Effectiveness of physical therapy for patients with neck pain: an individualized approach using a clinical decision-making algorithm

Effects of muscle specific as compared to movement specific muscle energy technique in mechanical neck pain: A randomized controlled trial

BACKGROUND

Muscle energy technique (MET) is found to be effective for the management of neck pain and in addition to the muscle specific approach, clinicians may also adopt movement specific approach for METs. However, the literature is deficient in terms of comparison of muscle specific and movement specific METs in the management of mechanical neck pain.

OBJECTIVE

To compare the effects of muscle specific and movement specific METs in the management of mechanical neck pain.

METHODS

A single blind parallel design randomized controlled trial was conducted on 66 participants with mechanical neck pain ranging from 40-80 mm on visual analogue scale (VAS), aged between 19-44 years with pain and limitation on cervical motion. Once included, the participants were randomly allocated to two groups, namely the muscle specific MET group and the movement specific MET group. Outcome measures included VAS, Neck Disability Index (NDI) and cervical range of motion (ROM).

RESULTS

No significant differences (p> 0.05) were observed, neither immediately nor after 5 days, between muscle specific and movement specific MET in terms of VAS, NDI and ROM. However, a significant difference (p< 0.05) was observed in both groups in terms of pre- and post-analysis for all outcome variables.

CONCLUSIONS

Both muscle specific and movement specific METs are effective in the management of mechanical neck pain, with no significant differences between the two treatment techniques.

Inter- and intra-rater-reliability of a clinical framework for spine-related neck-arm pain

OBJECTIVE

A mechanism-based clinical framework for spine-related pain differentiates (i) somatic referred pain, ii) heightened nerve mechanosensitivity, iii) radicular pain, iv) radiculopathy and mixed-pain. This study aimed to determine the reliability of proposed framework.

METHOD

Fifty-one people with unilateral spine-related neck-arm pain were assessed and categorized by examiner-1. The classifications were compared to those made by two other examiners, based on written documentation of examiner-1. Cohens kappa was calculated between examiner-pairs; Fleiss Kappa among all examiners to assess agreement in classifying subgroups and entire framework.

RESULT

Inter-rater-reliability showed moderate to almost perfect reliability (somatic: no variation, mechanosensitivity: 0.96 (95% CI 0.87-1.0) to 1.0 (95% CI: 1.0-1.0), radicular pain: 0.46 (95% CI: 0.19-0.69) to 0.62 (95% CI: 0.42-0.81), radiculopathy: 0.65 (95% CI: 0.43-0.84) to 0.80 (95% CI: 0.63-0.96) mixed-pain: 0.54 (95% CI: 0.21-0.81) to 0.75 (95% CI: 0.48-0.94). There was almost perfect to moderate reliability among all examiners (somatic: no variation, mechanosensitivity: 0.97 (95% CI: 0.82-1.0), radicular pain: 0.56 (95% CI: 0.40-0.71), radiculopathy: 0.74 (95% CI: 0.58-0.90), mixed-pain: 0.63 (95% CI: 0.47-0.79), entire framework: 0.64 (95% CI: 0.57-0.71)). Intra-rater-reliability showed substantial to almost perfect reliability (somatic: no variation, mechanosensitivity: 0.96 (95% CI: 0.87-1.0), radicular pain: 0.76 (95% CI: 0.57-0.92), radiculopathy: 0.84 (95% CI: 0.67-0.96), mixed-pain: 0.83 (95% CI: 0.60-1.0), entire framework: 0.80 (95% CI: 0.61-0.92).

CONCLUSION

Moderate to almost perfect reliability in subgrouping people with spine-related neck-arm pain and substantial reliability for entire framework support this classification's reliability.

Efficacy of telerehabilitation exercise in patients with chronic neck pain: a protocol for a non-inferiority randomized controlled trial

The aim of this study is to investigate if telerehabilitation is just as effective as the same face-to-face exercise program in patients with chronic neck pain (NP). 140 participants will participate in this non-inferiority randomized controlled trial. Primary outcomes will be pain intensity and disability, and secondary outcomes will be kinesiophobia, catastrophizing, fear avoidance beliefs, anxiety and depression symptoms, self-efficacy for pain and global perceived effect. It will be collected at baseline, 6 weeks and 6 months after intervention. The analysis of non-inferiority will be calculated by mixed linear models considering the non-inferiority margin. The results of this clinical trial will be able to overcome the barriers that physiotherapists face for the success of their therapies. In addition, it may reduce the high demands and public health costs with NP. Brazilian Clinical Trials Registry (RBR-6VBSMB). Clinical Trial Registration: REBEC (Brazilian Registry of Clinical Trials) RBR-6VBSMB (ClinicalTrials.gov).

Bee Venom Acupuncture for Neck Pain: A Review of the Korean Literature

Bee venom is a natural toxin that is effective in treating various types of pain. The purpose of this paper was to review all the features of clinical studies conducted on bee venom acupuncture (BVA) for the treatment of neck pain in Korean publications. Six Korean databases and 16 Korean journals were searched in August 2022 for clinical studies on BVA for neck pain. We identified 24 trials that met our inclusion criteria, of which 316 patients with neck pain were treated with BVA. The most common diagnosis in the patients with neck pain was herniated intervertebral discs (HIVDs) of the cervical spine (C-spine) (29.2%), and the concentration and dosage per session were 0.05-0.5 mg/mL and 0.1-1.5 mL, respectively. The visual analog scale was most often measured for neck pain severity (62.5%), and all clinical research reported improvements in 16 outcome measures. This study shows that BVA could be recommended for the treatment of neck pain, especially HIVD of the C-spine; however, the adverse effects of BVA must be examined in future studies.

High-dose cervical mobilization to improve central sensitization for a patient with post-fusion neck pain

BACKGROUND

Few studies have addressed the appropriate joint mobilization dosage for neck pain. Furthermore, the efficacy of manual therapy in patients with post-spinal fusion neck pain is unreported.

CASE DESCRIPTION

A 63-year-old man with a 2-year history of unresolved neck pain post-cervical fusion presented to therapy with an exacerbation of neck and left-shoulder pain. The patient presented with cervical impairments of intervertebral hypo-mobility above and below the fusion site. He exhibited a high Numeric Pain Rating Scale (NPRS) score of 8/10 related to his neck pain. Additionally, he demonstrated marked loss of cervical mobility. Indicators of central sensitization were present, including both hyperalgesia and allodynia. High-dose cervical joint mobilization was applied for durations of up to 10 minutes. Corrective exercises were added to improve muscle strength and endurance. Treatment was applied for 12 sessions over 4 months.

OUTCOMES

At the time of discharge, this patient reported a full recovery of neck function. This treatment reduced pain, improved passive joint accessory motion, and restored upper quarter function. The patient demonstrated a 33-point improvement in his Neck Disability Index (NDI) score and his pain was reduced to 0-1/10 on the NPRS. Markers of central sensitization were resolved. Intervertebral passive accessory joint mobility was pain free in addition to concurrent restoration of functional mobility.

CONCLUSION

A paucity of evidence exists for appropriate dosage with manual therapy interventions. This case report demonstrates marked improvement of pain and function with the use of high-dose joint mobilization. Improved cervical accessory joint mobility and central pain modulation were achieved with high-dose joint mobilization.

Rehabilitation Strategies for a Patient With Traumatic Multiple Fractures: A Case Report

Le Fort fractures are a specific kind of facial bone fracture that develops after a blow to the face. Most of the fractures of the spine occur in the thoracolumbar region. The benefits of physiotherapy, which includes manual therapies and exercise regimens, for patients are becoming more and more clear. We are going to report the case of a 25-year-old male adult with a thoracolumbar fracture and a Le Fort fracture. We made an effort to develop a post-surgical physical therapy rehabilitation program. The patient's condition and general quality of life were successfully improved. We focused on the patient's primary symptoms, which were thoracolumbar discomfort, lower limb weakness, edema and pain on the left side of the face, trismus, and restricted mouth opening. We worked on the complaints mentioned by the patient and were successful in resolving them.

Comparative effectiveness of different acupuncture therapies for neck pain

BACKGROUND

Neck pain is a common musculoskeletal symptom that has negative effects on quality of life and work productivity. Acupuncture has been widely used for neck pain, and a number of randomized controlled trials (RCTs) and systematic reviews (SRs) have evaluated its effectiveness. However, previous studies have obtained inconsistent results regarding the effects of acupuncture for neck pain, and there is no SR for the comparative efficacy and safety of various types of acupuncture. Therefore, we herein conducted a SR and network meta-analysis to compare and rank different types of acupuncture with respect to their effectiveness in treating neck pain.

METHODS

We searched 9 electronic databases for relevant RCTs published from their inception to July 1, 2021. Pairwise meta-analyses and network meta-analysis were performed with R software using the frequentist framework. Change of pain intensity was assessed as the primary outcome, and change of pain-related disability and efficacy rate were assessed as secondary outcomes. The Cochrane risk of bias tool and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) instrument were used to evaluate the quality of the included RCTs and the certainty of the evidence.

RESULTS

A total of 65 RCTs involving 5266 participants and 9 interventions were included. Three network meta-analyses were constructed for the following: pain intensity (42 RCTs, 3158 participants), pain-related disability (21 RCTs, 1581 participants), and efficacy rate (40 RCTs, 3512 participants). The results indicated that fire acupuncture, electroacupuncture, and warm acupuncture were more effective than manual acupuncture in terms of pain intensity reduction and efficacy rate, and that electroacupuncture decreased pain-related disability more effectively than manual acupuncture. Fire acupuncture ranked first among the 9 interventions. The overall q of evidence was very low according to the GRADE assessment. The reported adverse events were not serious.

CONCLUSION

Fire acupuncture, warm acupuncture, acupoint catgut embedding, and electroacupuncture ranked higher than other interventions (usual care, sham acupuncture, no treatment) in reducing the pain and disability index scores and the efficacy rate. However, the included trials were evaluated as being of low quality; thus, we recommend additional well-designed RCTs with larger sample sizes to confirm these findings.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021235274.

A Single-Center Study Comparing the Effects of Thoracic Spine Manipulation vs Mobility Exercises in 26 Office Workers with Chronic Neck Pain: A Randomized Controlled Clinical Study

Background

Neck pain is associated with computer work, poor posture, imbalanced neck muscles, and fatigue, particularly in office workers. This study from a single center aimed to compare the effects of thoracic spine mobility exercise and thoracic spine manipulation to improve cervical spine range of motion in 26 office workers who had chronic neck pain for more than 12 weeks.

Material/Methods

The participants were 26 office workers with neck pain lasting >12 weeks. These participants were randomly assigned to undergo TSME (n=13) or TSM (n=13). Both groups underwent cervical joint mobilization and deep cervical flexor muscle exercises for 25 min a day, twice weekly, for 6 weeks. The TSME group additionally performed TSME 15 min a day, twice a week, for 6 weeks, while the TSM group received TSM 2 times a day, twice a week, for 6 weeks. Cervical and thoracic spine ROM, numeric pain rating scale (NPRS), and neck disability index (NDI) were measured before and after interventions. The ROM of cervical and thoracic spine was measured using a dual inclinometer.

Results

Both groups showed significant changes in cervical spine ROM, thoracic spine ROM, NPRS, and NDI after intervention compared to before intervention (P<0.05). Cervical spine right lateral flexion and right rotation differed significantly between the groups (P<0.05), while thoracic spine ROM, NPRS, and NDI did not.

Conclusions

TSME and TSM have similar effects in improving pain and disability in office workers with non-specific chronic neck pain.

The effects of combined sternocleidomastoid muscle stretching and massage on pain, disability, endurance, kinesiophobia, and range of motion in individuals with chronic neck pain: A randomized, single-blind study

BACKGROUND

The effect of interventions to the Sternocleidomastoid (SCM)-muscle, as an important element of neck movement which is overactive in individuals with chronic neck pain (CNP), are unknown.

OBJECTIVE

The aim of the current study is to investigate the effects of SCM stretching and massage on pain, range of motion (ROM), endurance, disability, and kinesiophobia in individuals with CNP.

METHODS

In this study, individuals with CNP were randomized 1:1 to parallel SCM-Group (n = 30) or control group (CG) (n = 30). Conventional physiotherapy was applied to CG. In addition to the same interventions applied to the CG, classical massage and stretching exercises were applied to the SCM-muscle in the SCM-Group. Treatment sessions were administered three times each week for a total of 5 weeks. Pain, endurance, ROM, disability, and kinesiophobia were evaluated. Both prior to and immediately following the treatments. Mixed-model repeated measured ANOVAs were then employed to determine if a group*time interaction existed on the effects of the treatment on each outcome variable for each group as the between-subjects variable and time as the within-subjects variables.

RESULTS

Improvements in pain, disability, ROM(extension, left-lateral flexion, and right/left-rotation), and endurance were found to be greater in the SCM-Group compared to the CG (p < 0.05). Changes in flexion and right-lateral flexion ROM and kinesiophobia did not significantly differ between the groups (p > 0.05).

CONCLUSION

Stretching exercises and massage applied to the SCM-muscle, together with conventional physiotherapy, can reduce pain and disability, and increase ROM and endurance in individuals with CNP. This treatment may therefore be considered for use as an alternative method in treating CNP. The study was registered in ClinicalTrials.gov (NCT04345042).

Exploring the educational needs of Australian naturopaths (eNAT): A cross-sectional study

INTRODUCTION

To ensure clinical competency, and to facilitate the delivery of safe and effective care, it is important that continuing professional development (CPD) offerings for health professionals are relevant, appropriate and accessible. In the field of naturopathic medicine, there has been no research seeking to understand the educational needs and preferences of this workforce. This cross-sectional study aims to address this knowledge gap.

METHODS

Australian adults holding a formal qualification in naturopathy were invited to complete a novel 29-item online questionnaire, comprising items on knowledge/skill gaps, knowledge/skill development, education delivery preferences and education barriers.

RESULTS

One-hundred-ten naturopaths completed the survey. The most frequently reported knowledge and skills gaps of undergraduate naturopathic training were pathology test interpretation and business development/administration, respectively. Across the four broad areas of professional/clinical skills, clinical specialities, populations and clinical settings, respondents rated, respectively, effective patient education, mental health, care of adult populations, and working in integrative health care settings as high value or important areas for further education. Respondents indicated a preference for CPD to be delivered via seminars/workshops, webinars, journals and conferences, with a penchant for blended or online delivery. Correspondingly, most respondents reported cost and distance as major/moderate barriers to further education.

DISCUSSION

This study has identified several important knowledge/skills deficits in Australian undergraduate naturopathic medicine education. An important next step of this work is the translation of findings into future naturopathic medicine curricula and CPD offerings.

Neck pain with radiculopathy: A systematic review of classification systems

BACKGROUND

Disparities in eligibility criteria for cervical radiculopathy (CR) in clinical trials have been acknowledged previously. The increasing use of CR related neck pain classification systems to inform eligibility criteria in clinical trials warrants evaluation.

OBJECTIVE

To evaluate existing neck pain classification systems for CR.

DESIGN

Systematic review and critical appraisal, reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.

METHODS

Database searches were performed from inception until 31/7/2020. Neck pain classification systems containing CR as a component were included. Methodological quality of each classification system was assessed using seven measurement property domains and scored using a framework developed by Buchbinder and colleagues. Classification criteria for CR from classification systems assessed as moderate or good quality were narratively synthesised using inductive content analysis which consisted of selecting unit of analysis, open coding, grouping and categorisation.

RESULTS

Out of 19,975 references, 14,893 remained after elimination of duplicates with 17 articles reporting 11 classification systems included. Five moderate and one good quality classification systems were identified. Nine classification criteria for CR were derived, including dermatomal sensory deficit, positive Spurling's test, positive upper limb tension test.

CONCLUSION

All classification systems had methodological limitations with Childs et al. (2008) classification system identified as good quality and most clinically useful. Future studies should investigate the reliability of Childs et al. (2008) classification system as it has the potential to further strengthen its methodological quality and clinical utility. The nine derived classification criteria can inform eligibility criteria in future trials.

Development and validation of the ADVANCER framework for naturopathic education and practice: A delphi study

BACKGROUND

There has been little attempt to date to narrow the education-practice gap in naturopathic medicine. A framework that brings naturopathic medicine education and practice closer together could help codify the knowledge of naturopathic medicine by providing simultaneous guidance on curriculum development and clinical decision-making in the discipline.

OBJECTIVE

To develop, refine and validate the Advancing Naturopathic Education and Practice (ADVANCER) framework.

METHODS

Published literature and pertinent government, professional association and institutional websites were scoped to identify key constructs for the ADVANCER framework. The constructs were grouped into ten domains, with each domain defined and translated into teaching and clinical practice outcomes. A two-round e-Delphi method, comprising international experts in naturopathic medicine education, was used to refine and validate the framework definitions and outcomes.

RESULTS

Sixteen academics, from five different countries, participated in the Delphi study. In round one, nine of the ten domains of the ADVANCER framework were rated as either very important or extremely important by 81.2% of participants. Only 68.8% of participants rated the tenth domain as either very important or extremely important. Participant feedback on each domain were pooled and reviewed, and where suggested changes were recommended by more than one participant, respective definitions and outcomes of each domain were amended. In round two, at least 90% of participants rated each domain of the amended ADVANCER framework as either very important or extremely important, meaning consensus to retain these domains, definitions and outcomes had been reached.

CONCLUSIONS

The study findings indicate that the ADVANCER framework is conceptually sound and potentially applicable to diverse institutions and countries. An important next step of this research is to establish whether implementation of the ADVANCER framework within naturopathic medicine education and practice is feasible, effective and sustainable.

Treatment based classification systems for patients with non-specific neck pain. A systematic review

OBJECTIVE

We aimed to identify published classification systems with a targeted treatment approach (treatment-based classification systems (TBCSs)) for patients with non-specific neck pain, and assess their quality and effectiveness.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, CINAHL, EMBASE, PEDro and the grey literature were systematically searched from inception to December 2019.

STUDY APPRAISAL AND SYNTHESIS

The main selection criterium was a TBCS for patients with non-specific neck pain with physiotherapeutic interventions. For data extraction of descriptive data and quality assessment we used the framework developed by Buchbinder et al. We considered as score of ≤3 as low quality, a score between 3 and 5 as moderate quality and a score ≥5 as good quality. To assess the risk of bias of studies concerning the effectiveness of TBCSs (only randomized clinical trials (RCTs) were included) we used the PEDro scale. We considered a score of ≥ six points on this scale as low risk of bias.

RESULTS

Out of 7664 initial references we included 13 studies. The overall quality of the TBCSs ranged from low to moderate. We found two RCTs, both with low risk of bias, evaluating the effectiveness of two TBCSs compared to alternative treatments. The results showed that both TBCSs were not superior to alternative treatments.

CONCLUSION

Existing TBCSs are, at best, of moderate quality. In addition, TBCSs were not shown to be more effective than alternatives. Therefore using these TBCSs in daily practice is not recommended.

The clinical reasoning process in randomized clinical trials with patients with non-specific neck pain is incomplete: A systematic review

OBJECTIVE

Primarily to evaluate the completeness of the description of the clinical reasoning process in RCTs with patients with non-specific neck pain with an argued or diagnosed cause i.e. an impairment or activity limitation. Secondly, to determine the association between the completeness of the clinical reasoning process and the degree of risk of bias.

DATA SOURCES

Pubmed, Cinahl and PEDro were systematically searched from inception to July 2016.

STUDY SELECTION

RCTs (n = 122) with patients with non-specific neck pain receiving physiotherapy treatment published in English were included.

DATA EXTRACTION

Data extraction included study characteristics and important features of the clinical reasoning process based on the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II)].

DATA SYNTHESIS

Thirty-seven studies (30%) had a complete clinical reasoning process of which 8 (6%) had a 'diagnosed cause' and 29 (24%) had an 'argued cause'. The Spearmans rho association between the extent of the clinical reasoning process and the risk of bias was -0.2.

CONCLUSIONS

In the majority of studies (70%) the described clinical reasoning process was incomplete. A very small proportion (6%) had a 'diagnosed cause'. Therefore, a better methodological quality does not necessarily imply a better described clinical reasoning process.

Clinical Decision Support and the Electronic Health Record-Applications for Physiatry

Clinical decision support (CDS) is a process that provides information to assist the user in decision making for evaluation and treatment. Although many think only of rules and alerts, CDS is much more than that. Order sets, clinical documents, information fields, and medication sentences are just a few other CDS tools to be considered. CDS has been shown to improve care. Forming the third point of the triangle, CDS, along with process redesign and workflow considerations, improves care and helps create successful outcomes. Failure to address all 3 of these elements creates a less-than-perfect and potentially dangerous result. Examples of the application of CDS in the field of physical medicine and rehabilitation remain limited. This field has a huge opportunity to use CDS to enhance patient care, and is an open area for CDS development and research.

Is tailored treatment superior to non-tailored treatment for pain and disability in women with non-specific neck pain? A randomized controlled trial

BACKGROUND

The evidence for the effect of treatments of neck pain is modest. In the absence of causal treatments, a possibility is to tailor the treatment to the individuals' functional limitations and symptoms. The aim was to evaluate treatment effects of a tailored treatment versus a non-tailored treatment. Our hypothesis was that tailored treatment (TT) would have better effect on pain intensity and disability than either non-tailored treatment (NTT) (same treatment components but applied quasi-randomly) or treatment-as-usual (TAU) (no treatment from the study, no restrictions). We further hypothesized that TT and NTT would both have better effect than TAU.

METHOD

One hundred twenty working women with subacute and chronic non-specific neck pain were allocated to 11 weeks of either TT, NTT or TAU in a randomized controlled trial with follow-ups at 3, 9 and 15 months. The TT was designed from a decision model based on assessment of function and symptoms with defined cut-off levels for the following categories: reduced cervical mobility, impaired neck-shoulder strength and motor control, impaired eye-head-neck control, trapezius myalgia and cervicogenic headache. Primary outcomes were pain and disability. Secondary outcomes were symptoms, general improvement, work productivity, and pressure pain threshold of m. trapezius.

RESULTS

Linear mixed models analysis showed no differences between TT and NTT besides work productivity favoring TT at 9- and 15-months follow-ups. TT and NTT improved significantly more than TAU on pain, disability and symptoms at 3-month follow-up. General improvement also favored TT and NTT over TAU at all follow-ups.

CONCLUSION

Tailored treatment according to our proposed decision model was not more effective than non-tailored treatment in women with subacute and chronic neck pain. Both tailored and non-tailored treatments had better short-term effects than treatment-as-usual, supporting active and specific exercise therapy, although therapist-patient interaction was not controlled for. Better understanding of the importance of functional impairments for pain and disability, in combination with a more precise tailoring of specific treatment components, is needed to progress.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN 49348025. Registered 2 August 2011.

Feasibility of a Smartphone-Based Exercise Program for Office Workers With Neck Pain: An Individualized Approach Using a Self-Classification Algorithm

OBJECTIVE

To explore the feasibility of a newly developed smartphone-based exercise program with an embedded self-classification algorithm for office workers with neck pain, by examining its effect on the pain intensity, functional disability, quality of life, fear avoidance, and cervical range of motion (ROM).

DESIGN

Single-group, repeated-measures design.

SETTING

The laboratory and participants' home and work environments.

PARTICIPANTS

Offices workers with neck pain (N=23; mean age ± SD, 28.13±2.97y; 13 men).

INTERVENTION

Participants were classified as having 1 of 4 types of neck pain through a self-classification algorithm implemented as a smartphone application, and conducted corresponding exercise programs for 10 to 12min/d, 3d/wk, for 8 weeks.

MAIN OUTCOME MEASURES

The visual analog scale (VAS), Neck Disability Index (NDI), Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), Fear-Avoidance Beliefs Questionnaire (FABQ), and cervical ROM were measured at baseline and postintervention.

RESULTS

The VAS (P<.001) and NDI score (P<.001) indicated significant improvements in pain intensity and functional disability. Quality of life showed significant improvements in the physical functioning (P=.007), bodily pain (P=.018), general health (P=.022), vitality (P=.046), and physical component scores (P=.002) of the SF-36. The FABQ, cervical ROM, and mental component score of the SF-36 showed no significant improvements.

CONCLUSIONS

The smartphone-based exercise program with an embedded self-classification algorithm improves the pain intensity and perceived physical health of office workers with neck pain, although not enough to affect their mental and emotional states.

Subjective and clinical assessment criteria suggestive for five clinical patterns discernible in nonspecific neck pain patients. A Delphi-survey of clinical experts

BACKGROUND

Nonspecific neck pain patients form a heterogeneous group with different musculoskeletal impairments. Classifying nonspecific neck pain patients into subgroups based on clinical characteristics might lead to more comprehensive diagnoses and can guide effective management.

OBJECTIVE

To establish consensus among a group of experts regarding the clinical criteria suggestive of a clinical dominance of 'articular', 'myofascial', 'neural', 'central' and 'sensorimotor control' dysfunction patterns distinguishable in patients with nonspecific neck pain.

STUDY DESIGN

Delphi study.

METHODS

A focus group with 10 academic experts was organized to elaborate on the different dysfunction patterns discernible in neck pain patients. Consecutively, a 3-round online Delphi-survey was designed to obtain consensual symptoms and physical examination findings for the 5 distinct dysfunction patterns resulting from the focus group.

RESULTS

A total of 21 musculoskeletal physical therapists from Belgium and the Netherlands experienced in assessing and treating neck pain patients completed the 3-round Delphi-survey. Respectively, 33 (response rate, 100.0%), 27 (81.8%) and 21 (63.6%) respondents replied to rounds 1, 2 and 3. Eighteen 'articular', 16 'myofascial', 20 'neural', 18 'central' and 10 'sensorimotor control' clinical indicators reached a predefined ≥80% consensus level.

CONCLUSION

These indicators suggestive of a clinical dominance of 'articular', 'myofascial', 'neural', 'central', and 'sensorimotor control' dysfunction patterns may help clinicians to assess and diagnose patients with nonspecific neck pain. Future validity testing is needed to determine how these criteria may help to improve the outcome of physical therapy interventions in nonspecific neck pain patients.

Manual therapy and segmental stabilization in the treatment of cervical radiculopathy

Abstract Introduction: Cervical radiculopathy (CR) is one of the diseases that most affect the cervical spine, causing radicular symptoms in the ipsilateral limb. Conservative treatment aim recover of both mechanical and physiological functions through neural mobilization techniques, along with the activation of the deep neck flexors with cervical segmental stabilization, combining techniques of joint mobilization and manipulation, which seeks mobility improvement of crucial areas of the cervical spine. The objective of this study was to evaluate a multimodal treatment to enhance the outcomes of conservative care in patients diagnosed with CR. Methods: The sample consisted of 11 patients with CR, between 21 and 59 years old, 3 female and 8 male. It was recorded the Visual Analogue Scale (VAS) for pain, the Functional Development of the Neck Pain and Disability Scale (NPDS) and the goniometry during shoulder abduction. The intervention plan was composed by neural mobilization, intermittent cervical traction, pompages, stretching, myofascial inhibition techniques, manipulative techniques and cervical segmental stabilization exercises. After 12 weeks of treatment, subjects underwent a new evaluation process. Results: Before the treatment, subjects reported an average pain of 7 (± 1.48) in VAS, whose dropped to average 1.18 (± 1.99) (p < 0.01). Functional disability evaluated in NPDS was 36 (± 10.95) before treatment decreasing to 11.45 (± 9.8) (p < 0.01) after the treatment. Range of motion of the ipsilateral upper limb was restores by increasing from 9.2° (± 8.2) to 137° (± 24.4) (p < 0.01). Conclusion: The proposed treatment approach was effective, significantly improving the results of analgesia and functional disability a series of cases of patients diagnosed with cervical radiculopathy. {#}

Description of Common Clinical Presentations and Associated Short-Term Physical Therapy Clinical Outcomes in Patients With Neck Pain

OBJECTIVE

To determine the effect of clinical presentations of neck pain on short-term physical therapy outcomes.

DESIGN

Retrospective analysis of pair-matched groups from a clinical cohort.

SETTING

Thirteen outpatient physical therapy clinics in 1 health care system.

PARTICIPANTS

Patients (N=1069) grouped by common clinical presentations of neck pain: nonspecific neck pain (NSNP) with duration <4 weeks; NSNP with duration >4 weeks; neck pain with arm pain; neck pain with headache; and neck pain from whiplash.

INTERVENTION

Conservative interventions provided by physical therapists.

MAIN OUTCOME MEASURES

Neck Disability Index (NDI) and numerical pain rating scale (NPRS) recorded at the initial and last visits. The main outcome of interest was achieving recovery status on the NDI. Changes in NDI and NPRS were compared between clinical presentation groups.

RESULTS

Compared with patients presenting with NSNP >4 weeks, patients with NSNP <4 weeks had increased odds of achieving recovery status on the NDI (P<.0001) and demonstrated the greatest changes in clinical outcomes of pain (P≤.0001) and disability (P≤.0001). Patients with neck pain and arm pain demonstrated an increased odds of achieving recovery status on the NDI (P=.04) compared with patients presenting with NSNP >4 weeks.

CONCLUSIONS

Treating patients with NSNP within <4 weeks of onset of symptoms may lead to improved clinical outcomes from physical therapy compared with other common clinical presentations.

In a secondary care setting, differences between neck pain subgroups classified using the Quebec task force classification system were typically small - a longitudinal study

BACKGROUND

The component of the Quebec Task Force Classification System that subgroups patients based on the extent of their radiating pain and neurological signs has been demonstrated to have prognostic implications for patients with low back pain but has not been tested on patients with neck pain (NP). The main aim of this study was to examine the association between these subgroups, their baseline characteristics and outcome in chronic NP patients referred to an outpatient hospital department.

METHODS

This was an observational study of longitudinal data extracted from systematically collected, routine clinical data. Patients were classified into Local NP only, NP + arm pain above the elbow, NP + arm pain below the elbow, and NP with signs of nerve root involvement (NP + NRI). Outcome was pain intensity and activity limitation. Associations were tested in longitudinal linear mixed models.

RESULTS

A total of 1,852 people were classified into subgroups (64 % females, mean age 49 years). Follow ups after 3, 6 and 12 months were available for 45 %, 32 % and 40 % of those invited to participate at each time point. A small improvement in pain was observed over time in all subgroups. There was a significant interaction between subgroups and time, but effect sizes were small. The local NP subgroup improved slightly less after 3 months as compared with all other groups, but continued to have the lowest level of pain. After 6 and 12 months, those with NP + pain above the elbow had improved the least and patients with NP + NRI had experienced the largest improvements in pain intensity. Similar results were obtained for activity limitation.

CONCLUSIONS

This study found baseline and outcome differences between neck pain subgroups classified using the Quebec Task Force Classification System. However, differences in outcome were typically small in size and mostly differentiated the local NP subgroup from the other subgroups. A caveat to these results is that they were obtained in a cohort of chronic neck pain patients who only displayed small improvements over time and the results may not apply to other cohorts, such as people at earlier stages of their clinical course and in other clinical settings.

The effect of neurac training in patients with chronic neck pain

[Purpose] This study aimed to investigate the effects of neurac training on pain, function, balance, fatigability, and quality of life. [Subjects and Methods] Subjects with chronic neck pain who were treated in S hospital were included in this study; they were randomly allocated into two groups, i.e., the experimental group (n = 10) and the control group (n = 10). Both groups received traditional physical therapy for 3 sessions for 30 min per week for 4 weeks. The experimental group practiced additional neurac training for 30 min/day, for 3 days per week for 4 weeks. All subjects were evaluated using the visual analogue scale (VAS), the neck disability index (NDI), the biorescue (balance), the questionnaire for fatigue symptoms (fatigue), and the medical outcome 36-item short form health survey (SF-36) pre- and post-intervention. [Results] The experimental group effectively improved their pain, function, balance, fatigability, and quality of life. [Conclusion] Neurac training is thus considered an effective training program that enhances body functionality by improving pain, function, balance ability, fatigability, and quality of life in patients with chronic neck pain.

Neck Pain in Changi General Hospital: An Observational Study

Introduction:

The aim of this study is to describe the profile of neck pain patients in the local population and to investigate the efficacy of physiotherapy management of neck pain.

Methods:

A retrospective study was done with neck pain patients who have attended the Musculoskeletal Physiotherapy Clinic at Changi General Hospital from August 2010 to September 2011. The following data was collected from each patient: age, gender, occupation, mechanism of injury, chronicity, posture type, symptom location, physiotherapy management, number of treatment sessions, pain and functional scores pre- and post-therapy. The patients were also categorised according to International Classification of Functioning, Disability and Health (ICF) categories and observed for clinical profiles.

Results:

Ninety-one records were screened. The majority of patients (79%) were aged between 35–65 years. The condition was slightly more prevalent in males (55%) than females (45%). Seventy per cent of the patients had non-traumatic and 30% traumatic onset. The majority (69%) had chronic neck pain; 25% had sub-acute and 6% acute neck pain. The majority of patients had slouched sitting posture (84%). Almost half of the neck patients (48.9%) had unilateral neck pain; 20.2% had central neck pain, 16% had neck pain with shoulder pain, 12.8% had neck pain with radiating pain and 2.1% had neck pain with headache. The categorisation showed 51.1% reported neck pain with movement co-ordination, 30.9% with mobility deficit, 12.8% with radiating pain and 5.2% with headache. The multi-modal method showed significant improvement on the pain scale (p >0.001) within an average of 4.3 physiotherapy sessions.

Conclusion:

Neck pain is common in Singapore, affecting the middle-aged population. Many of these cases presented chronic neck pain, with no trauma involved at symptom onset. A slouched sitting posture was observed most commonly amongst patients with neck pain. Our study indicates that the classification system is valid for clinical use. Patients with headache registered a higher pain intensity than those in other categories. The multi-modal approach is effective in the treatment of neck pain.

The intra- and inter-rater reliability of five clinical muscle performance tests in patients with and without neck pain

Background

This study investigates the reliability of muscle performance tests using cost- and time-effective methods similar to those used in clinical practice. When conducting reliability studies, great effort goes into standardising test procedures to facilitate a stable outcome. Therefore, several test trials are often performed. However, when muscle performance tests are applied in the clinical setting, clinicians often only conduct a muscle performance test once as repeated testing may produce fatigue and pain, thus variation in test results. We aimed to investigate whether cervical muscle performance tests, which have shown promising psychometric properties, would remain reliable when examined under conditions similar to those of daily clinical practice.

Methods

The intra-rater (between-day) and inter-rater (within-day) reliability was assessed for five cervical muscle performance tests in patients with (n = 33) and without neck pain (n = 30). The five tests were joint position error, the cranio-cervical flexion test, the neck flexor muscle endurance test performed in supine and in a 45°-upright position and a new neck extensor test.

Results

Intra-rater reliability ranged from moderate to almost perfect agreement for joint position error (ICC ≥ 0.48-0.82), the cranio-cervical flexion test (ICC ≥ 0.69), the neck flexor muscle endurance test performed in supine (ICC ≥ 0.68) and in a 45°-upright position (ICC ≥ 0.41) with the exception of a new test (neck extensor test), which ranged from slight to moderate agreement (ICC = 0.14-0.41). Likewise, inter-rater reliability ranged from moderate to almost perfect agreement for joint position error (ICC ≥ 0.51-0.75), the cranio-cervical flexion test (ICC ≥ 0.85), the neck flexor muscle endurance test performed in supine (ICC ≥ 0.70) and in a 45°-upright position (ICC ≥ 0.56). However, only slight to fair agreement was found for the neck extensor test (ICC = 0.19-0.25).

Conclusions

Intra- and inter-rater reliability ranged from moderate to almost perfect agreement with the exception of a new test (neck extensor test), which ranged from slight to moderate agreement. The significant variability observed suggests that tests like the neck extensor test and the neck flexor muscle endurance test performed in a 45°-upright position are too unstable to be used when evaluating neck muscle performance.

Multimodal management of mechanical neck pain using a treatment based classification system

THE PURPOSE OF THIS CASE STUDY WAS TWOFOLD: 1) to illustrate the use of a treatment-based classification (TBC) system to direct the early intervention of a patient with mechanical neck pain, and 2) to show the progression of this patient with multimodal-modal intervention. The patient exhibited axial neck pain with referral into her upper extremity. Her pain peripheralized with cervical range of motion and centralized with joint mobilization placing her primarily in the centralization category. Her poor posture and associated muscle weakness along with the chronicity of symptoms placed her secondarily into the exercise and conditioning group resulting in a multi-modal treatment as the patient progressed. Although the design of this case report prevents wide applicability, this study does illustrate the effective use of the TBC system for the cervical spine as captured by accepted outcomes measures.

Diagnosis and management of degenerative neck pain

Neck pain is a common presenting complaint, but the precise patho-aetiology is often unclear. Broadly speaking, the cause of neck pain can be considered as degenerative or non-degenerative (Table 1). While detailing the important non-degenerative causes the clinician should not miss, this article reviews the diagnosis and management of the common degenerative orthopaedic causes of neck pain.

Reduced endurance of the cervical flexor muscles in patients with concurrent temporomandibular disorders and neck disability

Subjects with temporomandibular disorders (TMDs) have been found to have clinical signs and symptoms of cervical dysfunction. Although many studies have investigated the relationship between the cervical spine and TMD, no study has evaluated the endurance capacity of the cervical muscles in patients with TMD. Thus the objective of this study was to determine whether patients with TMD had a reduced endurance of the cervical flexor muscles at any level of muscular contraction when compared with healthy subjects. One hundred and forty-nine participants provided data for this study (49 subjects were healthy, 54 had myogenous TMD, and 46 had mixed TMD). There was a significant difference in holding time at 25% MVC between subjects with mixed TMD when compared to subjects with myogenous TMD and healthy subjects. This implies that subjects with mixed TMD had less endurance capacity at a lower level of contraction (25% MVC) than healthy subjects and subjects with myogenous TMD. No significant associations between neck disability, jaw disability, clinical variables and neck flexor endurance test were found.

The assessment of the cervical spine. Part 1: Range of motion and proprioception

Neck pain and headache of cervical origin are complaints affecting an increasing number of the general population. Mechanical factors such as sustained neck postures or movements and long-term "abnormal" physiologic loads on the neck are believed to affect the cervical structures and compromise neck function. A comprehensive assessment of neck function requires evaluation of its physical parameters such as range of motion, proprioception, strength and endurance/fatigue. The complicated structure of the cervical spine however, makes it difficult for any clinician to obtain reliable and valid results. The aim of the first part of this systematic critical review is to identify the factors influencing the assessment of range of motion and proprioception of the cervical spine.

Effect of global posture reeducation and of static stretching on pain, range of motion, and quality of life in women with chronic neck pain: a randomized clinical trial

PURPOSE

Compare the effect of conventional static stretching and muscle chain stretching, as proposed by the global posture reeducation method, in the manual therapy of patients with chronic neck pain.

METHODS

Thirty-three female patients aged 35 to 60 years old, 31 of whom completed the program, were randomly divided into two groups: The global posture reeducation group (n=15) performed muscle chain stretching, while the conventional stretching group (n=16) performed conventional static muscle stretching. Both groups also underwent manual therapy. Patients were evaluated before and after treatment and at a six-week follow-up appointment and tested for pain intensity (by means of visual analog scale), range of motion (by goniometry), and health-related quality of life (by the SF-36 questionnaire). The treatment program consisted of two 1-hour individual sessions per week for six weeks. Data were statistically analyzed at a significance level of p<0.05.

RESULTS

Significant pain relief and range of motion improvement were observed after treatment in both groups, with a slight reduction at follow-up time. Quality of life also improved after treatment, except for the global posture reeducation group in one domain; at follow-up, there was improvement in all domains, except that both groups reported increased pain. There were no significant differences between groups

CONCLUSION

Conventional stretching and muscle chain stretching in association with manual therapy were equally effective in reducing pain and improving the range of motion and quality of life of female patients with chronic neck pain, both immediately after treatment and at a six-week follow-up, suggesting that stretching exercises should be prescribed to chronic neck pain patients.

Clinimetric evaluation of methods to measure muscle functioning in patients with non-specific neck pain: a systematic review

Background

Neck pain is a significant health problem in modern society. There is evidence to suggest that neck muscle strength is reduced in patients with neck pain. This article provides a critical analysis of the research literature on the clinimetric properties of tests to measure neck muscle strength or endurance in patients with non-specific neck pain, which can be used in daily practice.

Methods

A computerised literature search was performed in the Medline, CINAHL and Embase databases from 1980 to January 2007. Two reviewers independently assessed the clinimetric properties of identified measurement methods, using a checklist of generally accepted criteria for reproducibility (inter- and intra-observer reliability and agreement), construct validity, responsiveness and feasibility.

Results

The search identified a total of 16 studies. The instruments or tests included were: muscle endurance tests for short neck flexors, craniocervical flexion test with an inflatable pressure biofeedback unit, manual muscle testing of neck musculature, dynamometry and functional lifting tests (the cervical progressive iso-inertial lifting evaluation (PILE) test and the timed weighted overhead test). All the articles included report information on the reproducibility of the tests. Acceptable intra- and inter-observer reliability was demonstrated for t enduranctest for short neck flexors and the cervical PILE test. Construct validity and responsiveness have hardly been documented for tests on muscle functioning.

Conclusion

The endurance test of the short neck flexors and the cervical PILE test can be regarded as appropriate instruments for measuring different aspects of neck muscle function in patients with non-specific neck pain. Common methodological flaws in the studies were their small sample size and an inappropriate description of the study design.

Neck muscle endurance in nonspecific patients with neck pain and in patients after anterior cervical decompression and fusion

OBJECTIVE

The purpose of this study was to investigate differences in ventral and dorsal neck muscle endurance (NME) among men and women with nonspecific neck pain (NP) or cervical disk disease (who had anterior cervical decompression and fusion [ACDF]) and healthy controls (C). Another purpose was to investigate changes in NME after intervention.

METHODS

Neck muscle endurance was measured in patients with NP (n = 78) and ACDF (n = 25) before and after the treatment period, and their results were compared to each other and to sex-specific reference values from controls (n = 116) at both the individual and group levels.

RESULTS

Patients had significantly decreased (P < .01) NME compared with control subjects, except for ventral NME in female patients with NP before treatment and male patients with ACDF after treatment. Female patients with ACDF had lower ventral NME than female patients with NP (P < .01). Among the patients, 35% to 100% had NME disability, with most of them having a lower rate than the 95% confidence interval of controls. Female patients with NP and male patients with ACDF showed improvement (P < .05) after treatment. Flexion/extension ratio in patients with NP (P = .36), but not in patients with ACDF (P < .0001), returned to normal levels after treatment. There was a significant negative correlation (P < .02) between NME and Neck Disability Index in both patient groups, except for ventral NME in patients with NP before treatment.

CONCLUSION

Many patients had impairment in NME before and after treatment. This suggests that additional exercise of specific training for NME should be incorporated into the rehabilitation program, which may improve treatment outcome.

Preliminary examination of a proposed treatment-based classification system for patients receiving physical therapy interventions for neck pain

BACKGROUND AND PURPOSE

Neck pain frequently is managed by physical therapists. The development of classification methods for matching interventions to subgroups of patients may improve clinical outcomes. The purpose of this study was to describe a proposed classification system for patients with neck pain by examining data for consecutive patients receiving physical therapy interventions.

SUBJECTS AND METHODS

Standardized methods for collecting baseline and intervention data were used for all patients receiving physical therapy interventions for neck pain over 1 year. Outcome variables were the Neck Disability Index (NDI), numeric pain rating, and number of visits. Treatment was provided at the discretion of the physical therapist. After the completion of treatment, each patient was classified by use of baseline variables. The interventions received by the patient were categorized as being matched or not matched to the classification. Outcomes for patients who received matched interventions were compared with those for patients who received nonmatched interventions. The interrater reliability of the classification algorithm was examined with a subset of 50 patients.

RESULTS

A total of 274 patients were included in this study (74% women; age [X+/-SD]=44.4+/-16.0 years). The most common classification was centralization (34.7%); next were exercise and conditioning (32.8%) and mobility (17.5%). The interrater reliability for classification decisions was high (kappa=.95, 95% confidence interval [CI]=0.87-1.0). A total of 113 patients (41.2%) received interventions matched to the classification. Receiving matched interventions was associated with greater improvements in the NDI (mean difference=5.6 points, 95% CI=2.6-8.6) and in pain ratings (mean difference=0.74 point, 95% CI=0.21-1.3) than receiving nonmatched interventions.

DISCUSSION AND CONCLUSION

The development of classification methods for patients with neck pain may improve the outcomes of physical therapy intervention. This study was done to examine a previously proposed classification system for patients receiving physical therapy interventions for neck pain. Receiving interventions matched to the classification system was associated with better outcomes than receiving nonmatched interventions. Although the design of this study prohibited drawing conclusions about the effectiveness of the system, the results suggest that further research on the system may be warranted.

Interrater Reliability of the History and Physical Examination in Patients With Mechanical Neck Pain

OBJECTIVE

To examine the interrater reliability of the history and physical examination in patients with mechanical neck pain.

DESIGN

Single-group repeated measures for interrater reliability.

SETTING

Outpatient physical therapy clinic.

PARTICIPANTS

Twenty-two patients with mechanical neck pain underwent a standardized history and physical examination by a physical therapist.

INTERVENTION

Following a 5-minute break, a second therapist who was blind to the findings of examiner 1 performed the second standardized history and physical examination.

MAIN OUTCOME MEASURES

The Cohen kappa and weighted kappa were used to calculate the interrater reliability of ordinal level data from the history and physical examination. Intraclass correlation coefficients model 2,1 (ICC(2,1)) and the 95% confidence intervals were calculated to determine the interrater reliability for continuous variables.

RESULTS

The kappa coefficients ranged from -.06 to .90 for the variables obtained from the history. Reliability values for categorical data collected during the physical examination ranged from no to substantial agreement depending on the particular test and measure. ICC(2,1) for cervical range of motion (ROM) measurements ranged between .66 and .78.

CONCLUSIONS

We have reported the interrater reliability of the history and physical examination in a group of patients with a primary report of neck pain. The reliability variables varied considerably for manual assessment techniques and were significantly higher for the examination of muscle length and cervical ROM. Ultimately, it will be up to each clinician to determine if a particular test or measure poses adequate reliability to assist in the clinical decision making process.

Clinical prediction rules: What are they and what do they tell us?

QUESTION

Clinical prediction rules are research-based tools that quantify the contributions of relevant patient characteristics to provide numeric indices that assist clinicians in making predictions. Clinical prediction rules have been used to describe the likelihood of the presence or absence of a condition, assist in determining patient prognosis, and help the classification of patients for treatment. The recent rapid rise in the use of clinical prediction rules raises questions about the conditions under which they may be used most appropriately. What is the potential role of clinical prediction rules in physiotherapy practice and what are the strategies by which clinicians can determine their appropriate use for a given clinical setting?

CONCLUSION

Clinical prediction rules use quantitative methods to build upon the body of literature and expert opinion and can provide quick and inexpensive estimates of probability. Clinical prediction rules can be of great value to assist clinical decision making but should not be used indiscriminately. They are not a replacement for clinical judgment and should complement rather than supplant clinical opinion and intuition. The development of valid clinical prediction rules should be a goal of physiotherapy research. Specific areas in need of attention include deriving and validating clinical prediction rules to screen patients for potentially serious conditions for which current tests lack adequate diagnostic accuracy or have unacceptable cost and risk, and to assist in classification of patients for treatments that are likely to result in substantially different outcomes in heterogeneous groups of patients.

Issues in relation to the repeatability of and correlation between EMG and Borg scale assessments of neck muscle fatigue

INTRODUCTION

The repeatability of subjective and objective assessments of neck muscle fatigue is very important with regard to the clinical applicability of these methods.

METHOD

To establish between-days reliability, 33 healthy volunteers performed a 60% maximum voluntary isometric contraction test from a standing position in all neck movements. Cervical muscle fatigue was assessed on three separate occasions from the spectral (median frequency, MF) and amplitude (root mean square, RMS) analysis of the electromyogram (EMG) signal recorded from the cervical paraspinal group, splenius capitis, levator scapulae and sternocleidomastoid. Subjective assessment of fatigue was rated by employing the Borg scale. Intraclass correlation coefficient ICC((1,1)), standard error of measurement (SEM), smallest detectable difference (SDD) indices and Pearson's correlation co-efficient were calculated for the analysis of the results.

RESULTS

Normalised median frequency (MF) slope had low repeatability and large between-day error (ICC((1,1))=0.28-0.61; SEM=0.33-0.60%/s; SDD=132.7-703.2%) for the protagonist muscles of each movement. Initial median frequency (IMF) had moderate to good reliability and small error (ICC((1,1))=0.64-0.81; SEM=2.8-8.8Hz; SDD=19.9-38.5%). The RMS slope yielded also poor repeatability. The Borg assessment was more reliable than the EMG estimate though variability between sessions was still quite high (SDD=29.2-136.5%). No correlation was found between the EMG and Borg assessment of neck muscle fatigue (r=-0.01-0.39).

CONCLUSION

The protocol used for assessing neck muscle fatigue proved to be reliable only for the IMF but the clinical usefulness of this measure remains questionable. The lack of correlation between objective and subjective estimation of neck muscle fatigue was possibly a consequence of the poor measurement repeatability. Further research is needed to identify the factors responsible for these results on neck area.