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6. Conclusion: The strengths of this study are how to reestablish the UCM, to identify the relationship between UCM and dysfunction, and to determine the long-term effects of the training in response to the neck pain. The study shows significant effects on pain, disability, and head repositioning accuracy, function endurance, cervical short flexors endurance, and range of motion in females with nonspecific chronic neck pain. The high reported effect size for direction- movement control exercises implicate that the application of such training as a supplementary method can improve chronic nonspecific neck pain in females. Further research in this area would be of great value. Acknowledgment: Gratitude is expressed to the study participants as well as to each of the assistants who were instrumental in the collection of the data. Funding sources and potential conflicts of interest: No funding sources or conflicts of interest were reported for this study. The researchers independently collected, analyzed, and interpreted the results and have no financial interests in the results of this study. Furthermore, dissemination of the results in this study does not constitute endorsement by the researchers or their institutional affiliations. 10
ACCEPTED MANUSCRIPT References: Cheng CH, Su TH, Yen WL, Liu YW, Cheng HK 2015 Review long-term effects of therapeutic exercise on nonspecific chronic neck pain: a literature review Journal of Physical Therapy Sciences 27(4): 1271–1276.
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Childs JD, Cleland JA, Elliott JM, Teyhen DS, Wainner RS, Whitman JM 2009 Neck Pain:Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health. Journal of Orthopetic Sports Physical Therapy 39(4): 297. Comerford K, & Mottram S 2012 Kinetic control: The management of uncontrolled movement. Churchill Livingstone of Elsevier. DeokJu kim, miLim Cho, Yunhee Park & Yeongae Yang 2015 Effect of an exercise program for posture correction on muscuskeletel pain. Journal of Physical Therapy Sciences 27: 1791–1794.
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Dvorak J, Froelich D, Penning L, Baumgartner H, Panjabi M 1988 Functional radiographic diagnosis of the cervical spine: flexion/extension. Spine 13 (7): 748–755.
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Falla D, O'Leary S, Farina D, Jull G 2012 The change in deep cervical flexor activity after training is associated with the degree of pain reduction in patients with chronic neck pain. The Clinical Journal of Pain 28(7): 628-34. Ferrari R, Russell AS 2003 Regional musculoskeletal conditions: neck pain. Best Practice & Research. Clinical Rheumatology: 17, 57–70.
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Grimmer K 1994 Measuring the endurance capacity of the cervical short flexor muscle group. Journal of Physiotherapy 40: 251-254 Hodges PW 2003 Core stability exercise in chronic low back pain. Orthopedic Clinics North America 34(2), 245– 254
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Jensen MP, Karoly P, Braver S 1986 The measurement of clinical pain intensity: a comparison of six methods. Pain 27, 117–26. Jeong JH, Hee KH 2011 Effect comb exercise program patients chronic neck pain. 19, 176–182.
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Jull, G, Sterling M, Falla D, Treleaven J, O’Leary S 2008 Whiplash, headache and neck pain. Elsevier, Edinburgh. Kim AH, Cho HN, Son MK, Lim HS 2013 Prevalence and Risk Factor of Neck Pain in Elderly Korean Community Residents. Journal of Korean Medicine Sciences 28(5): 680-686 Koning CHP, Heuvel SP, Bart StaalJ, Bouwien CM, Smits-Engelsman BCM, & Erik JM 2008 Clinimetric evaluation of methods to measure muscle functioning in patients with non-specific neck pain. A systematic review. BMC Musculoskeletal Disorders 9: 142 Kang WK, Kang WD, Kwon YG, Kim BH, Noh MK, Baek HG, Cha KJ & Kim KH 2015 The impact of head repositioning accuracy and proprioception on cervical stabilization exercise in healthy adults. Physical Therapy of Rehabilitation Sciences 4 (1): 49-54. 11
ACCEPTED MANUSCRIPT Lafond D, Champagne A, Cadieux R & Descarreaux M 2008 Case report rehabilitation program for traumatic chronic cervical pain associated with unsteadiness: a single case study. Chiropractic & Osteopathy 16:15. doi: 10.1186/1746-1340-16-15 Luomajoki H., Kool J., de Bruin E.D., Airaksinen O 2007 Reliability of movement control tests in the lumbar spine. BMC Musculoskeletal Disorders 8: 90.
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Mayer T, Barnes D, Kishino N, Gatchel R, Mayer H, & Mooney V 1988 Progressive isolation lifting evaluation. Spine B(9): 993-997
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Mottram S, Warner M, Chappell P, Morrissey D, & Stokes M 2009 Impaired control of scapular rotation during a clinical dissociation test in people with a history of shoulder pain. 3rd International Conference on Movement Dysfunction Edinburgh UK Manual Therapy 14 (1): S20 Mueller M.J., Maluf K.S. 2002 Tissue adaptation to physical stress: a proposed ‘physical stress theory’ to guide physical therapist practice, education, and research. Physical Therapy 82 (4): 383–403.
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Panjabi MM 1992 The stabilizing system of the spine. Part 1: Function, dysfunction adaption, and enhancement. Journal of Spinal Disorders 5: 383–389 Perez HA, Garcia FA, Villanueva LUI, Martínez GA, Alemany PA, Carnero FJ 2015 Effectiveness of a motor control therapeutic exercise program combined with motor imagery on the sensorimotor function of the cervical spine: a randomized controlled trial. International Journal of Sports Physical Therapy 10(6): 877
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Powell CV, Kelly AM, Williams A 2001 Determining the minimum clinically significant difference in visual analog pain score for children. Annals of Emergency Medicine 37:28–31 Roijezon U 2009 Sensorimotor function in chronic neck pain. Department of Community Medicine and Rehabilitation Physiotherapy, Umeå University, Sweden 901 87 Umea Printed in Sweden by Arkitektkopia Umea
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Sahrmann SA 2002 Diagnosis and treatment of movement impairment syndromes. Mosby, St Louis Sarig-Bahat H, Weiss PL, Laufer Y 2010 Neck pain assessment in a virtual environment. Spine 35: E105–E112.
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Skelly AC 2011 Science in spine Probability, proof, and clinical significance. Evidence-Based Spine-Care Journal 2/Issue 4: 9-11 Treleaven J 2008 Sensorimotor disturbances in neck disorders affecting postural stability, head and eye movement control. Neck Pain and Whiplash Research Unit Manual Therapy 13(1):2-11 Vernon H & Mior S 1992 The Neck Disability Index: A study of reliability and validity. Journal of Manipulative Physiological Therapy 15 (1) Wewers ME, & Lowe NK 2001 A critical review of visual analogue scales in the measurement of clinical phenomena. Research in Nursing and Health Journal of Clinical Nursing 13: 227-236.
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ACCEPTED MANUSCRIPT Youdas JW, Carey JR, & Garrett TR 1991 Reliability of Measurements of Cervical Spine Range Motion-comparison of Three Methods. Physical Therapy 71 (2)
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Yun S, Kim YL & Lee SM.2015 The effect of neurac training in patients with chronic neck pain. Journal of Physical therapy Sciences 27: 1303–1307
Exercise 2
Exercise 6
Exercise 7
Exercise 3
Exercise 4
Exercise 5
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Exercise 1
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FIGURES 1-10:
Exercise 9
Exercise 10
Table 1:
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Exercise 8
Table 1. direction- movement control training Exercises
Instructions
Thoracic flexion exercise
Exercise for low cervical flexion UCM(Standing)
Horizontal retraction
Exercise for upper cervical extension UCM(1:Standing, 2: Prone)
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Exercises for upper cervical flexion UCM(1:Standing , 2: Sitting on a chair, 3: Prone)
Lift exercise
Exercises for low cervical flexion UCM (1: Standing,2: Arms on wall, 3: head unsupported, 4: prone position, 5: Leaning backward with chair support) Exercise for low cervical flexion UCM(1: Standing with wall support, 2: Supine, 3:
Occiput lift exercise, nodding
Forward head lean exercise
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Standing in front of a wall and head without any support, 4: Side lying) Exercises for upper cervical flexion UCM(1:Standing position with wall support, 2: Sitting on a chair leaning forward on a table, 3: Four point kneeling position, 4: Leaning backward with chair support)
Exercises for upper cervical extension UCM(1: Standing position with wall support, 2:
Cervical extension control
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Hands on wall, head unsupported, 3: Leaning forward with table support, 4: Leaning backward with chair support) Exercises for upper cervical bending UCM(1: Standing with wall support and shoulder girdle unloaded, 2: Sitting unsupported with active shoulder control, 3: Leaning backward with chair support, 4: Four point kneeling position)
Upper neck tilt
Exercises for lower cervical bending UCM(1: Standing with wall support and shoulder girdle unloaded, 2: Arms on wall, head unsupported, 3: Four 4: point kneeling position)
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Lower neck tilt
rotation UCM (1: Standing with wall support and shoulder girdle unloaded. 2: Sitting. 3:
Head turn
Reading text on a cellphone Writing at a desk
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Table 2:
Sitting on a chair with hands on armchairs, Standing with wall support
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Typing text on a cellphone
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Four point kneeling)
Age (years) Height (cm) Weight (kg) BMI (kg/m2)
Experimental group
Control group
36.07±5.59
37.60±5.58
160.07±8.156
161.13±6.52
63.20±13.57 22.32 (2.87)
67.87±10.78 22.62 (1.68)
Table 3:
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Head Repositioning Accuracy scores (HRA) Endurance scores (s)
Control group
Effect size
Power
5.27±1.98
4.47±2.031
0.256
0.836
2.87±1.68
5.20±1.68 # -1.27±1.5 0.711
0.894
0.353
0.959
0.208
0.727
0.353
0.959
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3.60±0.21 37.33±11.53 19.47±12.22
38.53±12.05 # 0.26±2.7
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18.14±2.32 1.27±0.704
1.13±0.834
2.27±0.70
1.27±0.704 0.14±1.72#
*
1±0.89 5.85±8.87
8.27±5.86
3.20±2.65
8.87±5.11 -0.60±1.95#
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2.65±6.65 38.87±24.55
31.53±22.18 31.40±20.76 # 0.13±4.13
80.60±24.71 -50.27±2.49
Table 4:
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Experimental group
Control group
Effect size
Power
27.33±8.83
28.20±9.98
0.501
0.999
0.826
0.925
19.67±3.99 22.80±9.13 # 3.27±4.42
0.683
0.912
23.33±5.23
0.461
0.991
0.825
0.947
0.485
0.990
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Pre-training Post-training Difference Extension Pre-training Post-training Cervical range Difference of motion Lateral Pre-training scores (CROM) flexion Post-training (left) Difference Lateral Pre-training flexion Post-training (right) Difference Rotation Pre-training (left) Post-training Difference Rotation Pre-training (right) Post-training Difference
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Flexion
38.27±11.10
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Function scores (PILE)
Experimental group Pre-training Post-training Difference Pre-training Post-training Difference Pre-training Post-training Difference Pre-training Post-training Difference Pre-training Post-training Difference
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Visual analogue scale scores (VAS) (mm) Neck disability index scores (NDI)
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66.73±25.75
39.40±22.43*
29.73±13.04 1.53±8.15#
37.67±9.79
35.6±9.207
61.00±16.29
36.47±8.22 1.13±3.4#
24.67±6.12* 20.00±4.62 57.07±14.55 *
37.07±8.92 24.00±5.73
45.20±14.26 *
21.20±7.96 24.67±11.09 63.40±9.10 *
39.27±4.46 27.33±9.42
55.53±18.841 28.20±7.32
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*
25.33±6.44 # 2.00±2.79 25.33±7.89 23.33±6.44 # 2±1.2 25.67±9.61 27.33±9.84 # 2.34±1.59
S1360-8592(17)30128-6
DOI:
10.1016/j.jbmt.2017.06.004
Reference:
YJBMT 1551
To appear in:
Journal of Bodywork & Movement Therapies
Please cite this article as: Khosrokiani, Z., Letafatkar, A., Sokhangoie, Y., Long-term effect of directionmovement control training on female patients with chronic neck pain, Journal of Bodywork & Movement Therapies (2017), doi: 10.1016/j.jbmt.2017.06.004. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Long-term effect of direction- movement control training on female patients with chronic neck pain Zohreh Khosrokiani 1, Amir Letafatkar2, Yahya Sokhangoie3 Department of Biomechanics and Sports Injuries, Faculty of Physical Education and Sport Science, Kharazmi University, Tehran, Iran.
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Abstract Background: Treatment of movement faults in the neck is known as an important factor in treatment of chronic neck pain. Along with the identification of site and direction of the faults, direction-movement control intervention retrains the control of the movement faults. Purpose: This study was designed to investigate long-term effects of a direction- movement control training on pain, disability, head repositioning accuracy, function, cervical flexor endurance, and range of motion in female patients with chronic nonspecific neck pain. Material and Methods: Thirty women (36.5 ± 5.7 years) with chronic nonspecific neck pain were randomly allocated into two groups, i.e., an experimental group (n = 15) and a control group (n = 15). The experimental group performed the direction- movement control training for 30 min/day, three days per week for six months. All subjects were evaluated using the visual analog scale (VAS), range of motion (TOM), progressive iso-inertial lifting evaluation (PILE), neck disability Index (NDI), helmet attached with laser pointer using for head repositioning accuracy (HRA), and Trott's test (deep neck flexor endurance), in pre- and six-months posttreatment intervention. Results: Significant differences were observed for the pain, neck disability Index, function endurance, head repositioning accuracy, range of motion, and cervical flexor endurance in the experimental group compared to that of control group. Conclusion: Direction- movement control training is likely to be an effective training program to enhance body functionality through improvement of pain, function, endurance, head repositioning accuracy, range of motion, and cervical flexor endurance. Due to the high reported effect size for direction- movement control exercises, the application of the training is suggested as a supplementary method to improve chronic nonspecific neck pain in females. Keywords: Chronic neck pain, head repositioning accuracy, function.
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Highlights • The effects of direction-movement control exercises in the treatment of neck pain were examined. • It is observed that the exercises that are categorized with site and direction of uncontrolled movements will improve functionality in patients with neck pain. • High effect size of the direction-movement control training was reported in chronic nonspecific neck pain.
1*. Ms. (Corresponding author), Department of Biomechanics and Sport Injuries, Faculty of Physical Education and Sport Sciences, Kharazmi University, Mirdamad, Shahid Mofateh, Tehran, Iran. Email: [email protected]. 2 . Assistant professor, Department of Biomechanics and Sport Injuries, Faculty of Physical Education and Sport Sciences, Kharazmi University. 3. Assistant professor, physical therapist, Shahid beheshti University of Tehran, Tehran- Iran. 1
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1. Introduction Neck pain is one of the most common pain disorders, leading to considerable stress on healthcare systems. It is estimated that 67% of the population will experience neck pain at some point in their life (Yun et al., 2015). Neck pain is now second to back pain, the most common musculoskeletal disorder (Ferrari and Russell, 2003). More than 50% of adults have experienced neck pain within the past 6 months; the one-year incidence of neck pain was between 10.4% and 21.3%, and the one-year prevalence ranged from 4.8% to 79.5% (mean, 25.8%) (Cheng et al., 2015). Women are more likely to experience persistent neck pain than men (DeokJu et al., 2015). The prevalence in women, 27.2%, is higher than in men, 17.4% (Cheng et al., 2015). Nonspecific neck pain induced by nonspecific musculoskeletal disorders may occur repeatedly, resulting in a vicious cycle of chronic pain (pain persisting for more than three months) (Lafond et al., 2008; Childs et al., 2009; Kim et al., 2013; Cheng et al., 2015).
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Neck muscles are required to generate, sustain, and maintain precision of neck activities. Changes in neck muscles have potentially disastrous consequences for the neck because the neck relies on muscles for mechanical stability (Roijezon, 2009).
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Identifying and classifying movement faults is fast becoming the key of recent neuromusculoskeletal rehabilitation (Sahrmann 2002). In recent years clinicians and researchers have described movement faults and used many terms to describe these abnormal patterns. Some terms include substitution strategies (Jull et al 2008), muscle imbalance ( Sahrmann 2002), faulty movement (Sahrmann 2002), abnormal dominance of the mobiliser synergists ( Jull et al 2008), and movement impairments (Sahrmann 2002). All of these terms describe aspects of movement dysfunction, many of which are linked to UCM. Uncontrolled movement (UCM), contributing to neck pain symptoms, can cause compression or impingement on one side of joints while developing tensile strain on the other side. If UCM is not managed, and the related tissue stress and strain are sustained or repeated beyond the limits of tissue tolerance, multiple tissue pathology may develop eventually and a combination of symptoms may occur (Comerford & Mottram, 2012). The management of neck pain, a significant factor in musculoskeletal disorders, is still poorly described, utilized and researched (Jull et al., 2008). A common feature of movement control faults is reduced control of active movements, or movement control dysfunction (Luomajoki et al, 2007). The distinctive features of the exercise start with the positioning of the spine or segment in its ‘neutral position’ by the therapist, which is then actively controlled by the patient while they move the joint region either above or below the joint system. The direction- movement control training is based on identifying, firstly, a consistent pattern of movement which is associated with the patient’s symptoms and, secondly, a decrease in pain when the uncontrolled movement is corrected. The suggestion is that uncontrolled movement links to the pattern of movement during everyday activities and relates to neck pain. The hypothesis here is that early movement during everyday activities suggests an increase in frequency of movement of a specific region which may contribute to increased stress on tissue resulting in pain (Mueller & Maluf 2002). Patients with neck pain present diverse clinical findings, courses of disease and prognoses. They therefore make up a heterogeneous group of patients, which may explain why treatment effects in numerous studies looking at specific physiotherapy treatments in the chronic neck pain group are often discouraging. There is low level evidence that cervical interventions are effective on pain and range of motion at the immediate follow up, but no evidence on the effectiveness of the direction movement control intervention especially on the effectiveness of long term follow up. In addition, results from previous studies remain controversial because most of the studies on the effects of chronic neck painxercises for reducing neck pain are cross-sectional studies with no control group for comparison(Jeong & Hee, 2011). For this reason, exercise 2
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treatments for neck pain patients tend to be based on the subjective judgment of the therapist, rather than on scientific evidence (Sarig-Bahat, Weiss, Laufer, 2010). Different therapeutic exercises have been evidently proved beneficial for many groups of patients. The development of rehabilitation strategies directed at correcting the UCM, identified by evidence, is gaining recognition and acceptance because patients may present with a similar diagnosis of pathology but different kinematic mechanisms (Comerford & Mottram, 2012). Moreover, active movement therapy can effectively improve short- and medium-term pain and disabilities of patients with chronic nonspecific neck pain (Jull et al., 2008). However, the long-term (six months or longer) effectiveness of movement therapy remains unknown. Thus, this study was designed to investigate the long-term effects of direction-movement control training on pain, disability, head repositioning accuracy, function endurance, deep neck flexor endurance, and range of motion in females with chronic nonspecific neck pain.
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2. Methods 2.1. Participants: The subjects were recruited from hospital patients presented with neck pain during the period April 2016–May 2016. The first step included a reply to a questionnaire sent out to 100 female computer worker patients with neck pain, age 25–45 years. The following inclusion criteria had to be fulfilled: 1) Pain between three and eight using VAS. 2) Neck disability index (NDI) score over 25. 3) Neck pain at least within the last 3 months. 4) Female administrative staffs that had similar number of work hours and more than four hours of computer usage per day. The following exclusion criteria had to be fulfilled as well: 1) Acute neck pain, lasting less than three months. 2) A previous history of neck surgery, presence of other neurological or orthopedic disorders affecting the neck. 3) Receiving muscle relaxant treatment. Each Patient was independently examined by two physicians, to determine any neurological or orthopedic disorders. Two experienced physiotherapists assessed the subjects based on clinical history, mechanism of injury, and symptom responses to active movements. The physiotherapists also controlled the operation of whole protocol. For preliminary and baseline data, the assessors were blinded to group allocation. Only the data analyst was blinded to treatment allocation. The physiotherapists and two trainers oversaw the training. A total of 60 women fulfilled the inclusion criteria, 30 were excluded due to the above exclusion criteria or due to unavailability during the intervention. The participants were randomized at the cluster level to 1 of the 2 groups in a balanced design accounting for similar age, body mass index, and VAS on neck pain. Finally, a total of 30 subjects participated in the study. The participants were randomly assigned to the control (n = 15) and intervention groups (n = 15) (age 36.5 ± 5.7 years, height 160.6 ± 6.83 cm). Based on the formula below the sample size was calculated to be about 12 but to overcome the loss of some subjects during the training period, 15 subjects were considered in each group.
M1: mean of NDI for experimental group in post- test. M2: mean of NDI for control group in post-test. S1: standard deviation of NDI for experimental group in post-test. S2: standard deviation of NDI for control group in post-test.
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Uncontrolled criteria were sleep, nutrition, environmental, psychosocial, and physiological factors of the subjects. The experiment was conducted with the approval of the Institutional Review Board of Kharazmi University. All subjects were provided with written informed consent prior to study enrollment. The experimental group practiced direction-movement control training for six months, 30 minutes per day, three days per week for eight weeks and was also allocated two training and one home sessions per week for the remaining time. The control group was allocated only a total of 3 hour per week home exercise program described postural correction on daily activities explained in the digital video disk but met more irregularly for lectures giving information on activities promoting general health. All the subjects could take medications to reduce pain if needed. The experimental group did not report use of any pills. Outcomes were obtained three times in each group, and participants were supplied with self-report questionnaires, VAS and NDI, before intervention and 48 hours after the 8-week, and six-month intervention. The other assessments of subjects in both groups were performed before, 48 hours after the 8-week, and sixmonth intervention. The measurements performed included: 1) Cervical range of motion (ROM), 2) Head Repositioning Accuracy (HRA) test, 3) The deep neck flexor endurance test (Trott's test), and 4) progressive isoinertial lifting evaluation (PILE) test.
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2.2. Instrumentation 2.2.1. Range of motions All subjects sat on a chair with backrest so that their lumbosacral spine filled the gap between the seat and the backrest. Their feet were positioned flat on the floor, and their arms rested freely at their sides. As instructed by the tester, each subject performed three repetitions of neck active range of motion (ARM) in each direction within a designated cardinal plane to increase compliance of the neck's soft tissues (warm-ups). The tester then measured the subject's cervical active range of motion, in both directions within a cardinal plane, by goniometer, providing two sets of six measurements. Alignment of the goniometer to measure active range of motion was performed according to the instructions in the procedure for measuring cervical flexion and extension. The examiner positioned the center of the goniometer (A) at the center of the subject's external auditory meatus. The fixed arm (B) was vertical and the movable arm (C) was aligned parallel to the imaginary line between the external auditory meatus and the base of the nose. The patient was then asked to move down her chin. The recorder wrote down both start and end points of the cervical active range of motion. For the extension, following the procedure as said above, the subject was then asked to move her chin up. The recorder wrote down both start and end points of the cervical AROM. In the procedure for measuring cervical lateral flexion, the examiner positioned the goniometer center (A) over the center of the subject's sternal notch. The fixed arm (B) was aligned parallel to an imaginary line between the subject's acromion processes; the movable arm (C) was aligned with the center of the subject's nose. The recorder wrote down both start and end points of the cervical AROM. For the reverse side, same procedure was followed. The examiner positioned the axis (A) over the center of the subject's head. The fixed arm (B) of goniometer was aligned with an imaginary line between the subject's acromion processes; the movable arm (C) was aligned with the tip of the subject's nose. The recorder wrote down both start and end points of the cervical AROM. For the reverse side, same measurements were taken as well (Youdas et al., 1991). 2.2.2. Pain intensity
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The initial and post-program evaluations of pain were performed using the visual analog scale; each participant marked neck pain levels on an 11-point scale. After explaining the pain scale, the participants indicated their current pain level by choosing a number from 0 (no pain at all) to 10 (unbearable pain), which were displayed along a horizontal line. This scale is widely used in clinical settings as it best reflects the pain level and has been utilized as an important tool to assess the effectiveness of pain treatment (Wewers et al., 2001; DeokJu et al., 2015). SCORING: Using a ruler, the score is determined by measuring the distance (mm) on the 10-cm line between the “no pain” anchor and the patient's mark, providing a range of scores from 0–100 (Jensen, Karoly, Braver, 1986).
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2.2.3. Functional endurance Functional endurance was measured by PILE test. PILE test or lifting weights, is recommended as a functional test to measure muscle endurance (Mayer et al., 1988; Koning et al., 2008). Women began with an eight-pound load (five-pound iron bar plus container weight). Weight was increased at a rate equal to the initial free weight (8, 13, 18, 23, 28 pounds) every 20 seconds. Four lifting movements were performed at 20-second intervals. The PILE protocol involved the lifting of weights in a plastic box, in a cervical test lifting capacity from waist to shoulder height (30-54 inches). The test end-point also established when aerobic capacity or neuromuscular fatigue was felt (Mayer et al., 1988; Koning et al., 2008).
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2.2.4. Neck Disability Index (NDI) This questionnaire has been designed to give the researchers information about how the subject's neck pain has affected their everyday life. 1. The patients were instructed to put a mark next to each appropriate statement. 2. The total number of marked statements was added by the clinician. 3. Clinical improvement over time could be graded based on the analysis of serial questionnaire scores. For each section, the total score was 5: if the first statement was marked, the section score is 0, if the last statement was marked, it equals 5. If all ten sections were completed the score was calculated as follows: 16 (total score)/ 50 (total possible score) x 100 = 32%. If one section was missed or not applicable the score was calculated as 16 (total score)/ 45 (total possible score) x 100 = 35.5%. Minimum detectable change (90% confidence) is 5 points or 10% points. With this system, 28-10% of the score was a sign of mild physical disability, 45-30% a sign of average disability, 68-50 % a sign of severe disability and 72% score or more sign of disability (Vernon & Mior, 1992).
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2.2.5. Head Repositioning Accuracy (HRA) To measure HRA, a helmet attached with a laser pointer was used. In order to measure HRA, a 1 m × 1 m graph paper was attached on the wall that was 2 m away from the subject. The subject was asked to sit upright on a chair put in line with the central line of a graduated ruler. After wearing a helmet with a laser pointer attached on it, the subject was asked to move her head and aim the beam at the center of the graph paper. And then the subject was asked to carry out a preliminary training five times. After completing the preliminary training, the experimenter asked the subject to aim the beam at the center of graph paper after turning the subject’s head to the right. The experimenter measured the distance between spot where the beam was shot and the center of the graph paper. The test was performed three times, and the average value was used as the head repositioning accuracy. Less deviation implied that the head repositioning accuracy has improved. The experimenter asked the subject to stare forward naturally, and marked the point on the graph paper, which was in accordance with the laser beam. And the subject was instructed to stare forward naturally again after carrying out left-right 5
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2.2.6. Endurance of the cervical flexor muscle Isometric endurance of the deep flexors was measured by Trott's (1988) test. In this protocol, subjects lay supine on a plinth, retracted their chin and lifted their head a short distance from a pillow placed under the head. The proposed method of cervical short flexor muscle endurance was measured in three steps: (l) No pillow was used. (2) A distance of 2 cm from the back of the head to the plinth was arbitrarily chosen to standardize the lift from the plinth. The 2-cm lift was confirmed visually by the examiner, using a vertical ruler placed by the side of the plinth. Since head weight differs from subject to subject, the same amount of head lift on test and retest ensured the same load was placed on individual cervical short flexor muscles. (3) The time between assuming the test position until the chin began to thrust was measured in seconds with a stop watch. Chin thrust was determined in two ways: by light finger pressure over the point of the subject's chin, and by observation (Grimmer, 1994).
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2.2.7. Direction-movement control training: Establishment of the neutral region is a key requirement of the training process. The “anatomical or postural ideal” joint position or “loose pack” joint position is often arbitrarily chosen as the reference for “neutral" (Panjabi, 1992). Retraining in control of the site and direction of UCM is instructed as follows: 1- The site of UCM was positioned within its neutral training region and the patient was demonstrated how to recruit the appropriate muscles to control a specific direction of movement at this site, while concurrently moving an adjacent joint (above or below) in the same direction independent of the UCM. Control can be maintained at the site of the UCM, and joint or myofascial restrictions were permitted. 2-The retraining emphasis is focused on the joint and in the direction of movement that is isometrically controlled (not where the movement is actively performed). 3- A variety of feedback tools (tactile, visual, adhesive tape and skin tension or verbal cueing) can be employed to teach and facilitate the required retraining movement. These can involve visual, palpation, and kinaesthetic feedbacks (with adhesive tape and skin tension); visualization, verbal instruction and correction; 4- Slow, low effort repetitions are required to change motor control patterns; 5-The focus is on the quality of control; 6-The efficiency of control at the UCM is more important initially than the range of motion at the adjacent joint; 7- Each movement is practiced until it feels familiar and natural; 8-The aim of this retraining is to facilitate the active and eventually automatic recruitment of the local and global stability muscle systems to control movement and by restoring the appropriate use of stiff muscles. The directionmovement control training consists of many strategies, employed in the retraining of movement. Through the intervention, ratio between the maintenance of each exercise and the intervals between movements was 1:1, and ratio between the maintenance of each exercise and intervals between sets was 1:2. The overload principle was considered by adding weekly exercises and repetitions. The experimental group practiced the directionmovement control training three days a week for eight weeks. Slow repetitions for each move were performed for duration of 10 seconds up to two minutes. Some examples of moves are: 1- Nodding, while the lower and upper cervical spine, the scapula and TMJ are positioned in the neutral training region, the patient sits tall with their feet unsupported and the pelvis in neutral position. Then, the patient performs the occiput lift exercise, nodding, actively dissociates and controls low cervical flexion and moves the upper cervical spine into flexion. 2In the overhead arm lift exercise, the patient actively performs shoulder flexion to the overhead position while concurrently keeping low cervical spine and head in neutral position. The subject stands with the arms resting by the side in neutral rotation (palm in) and with the scapula, the low and upper cervical spine, and TMJ in a neutral position. The plane of the face should be vertical. The patient is instructed to keep the low cervical spine and the head in the neutral position and lift both arms over the head and lower them back to the side. 36
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Thoracic flexion dissociation assesses the ability to actively dissociate and control low cervical flexion and move the thoracic spine into flexion. Overhead arm lift dissociation retrains the ability to actively dissociate and control low cervical flexion and move the shoulders through overhead flexion. 4- Forward head lean dissociation retrains the ability to actively dissociate and control upper cervical flexion and moves the low cervical spine into flexion. The subject needs to learn the concept of movement retraining and the importance of cognitive input into the retraining process. This promoted a concept of “mindful” movement. Awareness and concentration were essential in these exercises. The focus was on retraining the coordination of movement patterns, not the range of movement or the strength of muscle activation. The Direction-movement control training used for this research is included the following exercises: 1) Thoracic flexion exercise (Figure 1, Exercise 1); 2) Horizontal retraction (Figure 1, Exercise 2); 3) Arm extension exercise(Figure 1, Exercise 3); 4) Lift exercise(Figure 1, Exercise 4); 5) Occiput lift exercise, nodding(Figure 1, Exercise 5); 6) Forward head lean exercise(Figure 1, Exercise 6); 7) Cervical extension control (Figure 1, Exercise 7); 8) Lower neck tilt(Figure 1, Exercise 8); 9) Upper neck tilt (Figure 1, Exercise 9); 10) Head turn(Figure 1, Exercise 10); 11) Reading text on a cellphone; 12) Writing at a desk; 13) Typing text on a cellphone.
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Figure 1. Exercises that were used in the Direction-movement control training: 1) Thoracic flexion exercise; 2) Horizontal retraction; 3) Arm extension exercise; 4) Lift exercise; 5) Occiput lift exercise, nodding; 6) Forward head lean exercise; 7) Cervical extension control; 8) Lower neck tilt; 9) Upper neck tilt; 10) Head turn The subjects in the experimental group underwent the Direction-movement control training. (Table 1)
Please insert Table 1 here.
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3. Statistical analysis All statistical analyses were performed using SPSS version 20 statistical software (SPSS Inc., Chicago, IL, USA). Results are presented as mean ± standard deviation (SD). Prior to the training, the normality of the data was assessed by Shapiro-Wilk test. Sample and paired t-tests were used to examine the significance of differences for variables. The paired t-test was used to assess pain, function, movement accuracy, range of motion, and endurance before and after the treatments. The independent t-test was performed to identify differences between groups. For all tests, statistical significance threshold was set at p < 0.05.
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4. Results A total of 30 subjects participated in this study, with 15 subjects in the experimental group and 15 in the control group. The general characteristics of the study subjects are summarized in Table 2. There were no significant differences in the baseline values between the experimental and control groups (Skelly 2011). Table 2. The subjects’ characteristics Please insert Table 2 here. Values are expressed as mean ± SD.
VAS, NDI and HRA scores decreased significantly in the experimental group (p< 0.05), with significant differences in the score changes of the two groups (p< 0.05) (Table 3). 7
ACCEPTED MANUSCRIPT The Endurance and Function scores increased significantly in the experimental group (p< 0.05), with a significant difference in the score changes of the two groups (p< 0.05) (Table 3). Table3. Visual analogue scale (VAS), Neck Disability Index (NDI), function, Head repositioning accuracy (HRA) , and endurance scores at pre- and post-training Please insert Table 3 here.
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Values are expressed as mean ± SD. *, A significant change between the pre- and post- Direction-movement control intervention; #, a significant difference between the experimental and control groups (p < 0.05).
The Cervical range of motion scores increased significantly in the experimental group (p< 0.05), with a significant difference in the score changes of the two groups (p< 0.05) (Table 4).
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Table 4. Cervical range of motion scores at pre- and post-training Please insert Table 4 here.
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Values are expressed as mean ± SD. *, A significant change between the pre- and post- Direction-movement control intervention; #, a significant difference between the experimental and control groups (p< 0.05).
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5. Discussion: This study was performed to determine the long-term effects of the direction-movement control training, an active therapeutic intervention; focusing on retraining the normal movement of the neck spine. This study showed that the six-month training had significant effects on pain and disability in the experimental group. However, the control group showed no marked difference in dependent variables compared with the experimental group, which may be explained by the fact that the patients did not have the supervision and guidance of the clinician (they only had an audio-visual and manual material). This observation highlights the importance of the presence of the physiotherapist and the trainer during treatment sessions. Yun et al. (2015) and DeokJu et al. (2015) reported that therapeutic training was effective to reduce pain and disability in people with chronic neck pain. Our results were consistent with these studies as well as with those of the previous studies, demonstrating that active treatment could help to reduce subjective symptoms in patients with chronic neck pain. Literature indicates how alteration in the cervical motion seen at segmental levels in neck leads to pain. People with neck pain have altered movement control strategies and these changes are associated with pain and disability (Roijezon, 2009). These altered strategies often will influence the control of movement that lead to compensation, dysfunction, and pain. Insufficient active control (UCM) shows dysfunction in dynamic stability and has potential to accumulate micro-traumas in different tissues. If this accumulation exceeds tissue tolerance it can contribute to dysfunction and pain (Comerford & Mottram, 2012). Along with the identification and the correction of impaired movement control, it is also possible to manage environmental changes (psychosocial and physiological factors although mentioned as uncontrolled factors), which influenced disability (Jull et al., 2008) by this treatment. Changes in pain were considered clinically significant when a statistically significant change of at least one was observed (Powell et al., 2001). The experimental group showed a decrease of 3.60 ±0.21 in pain and a decrease of 18.14 ±2.32 in disability six months after exercise, which is considered to be clinically significant. Due to the significant reduction of pain in the experimental group after the intervention, it could be inferred that the direction-movement control training could cause reduction in the mechanical stimulation and damages to sensitive structures. Such training may resolve the pain through retraining the normal and controlled movements of the neck segments, probably with coordination of the co-contraction of muscles, management of 8
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the symptoms, and changing in the sensorimotor recruitment strategies triggering pain. After reduction in pain level, the NDI reduction could be also expected. The six-month intervention also resulted in significant improvement of HRA. Perez et al. (2015) reported significant differences in HRA after the therapeutic exercise. Kang et al. (2015), however, could not identify any significant changes in HRA after the exercise, probably due to the short-term exercise program employed. In neck disorders, dysfunction of the receptors can change afferent data and consequently change integrity, timing and regulation of the sensorimotor control (Treleaven, 2008). The HRA is one of the factors frequently used to evaluate the sensory-motor control (Treleaven, 2008). The training is primarily directed towards changing recruitment patterns and active control of site and direction dysfunction in movements associated with muscle instability. The training process aims at the reprogramming of the movement control. During pain, the options to control movements available to the CNS become limited. However, research indicates that in the pain-free state, the brain and the central nervous system (CNS) can utilize a variety of movement control strategies to maintain joint stability. Considering the observed reduction in pain scale, improvement of HRA in the experimental group can be also expected (Hodges, 2003). Significant changes in HRA of the experimental group is possibly the result of control gain on the direction of motion and the abnormal movements, sensation of easy effort in low load exercise, and reestablishment of the uncontrolled movement and sensorimotor program after the intervention. Functionality was increased significantly after the intervention. Our results were consistent with Perez et al. (2015) and Yun et al. (2015) demonstrating that active treatment helps to improve function in patients with chronic neck pain. Grimby and Hannerz (1976) reported when proprioception is diminished, the sense of effort necessary for efficient activation of slow motor units is increased i.e. during low load activity, the subject feels, she must try harder (even if it feels like maximum effort) to achieve tonic recruitment of slow motor units (Comerford and Mottram, 2012). The pain related changes in the patterns or the thresholds of recruitment between one joint stabilizer and their multipoint mobiliser synergists can only be demonstrated during unloaded or low threshold function (Sahrmann 2002; Kang et al 2015). One-joint muscles that should be dominant in non-fatiguing function and postural control demonstrate downregulation of activation and are less active in experimental subjects compared to controls with no pain. When a low load exercise feels, or looks like hard work this usually indicates a motor control recruitment dysfunction (not weakness) and needs specific low threshold retraining. When maximum or high sensation of effort is needed to perform a low load activity or movement then it is most likely there is inefficient facilitation of slow motor unit recruitment and dysfunction of normal spindle responses (Comerford and Mottram, 2012). For the same reasons though, when less sensation of effort was needed to perform that same low load activity or movement (and it feels easier) in the functional PILE post-test in the experimental group, then it is likely there is better facilitation of slow motor unit recruitment in the pain free state. The results showed significant changes in the neck short flexor endurance after the intervention in the experimental group. This can be explained by the fact that some exercises were more focused on the deep neck flexors. This result is in accordance with Perez et al. (2015), suggesting that active treatment helps to improve function in patients with chronic neck pain. Damages to muscles or joints may bring about a dysfunction on muscle spindle. If there is damage to the proprioception, it will be difficult to make a proper response based on the collaboration of related muscles (Roijezon, 2009). The changes in the neck short flexor endurance, have positive effects on proprioception, and further resulted in activation of the neck deep flexor muscles which have a high volume of afferent spindles. One of the factors contributed to the change in deep cervical flexor activity after training is likely associated with the degree of pain reduction caused with the training in patients with chronic neck pain (Falla et al., 2012).
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Recruitment altered in the presence of pain, and the resultant muscle spasm and guarding also contribute to inhibition of SMU recruitment and the dysfunctional compensatory movement patterns (Comerford and Mottram, 2012). Through the training, efficiently controlled compensation does not appear to contribute to the development of altered SMU recruitment. The exercises are categorized by the site and direction of uncontrolled movements. In the low cervical flexion, one of the exercises, ability to actively dissociate and control low cervical flexion and move the upper cervical spine into flexion are retrained. Retraining actively to flex low cervical spine can likely be considered as a mechanism to activate the neck deep flexor afferents. Furthermore, this study showed that after the six-month direction-movement control training, range of motion of the neck in experimental group was significantly improved. The development and maintenance of cervical pain influence the management. If the UCM is range related, it may be associated with elongation or a change in recruitment sequencing of global muscles resulting in a lack of myofascial coordination or a lack of force. During UCM, direction specific hypermobility is re-enforced and if repetitively loaded, tissue pathology can develop (Comerford and Mottram, 2012). The direction-movement control training could reprogram restrictions and direction specific hypermobility which influence both uncontrolled translatory movement and uncontrolled range or physiological motion. These restrictions can be due to muscle spasm or guarding in response to the pain, tenderness/stiffness related to altered recruitment strategies between co-contraction muscles or tension response to the psychosocial and physiological factors (Dvorak et al., 1988). Direction-movement control training does not change the peripheral muscle structure to any great extent, but instead improves the central nervous recruitment system of muscles to fine-tune muscle coordination and improve the efficiency of movement. The direction-movement control training most likely brings about reduction in tension and restrictions of physiological motion related to the altered recruitments through decreasing pain and retraining the normal and ideal movements in the neck spine. The sample consists of only female subjects which is a limitation of our study. However, the fact that chronic neck pain incidence affects mostly women can partly justify this limitation. Also, the fact that the therapy was performed from two different therapists and trainers indicates the possibility that maybe one therapist or trainer outperformed the other one.
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6. Conclusion: The strengths of this study are how to reestablish the UCM, to identify the relationship between UCM and dysfunction, and to determine the long-term effects of the training in response to the neck pain. The study shows significant effects on pain, disability, and head repositioning accuracy, function endurance, cervical short flexors endurance, and range of motion in females with nonspecific chronic neck pain. The high reported effect size for direction- movement control exercises implicate that the application of such training as a supplementary method can improve chronic nonspecific neck pain in females. Further research in this area would be of great value. Acknowledgment: Gratitude is expressed to the study participants as well as to each of the assistants who were instrumental in the collection of the data. Funding sources and potential conflicts of interest: No funding sources or conflicts of interest were reported for this study. The researchers independently collected, analyzed, and interpreted the results and have no financial interests in the results of this study. Furthermore, dissemination of the results in this study does not constitute endorsement by the researchers or their institutional affiliations. 10
ACCEPTED MANUSCRIPT References: Cheng CH, Su TH, Yen WL, Liu YW, Cheng HK 2015 Review long-term effects of therapeutic exercise on nonspecific chronic neck pain: a literature review Journal of Physical Therapy Sciences 27(4): 1271–1276.
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Childs JD, Cleland JA, Elliott JM, Teyhen DS, Wainner RS, Whitman JM 2009 Neck Pain:Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health. Journal of Orthopetic Sports Physical Therapy 39(4): 297. Comerford K, & Mottram S 2012 Kinetic control: The management of uncontrolled movement. Churchill Livingstone of Elsevier. DeokJu kim, miLim Cho, Yunhee Park & Yeongae Yang 2015 Effect of an exercise program for posture correction on muscuskeletel pain. Journal of Physical Therapy Sciences 27: 1791–1794.
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Dvorak J, Froelich D, Penning L, Baumgartner H, Panjabi M 1988 Functional radiographic diagnosis of the cervical spine: flexion/extension. Spine 13 (7): 748–755.
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Falla D, O'Leary S, Farina D, Jull G 2012 The change in deep cervical flexor activity after training is associated with the degree of pain reduction in patients with chronic neck pain. The Clinical Journal of Pain 28(7): 628-34. Ferrari R, Russell AS 2003 Regional musculoskeletal conditions: neck pain. Best Practice & Research. Clinical Rheumatology: 17, 57–70.
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Grimmer K 1994 Measuring the endurance capacity of the cervical short flexor muscle group. Journal of Physiotherapy 40: 251-254 Hodges PW 2003 Core stability exercise in chronic low back pain. Orthopedic Clinics North America 34(2), 245– 254
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Jensen MP, Karoly P, Braver S 1986 The measurement of clinical pain intensity: a comparison of six methods. Pain 27, 117–26. Jeong JH, Hee KH 2011 Effect comb exercise program patients chronic neck pain. 19, 176–182.
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Jull, G, Sterling M, Falla D, Treleaven J, O’Leary S 2008 Whiplash, headache and neck pain. Elsevier, Edinburgh. Kim AH, Cho HN, Son MK, Lim HS 2013 Prevalence and Risk Factor of Neck Pain in Elderly Korean Community Residents. Journal of Korean Medicine Sciences 28(5): 680-686 Koning CHP, Heuvel SP, Bart StaalJ, Bouwien CM, Smits-Engelsman BCM, & Erik JM 2008 Clinimetric evaluation of methods to measure muscle functioning in patients with non-specific neck pain. A systematic review. BMC Musculoskeletal Disorders 9: 142 Kang WK, Kang WD, Kwon YG, Kim BH, Noh MK, Baek HG, Cha KJ & Kim KH 2015 The impact of head repositioning accuracy and proprioception on cervical stabilization exercise in healthy adults. Physical Therapy of Rehabilitation Sciences 4 (1): 49-54. 11
ACCEPTED MANUSCRIPT Lafond D, Champagne A, Cadieux R & Descarreaux M 2008 Case report rehabilitation program for traumatic chronic cervical pain associated with unsteadiness: a single case study. Chiropractic & Osteopathy 16:15. doi: 10.1186/1746-1340-16-15 Luomajoki H., Kool J., de Bruin E.D., Airaksinen O 2007 Reliability of movement control tests in the lumbar spine. BMC Musculoskeletal Disorders 8: 90.
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Mayer T, Barnes D, Kishino N, Gatchel R, Mayer H, & Mooney V 1988 Progressive isolation lifting evaluation. Spine B(9): 993-997
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Mottram S, Warner M, Chappell P, Morrissey D, & Stokes M 2009 Impaired control of scapular rotation during a clinical dissociation test in people with a history of shoulder pain. 3rd International Conference on Movement Dysfunction Edinburgh UK Manual Therapy 14 (1): S20 Mueller M.J., Maluf K.S. 2002 Tissue adaptation to physical stress: a proposed ‘physical stress theory’ to guide physical therapist practice, education, and research. Physical Therapy 82 (4): 383–403.
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Panjabi MM 1992 The stabilizing system of the spine. Part 1: Function, dysfunction adaption, and enhancement. Journal of Spinal Disorders 5: 383–389 Perez HA, Garcia FA, Villanueva LUI, Martínez GA, Alemany PA, Carnero FJ 2015 Effectiveness of a motor control therapeutic exercise program combined with motor imagery on the sensorimotor function of the cervical spine: a randomized controlled trial. International Journal of Sports Physical Therapy 10(6): 877
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Powell CV, Kelly AM, Williams A 2001 Determining the minimum clinically significant difference in visual analog pain score for children. Annals of Emergency Medicine 37:28–31 Roijezon U 2009 Sensorimotor function in chronic neck pain. Department of Community Medicine and Rehabilitation Physiotherapy, Umeå University, Sweden 901 87 Umea Printed in Sweden by Arkitektkopia Umea
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Sahrmann SA 2002 Diagnosis and treatment of movement impairment syndromes. Mosby, St Louis Sarig-Bahat H, Weiss PL, Laufer Y 2010 Neck pain assessment in a virtual environment. Spine 35: E105–E112.
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Skelly AC 2011 Science in spine Probability, proof, and clinical significance. Evidence-Based Spine-Care Journal 2/Issue 4: 9-11 Treleaven J 2008 Sensorimotor disturbances in neck disorders affecting postural stability, head and eye movement control. Neck Pain and Whiplash Research Unit Manual Therapy 13(1):2-11 Vernon H & Mior S 1992 The Neck Disability Index: A study of reliability and validity. Journal of Manipulative Physiological Therapy 15 (1) Wewers ME, & Lowe NK 2001 A critical review of visual analogue scales in the measurement of clinical phenomena. Research in Nursing and Health Journal of Clinical Nursing 13: 227-236.
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Yun S, Kim YL & Lee SM.2015 The effect of neurac training in patients with chronic neck pain. Journal of Physical therapy Sciences 27: 1303–1307
Exercise 2
Exercise 6
Exercise 7
Exercise 3
Exercise 4
Exercise 5
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Exercise 1
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FIGURES 1-10:
Exercise 9
Exercise 10
Table 1:
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Exercise 8
Table 1. direction- movement control training Exercises
Instructions
Thoracic flexion exercise
Exercise for low cervical flexion UCM(Standing)
Horizontal retraction
Exercise for upper cervical extension UCM(1:Standing, 2: Prone)
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Exercises for upper cervical flexion UCM(1:Standing , 2: Sitting on a chair, 3: Prone)
Lift exercise
Exercises for low cervical flexion UCM (1: Standing,2: Arms on wall, 3: head unsupported, 4: prone position, 5: Leaning backward with chair support) Exercise for low cervical flexion UCM(1: Standing with wall support, 2: Supine, 3:
Occiput lift exercise, nodding
Forward head lean exercise
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Standing in front of a wall and head without any support, 4: Side lying) Exercises for upper cervical flexion UCM(1:Standing position with wall support, 2: Sitting on a chair leaning forward on a table, 3: Four point kneeling position, 4: Leaning backward with chair support)
Exercises for upper cervical extension UCM(1: Standing position with wall support, 2:
Cervical extension control
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Hands on wall, head unsupported, 3: Leaning forward with table support, 4: Leaning backward with chair support) Exercises for upper cervical bending UCM(1: Standing with wall support and shoulder girdle unloaded, 2: Sitting unsupported with active shoulder control, 3: Leaning backward with chair support, 4: Four point kneeling position)
Upper neck tilt
Exercises for lower cervical bending UCM(1: Standing with wall support and shoulder girdle unloaded, 2: Arms on wall, head unsupported, 3: Four 4: point kneeling position)
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Lower neck tilt
rotation UCM (1: Standing with wall support and shoulder girdle unloaded. 2: Sitting. 3:
Head turn
Reading text on a cellphone Writing at a desk
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Table 2:
Sitting on a chair with hands on armchairs, Standing with wall support
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Four point kneeling)
Age (years) Height (cm) Weight (kg) BMI (kg/m2)
Experimental group
Control group
36.07±5.59
37.60±5.58
160.07±8.156
161.13±6.52
63.20±13.57 22.32 (2.87)
67.87±10.78 22.62 (1.68)
Table 3:
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Head Repositioning Accuracy scores (HRA) Endurance scores (s)
Control group
Effect size
Power
5.27±1.98
4.47±2.031
0.256
0.836
2.87±1.68
5.20±1.68 # -1.27±1.5 0.711
0.894
0.353
0.959
0.208
0.727
0.353
0.959
*
3.60±0.21 37.33±11.53 19.47±12.22
38.53±12.05 # 0.26±2.7
*
18.14±2.32 1.27±0.704
1.13±0.834
2.27±0.70
1.27±0.704 0.14±1.72#
*
1±0.89 5.85±8.87
8.27±5.86
3.20±2.65
8.87±5.11 -0.60±1.95#
*
2.65±6.65 38.87±24.55
31.53±22.18 31.40±20.76 # 0.13±4.13
80.60±24.71 -50.27±2.49
Table 4:
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Experimental group
Control group
Effect size
Power
27.33±8.83
28.20±9.98
0.501
0.999
0.826
0.925
19.67±3.99 22.80±9.13 # 3.27±4.42
0.683
0.912
23.33±5.23
0.461
0.991
0.825
0.947
0.485
0.990
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Pre-training Post-training Difference Extension Pre-training Post-training Cervical range Difference of motion Lateral Pre-training scores (CROM) flexion Post-training (left) Difference Lateral Pre-training flexion Post-training (right) Difference Rotation Pre-training (left) Post-training Difference Rotation Pre-training (right) Post-training Difference
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Flexion
38.27±11.10
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Function scores (PILE)
Experimental group Pre-training Post-training Difference Pre-training Post-training Difference Pre-training Post-training Difference Pre-training Post-training Difference Pre-training Post-training Difference
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Visual analogue scale scores (VAS) (mm) Neck disability index scores (NDI)
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66.73±25.75
39.40±22.43*
29.73±13.04 1.53±8.15#
37.67±9.79
35.6±9.207
61.00±16.29
36.47±8.22 1.13±3.4#
24.67±6.12* 20.00±4.62 57.07±14.55 *
37.07±8.92 24.00±5.73
45.20±14.26 *
21.20±7.96 24.67±11.09 63.40±9.10 *
39.27±4.46 27.33±9.42
55.53±18.841 28.20±7.32
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25.33±6.44 # 2.00±2.79 25.33±7.89 23.33±6.44 # 2±1.2 25.67±9.61 27.33±9.84 # 2.34±1.59