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Manual Therapy: Zacharias Dimitriadis, Eleni Kapreli, Nikolaos Strimpakos, Jacqueline Oldham
Manual Therapy: Zacharias Dimitriadis, Eleni Kapreli, Nikolaos Strimpakos, Jacqueline Oldham
Manual Therapy: Zacharias Dimitriadis, Eleni Kapreli, Nikolaos Strimpakos, Jacqueline Oldham
Manual Therapy
journal homepage: www.elsevier.com/math
Original article
Physiotherapy Department, Technological Educational Institute (TEI) of Lamia, 3rd km Old National Road Lamia-Athens, 35100 Lamia, Greece
Manchester Academic Health Sciences Centre, The University of Manchester, Oxford Road, Manchester M13 9PL, UK
a r t i c l e i n f o
a b s t r a c t
Article history:
Received 1 April 2012
Received in revised form
24 October 2012
Accepted 30 October 2012
Respiratory muscle strength is one parameter that is currently proposed to be affected in patients with
chronic neck pain. This study was aimed at examining whether patients with chronic neck pain have
reduced respiratory strength and with which neck pain problems their respiratory strength is associated.
In this controlled cross-sectional study, 45 patients with chronic neck pain and 45 healthy well-matched
controls were recruited. Respiratory muscle strength was assessed through maximal mouth pressures.
The subjects were additionally assessed for their pain intensity and disability, neck muscle strength,
endurance of deep neck exors, neck range of movement, forward head posture and psychological states.
Paired t-tests showed that patients with chronic neck pain have reduced Maximal Inspiratory (MIP)
(r 0.35) and Maximal Expiratory Pressures (MEP) (r 0.39) (P < 0.05). Neck muscle strength (r > 0.5),
kinesiophobia (r < 0.3) and catastrophizing (r < 0.3) were signicantly associated with maximal
mouth pressures (P < 0.05), whereas MEP was additionally negatively correlated with neck pain and
disability (r < 0.3, P < 0.05). Neck muscle strength was the only predictor that remained as signicant
into the prediction models of MIP and MEP. It can be concluded that patients with chronic neck pain
present weakness of their respiratory muscles. This weakness seems to be a result of the impaired global
and local muscle system of neck pain patients, and psychological states also appear to have an additional
contribution. Clinicians are advised to consider the respiratory system of patients with chronic neck pain
during their usual assessment and appropriately address their treatment.
2012 Elsevier Ltd. All rights reserved.
Keywords:
Chronic neck pain
Maximal expiratory pressure
Maximal inspiratory pressure
Respiration
1. Introduction
Chronic neck pain is one of the most frequent musculoskeletal
complaints and can lead to adaptive musculoskeletal and motor
control changes in cervical region and related structures (Falla and
Farina, 2008; Jull et al., 2008a). Although neck pain is predominantly considered and treated in clinical practice as a neuromusculoskeletal problem, the close anatomical connection of the
cervical region with the thoracic spine in parallel with their
musculoskeletal and neural connection have led some researchers
to believe that neck pain may lead to associated changes in thoracic
spine and rib cage and consequential changes in pulmonary function (Kapreli et al., 2008).
Cervical spine studies have shown that muscle strength and
endurance (Chiu and Lo, 2002; Harris et al., 2005), cervical mobility
(Rix and Bagust, 2001), head posture (Lau et al., 2009) and cervical
proprioception (Cheng et al., 2010) are all affected in patients with
249
2. Methods
2.1. Sample
In this cross-sectional study, 45 patients with chronic neck pain
and 45 healthy gender-, age-, height- and weight-matched controls
were conveniently recruited. Patients were included if they had
pain for at least 6 months with pain complaints at least once a week
and were between 18 and 65 year old. Patients with spinal or chest
surgeries, smoking history, traumatic cervical injuries, acute or
chronic neuromusculoskeletal pain in any other non-related body
area, serious obesity (Body Mass Index (BMI) >40), clinical abnormalities of the thoracic cage or vertebral column, occupational
industrial exposures, serious comorbidities (neurological, neuromuscular, cardiorespiratory, psychiatric and musculoskeletal
disorders), diabetes mellitus and/or malignancies were excluded
from the study.
The same eligibility criteria were applied for the healthy control
group. Healthy controls were individually matched with neck pain
patients in terms of gender, age (5 years), height (10 cm) and
weight (10%). All the participants were assessed at the cardiorespiratory lab of the Physiotherapy Department, Technological
Educational Institute (TEI) of Lamia, Lamia, Greece during the
2009e2010 years. All the subjects had to sign an informed consent
before their participation to this study. The study was approved by
the Ethics Committee of the Department of Physiotherapy, School
of Health and Caring Professions, TEI Lamia, Greece and the
University of Manchester Ethics Committee.
2.2. Procedure
Maximal Inspiratory Pressure (MIP) and Maximal Expiratory
Pressure (MEP) were assessed in a randomized order from
a standing position (Fig. 1) with a portable mouth pressure meter
250
isometric neck dynamometer using a previously described procedure (Strimpakos et al., 2004). High reliability values with small
measurement error have been also previously published
(ICC 0.9e0.96, SEM 12.6e20.8 N) (Strimpakos et al., 2004).
The craniocervical exion test was used for assessing the
endurance of deep neck exors. Details about the procedure and
reliability values are provided by previous publications (ICC 0.91)
(Jull et al., 2008a, 2008b; Arumugam et al., 2011). The measurements were performed from a crook lying position with a pressure
biofeedback device (Stabilizer, Chattanooga, USA), which was
placed behind participants neck. The device was initially inated to
a baseline pressure of 20 mmHg. The participants had to successively perform 3 10-s holds of a head nodding action at each of the 5
pressure levels (22 mmHg, 24 mmHg, 26 mmHg, 28 mmHg and
30 mmHg). Participants deep neck exors were considered
fatigued when pressure decrease at the pressure sensor, apparent
activation of the supercial neck exors or a jerky action during
holding of the pressure level were observed. The endurance of deep
neck exors of each participant was considered the maximal
pressure that the participant was able to keep steady for three 10-s
holds without any other substitution strategy.
Cervical Range of Movement (ROM) of all neck movements was
assessed by using the Zebris ultrasound-based motion analysis
system (Zebris Meditchnic GmbH, Isny, Germany) from a standing
position, based on instructions provided by a previously published
paper (Strimpakos et al., 2005). After calibrating the Zebris in order
for the NHP to be dened equal to 0 , the participants were asked to
perform three repetitions for each cervical movement. For each
cervical movement the best trial was accepted. The procedure has
been found very reliable with small measurement error
(ICC 0.73e0.86, SEM 6.5e8.5 ) (Strimpakos et al., 2005).
The Forward Head Posture (FHP) was assessed through the
craniovertebral angle (CVA), the angle between the line extending
from the tragus of the ear to the 7th cervical vertebra (C7) spinous
process and the horizontal line through C7. For this purpose three
lateral photographs were obtained after asking the participants to
focus their vision on a predetermined reference point at the height
of their eyes. The photographs were obtained by using a digital
colour camera (HDR-SR11E, Sony, Belgium), and the values were
calculated by using a 3-D drawing software (Auto-CAD 2000,
Autodesk Inc., San Raphael, CA). The mean of the three CVAs was
used for data analysis. The procedure has been previously reported
as very reliable (ICC 0.88) (Raine and Twomey, 1997).
A number of questionnaires were given to participants including
Visual Analogue Scales for assessing current and usual neck pain
intensity (Price et al., 1983), Neck Disability Index for assessing
pain-induced disability (Trouli et al., 2008) and the Baecke Questionnaire of Habitual Physical Activity for assessing physical activity
level (Baecke et al., 1982). Furthermore, the cross-cultural validated
Hospital Anxiety and Depression Scale (Georgoudis and Oldham,
2001), Tampa Scale for Kinesiophobia (Georgoudis et al., 2007)
and Pain Catastrophizing Scale (Argyra et al., 2006) were completed
in a randomized order to reduce any potential bias and ordering
effects.
2.3. Data analysis
Pearson correlation coefcients and paired t-tests were used for
examining the correlations between the variables and the differences between the groups, respectively. A backward stepwise
multiple regression analysis (removal 0.1) was performed for MIP
and MEP. The strength of neck extensors, endurance of deep neck
exors, sagittal ROM, FHP, usual pain intensity, anxiety, depression,
kinesiophobia and catastrophizing were selected to be the predictors of these models. When data were missing, the individual with
MIP (cmH2O)
MEP (cmH2O)
MIP/MEP
Neck pain
M (SD)
Controls
M (SD)
Mean difference
(95% CI)
86.9 (31.2)
107.36 (43.3)
0.85 (0.22)
100.8 (34.5)
126.9 (43.1)
0.81 (0.17)
0.35
0.39
0.12
*P < 0.05, **P < 0.01 MIP: Maximal Inspiratory Pressure, MEP: Maximal Expiratory
Pressure.
251
catastrophizing (r 0.36, P < 0.05) (Fig. 3). All the other correlations were not signicant and of small effect size (r < 0.3,
P > 0.05).
The regression analysis showed that the assumption of independent errors, homoscedasticity, linearity and normally distributed errors had been met. Multicollinearity was not found to be of
concern and no inuential outliers were recognized. The models
Fig. 3. Correlations between maximal mouth pressures [maximal inspiratory pressure (black dots, solid line) and maximal expiratory pressure (white dots, dashed line)] and
strength of neck extensors (upper left), strength of neck exors (upper right), pain intensity (middle left), disability (middle right), kinesiophobia (bottom left) and catastrophizing
(bottom right) (NDI: Neck Disability Index, TSK: Tampa Scale for Kinesiophobia, PCK: Pain Catastrophizing Scale).
252
SE B
23.27
0.46
0.57
0.54
0.23
43.16
0.57
0.89
0.7
0.21
253
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