Effects of training on female trapezius Myalgia: An intervention study with a 3-year follow-up period

The Unseen Strain: Investigating the Awareness of Rhinoplasty Surgeons Regarding Their Spine Health

BACKGROUND

Musculoskeletal pain is a common occupational health problem among surgeons that can affect work productivity and quality of life.

OBJECTIVES

The aim of the study was to investigate the prevalence and causes of back pain among rhinoplasty surgeons, evaluate their routine practice, and identify unique risk factors. A further goal was to measure functional disabilities with the Total Disability Index (TDI) questionnaire.

METHODS

A structured online questionnaire was distributed to plastic surgeons performing rhinoplasty internationally. The questionnaire comprised sections on biodata, routine practice posture, length of practice, surgical duration, and the history of surgery or hospitalization related to these issues. In the second part of the survey, participants were asked to complete the TDI questionnaire.

RESULTS

The prevalence of back pain was reported by 93.6% of surgeons, with low back pain being the most common (76.7%). The average pain intensity for low back pain was 44.8 ± 26.8. The mean TDI score was calculated as 31 ± 12.1, with 58.2% of surgeons experiencing mild to moderate disability. Significant associations were found between musculoskeletal pain severity and disability index and factors such as BMI, exercise, years of rhinoplasty practice, number of surgeries performed per week, and average procedure length. Interestingly, only 16.4% of rhinoplasty surgeons had previous ergonomic training or education.

CONCLUSIONS

Musculoskeletal issues related to the spine are prevalent among rhinoplasty surgeons. It is imperative to educate surgeons about this underestimated health problem, provide proper physical rehabilitation targeting ergonomic concerns, and make changes to current practices to address this issue effectively.

LEVEL OF EVIDENCE: 5

Effectiveness and Safety of Polydioxanone Thread Embedding Acupuncture Compared to Physical Therapy in the Treatment of Patients with Non-Specific Chronic Neck Pain: An Assessor-Blinded, Randomized, Controlled, Clinical Trial

Background

Thread embedding acupuncture (TEA) has recently been used as a conservative treatment method for non-specific chronic neck pain (CNP). The objective of this study was to evaluate the effectiveness and safety of TEA compared to physical therapy (PT) for treating patients with CNP.

Methods

A total of 128 patients diagnosed with CNP were randomly assigned to a TEA group and a PT group at a 1:1 ratio. The TEA group received four sessions of TEA, while the PT group received eight sessions of PT over 4 weeks. Outcomes were assessed using Neck Pain and Disability Scale (NPDS), clinically important difference (CID), cervical spinal angle, Beck Depression Inventory II (BDI-II), Beck Anxiety Inventory (BAI), Patient Global Impression of Change (PGIC), and EuroQol Five-Dimension (EQ-5D) at baseline and 5, 9, and 13 weeks.

Results

The TEA group showed significant improvement in NPDS compared to the PT group at 5, 9, and 13 weeks. Proportions of patients with decreased NPDS scores of more than 11.5 points (minimal CID) were significantly higher in the TEA group at 5, 9, and 13 weeks. There were significant differences between the two groups at 5, 9, and 13 weeks for BDI-II, and at 5 and 9 weeks for BAI. For EQ-5D, the TEA group showed significant improvement at 5, 9, and 13 weeks. There was no significant difference in cervical spinal angle between the two groups. For PGIC, better improvement was observed at 9 and 13 weeks in the TEA group. Adverse events associated with interventions were mostly temporary and mild.

Conclusion

For patients with CNP, TEA treatment was found to be more effective than PT treatment for improving their pain and dysfunction, quality of life, and psychological distress. Despite some post-treatment discomfort, TEA treatment can be considered as a useful treatment method for patients with CNP.

Trial Registration

This trial has been registered 5 April 2019 in Clinical Research Information Service of South Korea (CRIS- KCT0003720).

Effectiveness and optimal dosage of exercise training for chronic non-specific neck pain: A systematic review with a narrative synthesis

BACKGROUND

Clinical guidelines make vague recommendations as to exercise training (ET) type and dosage to manage chronic non-specific neck pain (CNSNP).

OBJECTIVE

To synthesise evidence on the effectiveness of different ET programmes to reduce CNSNP and associated disability, and whether dosage affects outcomes.

METHODS

A systematic review and data synthesis was conducted according to a published registered protocol (PROSPERO CRD42018096187). A sensitive topic-based search was conducted of CINAHL, MEDLINE, EMBASE, PEDro, grey literature sources and key journals from inception to 6th January 2020 for randomised controlled trials, investigating ET for CNSNP or disability. Two reviewers independently completed eligibility screening, data extraction, risk of bias assessment (Cochrane Risk of Bias Tool) and rated the overall strength of evidence using Grading of Recommendations Assessment, Development and Evaluation. Data was tabulated for narrative synthesis and grouped by intervention, outcome and time point to compare across studies.

RESULTS

Twenty-six trials from 3990 citations (n = 2288 participants) investigated fifteen ET programmes. High RoB and low sample sizes reduced evidence quality. Clinical heterogeneity prevented meta-analyses. A range of ET programmes reduce pain/disability in the short term (low to moderate evidence). Pillar exercises reduce pain/disability in the intermediate term (low level evidence). Moderate to very large pain reduction is found with ET packages that include motor control + segmental exercises (low to moderate evidence). No high-quality trials investigated long term outcomes. Increased frequency of motor control exercises and progressively increased load of pillar exercise may improve effectiveness.

CONCLUSIONS

Motor control + segmental exercises are the most effective ET to reduce short term pain/disability, but long-term outcomes have not been investigated. Optimal motor control + segmental exercise variables and dosage is unknown and requires clarification. An adequately powered, low RoB trial is needed to evaluate the effectiveness and optimal dosage of motor control + segmental on long term outcomes.

TRIAL REGISTRATION

PROSPERO CRD42018096187.

Comparing the effectiveness of integrating ergonomics and motor control to conventional treatment for pain and functional recovery of work-related neck-shoulder pain: A randomized trial

BACKGROUND

Work-related neck and shoulder pain (WRNSP) is highly prevalent among patients who seek physiotherapy treatment. Clinicians may tend to focus on teaching home exercises and provide general advice about workplace improvement. The present study investigates the short- and long-term impact of an intervention approach that emphasizes on integrating the motor control re-education with ergonomic advice.

METHODS

Participants diagnosed with WRNSP (n = 101) were randomly assigned into two groups in this randomized controlled trial. The Ergo-motor Group (EM, n = 51) received an integrated intervention with ergonomic advice/modifications and motor control training individualized for each participant based on their specific work demands. Control Group (CO, n = 50) received treatment for pain relief and general exercises of their necks at a designated physiotherapy clinic. Neck pain intensity and functional outcome measures were assessed before, immediately and 1-year after the 12-week intervention programmes. Global Rating of Change Score was used to evaluate the perceived recovery at 1-year follow-up.

RESULTS

Both groups reported significant reductions in pain and functional disability scores at post-intervention (EM, n = 44; CO, n = 42) and 1-year follow-up (EM, n = 40; CO, n = 38); however, no significant between-group differences were found (p > 0.05). Significantly higher rating in global recovery score was reported in EM group at 1-year follow-up (p < 0.05).

CONCLUSIONS

Intervention integrating ergonomic advice/modification with motor control exercise was found to be equally effective as pain relief and general exercise for pain and functional recovery. However, at 1-year follow-up, such integrated approach resulted in significantly better global recovery perceived by people with WRNSP.

SIGNIFICANCE

Integrating ergonomic intervention and motor control training achieved similar reduction in pain and functional outcomes compared to conventional physiotherapy at post-intervention and at 1-year follow-up, for patients with moderate level of work-related neck-shoulder pain and mild degree of functional disability. The Ergo-motor Group reported significantly better perceived overall recovery at 1-year follow-up.

Does Deep Cervical Flexor Muscle Training Affect Pain Pressure Thresholds of Myofascial Trigger Points in Patients with Chronic Neck Pain? A Prospective Randomized Controlled Trial

Background. We need to understand more about how DNF performs in different contexts and whether it affects the pain threshold over myofascial trigger points (MTrPs). Purpose. The objectives were to investigate the effect of neck muscles training on disability and pain and on pain threshold over MTrPs in people with chronic neck pain. Methods. Patients with chronic neck pain were eligible for participation with a Neck Disability Index (NDI) score of over 5/50 and having at least one MTrP on either levator scapulae, upper trapezoid, or splenius capitis muscle. Patients were randomly assigned into either DNF training, superficial neck muscle exercise, or advice group. Generalized linear model (GLM) was used to detect differences in treatment groups over time. Results. Out of 67 participants, 60 (47 females, mean age: 39.45 ± 12.67) completed the study. Neck disability and neck pain were improved over time between and within groups (p < 0.05). However, no differences were found within and between the therapeutic groups (p < 0.05) in the tested muscles' PPTs and in cervicothoracic angle over a 7-week period. Conclusion. All three groups improved over time. This infers that the pain pathways involved in the neck pain relief are not those involved in pain threshold.

Long-term effects of therapeutic exercise on nonspecific chronic neck pain: a literature review

[Purpose] Nonspecific neck pain is a common musculoskeletal disease. Therapeutic exercise has been shown to improve pain and disability in short-term and midterm follow-ups. This study performed a literature review of the long-term effects of therapeutic exercise on subjects with nonspecific chronic neck pain. [Subjects and Methods] The databases of the CINAHL, MEDLINE, PEDro and PubMed were used. Randomized controlled trials (RCT) published from January 2000 to January 2014 and explicitly including a one-year follow-up were identified. [Results] Only six articles were included in this review. They had scores of 5 to 8 points on the PEDro scale, and the level of evidence was grade I. The study results show that the main exercises used were cervical strengthening and endurance training exercise. Short-term exercises (10 to 12 weeks) helped to improve the body function, structure, activity and participation immediately after the intervention, but not at the long-term follow-up. On the other hand, long-term interventions (1 year) resulted in improvements in body function and structure at the 3 year follow-up. [Conclusion] The results of the six high-quality studies suggest that long-term exercise have long-term benefits for patients with nonspecific neck pain in terms of body function and structure.

Exercises for mechanical neck disorders

BACKGROUND

Neck pain is common, disabling and costly. Exercise is one treatment approach.

OBJECTIVES

To assess the effectiveness of exercises to improve pain, disability, function, patient satisfaction, quality of life and global perceived effect in adults with neck pain.

SEARCH METHODS

We searched MEDLINE, MANTIS, ClinicalTrials.gov and three other computerized databases up to between January and May 2014 plus additional sources (reference checking, citation searching, contact with authors).

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing single therapeutic exercise with a control for adults suffering from neck pain with or without cervicogenic headache or radiculopathy.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted trial selection, data extraction, 'Risk of bias' assessment and clinical relevance. The quality of the evidence was assessed using GRADE. Meta-analyses were performed for relative risk and standardized mean differences (SMD) with 95% confidence intervals (CIs) after judging clinical and statistical heterogeneity.

MAIN RESULTS

Twenty-seven trials (2485 analyzed /3005 randomized participants) met our inclusion criteria.For acute neck pain only, no evidence was found.For chronic neck pain, moderate quality evidence supports 1) cervico-scapulothoracic and upper extremity strength training to improve pain of a moderate to large amount immediately post treatment [pooled SMD (SMDp) -0.71 (95% CI: -1.33 to -0.10)] and at short-term follow-up; 2) scapulothoracic and upper extremity endurance training for slight beneficial effect on pain at immediate post treatment and short-term follow-up; 3) combined cervical, shoulder and scapulothoracic strengthening and stretching exercises varied from a small to large magnitude of beneficial effect on pain at immediate post treatment [SMDp -0.33 (95% CI: -0.55 to -0.10)] and up to long-term follow-up and a medium magnitude of effect improving function at both immediate post treatment and at short-term follow-up [SMDp -0.45 (95%CI: -0.72 to -0.18)]; 4) cervico-scapulothoracic strengthening/stabilization exercises to improve pain and function at intermediate term [SMDp -14.90 (95% CI:-22.40 to -7.39)]; 5) Mindfulness exercises (Qigong) minimally improved function but not global perceived effect at short term. Low evidence suggests 1) breathing exercises; 2) general fitness training; 3) stretching alone; and 4) feedback exercises combined with pattern synchronization may not change pain or function at immediate post treatment to short-term follow-up. Very low evidence suggests neuromuscular eye-neck co-ordination/proprioceptive exercises may improve pain and function at short-term follow-up.For chronic cervicogenic headache, moderate quality evidence supports static-dynamic cervico-scapulothoracic strengthening/endurance exercises including pressure biofeedback immediate post treatment and probably improves pain, function and global perceived effect at long-term follow-up. Low grade evidence supports sustained natural apophyseal glides (SNAG) exercises.For acute radiculopathy, low quality evidence suggests a small benefit for pain reduction at immediate post treatment with cervical stretch/strengthening/stabilization exercises.

AUTHORS' CONCLUSIONS

No high quality evidence was found, indicating that there is still uncertainty about the effectiveness of exercise for neck pain. Using specific strengthening exercises as a part of routine practice for chronic neck pain, cervicogenic headache and radiculopathy may be beneficial. Research showed the use of strengthening and endurance exercises for the cervico-scapulothoracic and shoulder may be beneficial in reducing pain and improving function. However, when only stretching exercises were used no beneficial effects may be expected. Future research should explore optimal dosage.

Lasting effects of workplace strength training for neck/shoulder/arm pain among laboratory technicians: natural experiment with 3-year follow-up

Objectives. This study investigated long-term effects and implementation processes of workplace strength training for musculoskeletal disorders. Methods. 333 and 140 laboratory technicians from private and public sector companies, respectively, replied to a 3-year follow-up questionnaire subsequent to a 1-year randomized controlled trial (RCT) with high-intensity strength training for prevention and treatment of neck, shoulder, and arm pain. Being a natural experiment, the two participating companies implemented and modified the initial training program in different ways during the subsequent 2 years after the RCT. Results. At 3-year follow-up the pain reduction in neck, shoulder, elbow, and wrist achieved during the first year was largely maintained at both companies. However, the private sector company was rated significantly better than the public sector company in (1) training adherence, (2) training culture, that is, relatively more employees trained at the workplace and with colleagues, (3) self-reported health changes, and (4) prevention of neck and wrist pain development among initially pain-free employees. Conclusions. This natural experiment shows that strength training can be implemented successfully at different companies during working hours on a long-term basis with lasting effects on pain in neck, shoulder, and arm.

Effect of brief daily resistance training on occupational neck/shoulder muscle activity in office workers with chronic pain: randomized controlled trial

Purpose. This study investigates the acute and longitudinal effects of resistance training on occupational muscle activity in office workers with chronic pain. Methods. 30 female office workers with chronic neck and shoulder pain participated for 10 weeks in high-intensity elastic resistance training for 2 minutes per day (n = 15) or in control receiving weekly email-based information on general health (n = 15). Electromyography (EMG) from the splenius and upper trapezius was recorded during a normal workday. Results. Adherence to training and control interventions were 86% and 89%, respectively. Compared with control, training increased isometric muscle strength 6% (P < 0.05) and decreased neck/shoulder pain intensity by 40% (P < 0.01). The frequency of periods with complete motor unit relaxation (EMG gaps) decreased acutely in the hours after training. By contrast, at 10-week follow-up, training increased average duration of EMG gaps by 71%, EMG gap frequency by 296% and percentage time below 0.5%, and 1.0% EMGmax by 578% and 242%, respectively, during the workday in m. splenius. Conclusion. While resistance training acutely generates a more tense muscle activity pattern, the longitudinal changes are beneficial in terms of longer and more frequent periods of complete muscular relaxation and reduced pain.

Conservative interventions for treating work-related complaints of the arm, neck or shoulder in adults

BACKGROUND

Work-related upper limb disorder (WRULD), repetitive strain injury (RSI), occupational overuse syndrome (OOS) and work-related complaints of the arm, neck or shoulder (CANS) are the most frequently used umbrella terms for disorders that develop as a result of repetitive movements, awkward postures and impact of external forces such as those associated with operating vibrating tools. Work-related CANS, which is the term we use in this review, severely hampers the working population.

OBJECTIVES

To assess the effects of conservative interventions for work-related complaints of the arm, neck or shoulder (CANS) in adults on pain, function and work-related outcomes.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, 31 May 2013), MEDLINE (1950 to 31 May 2013), EMBASE (1988 to 31 May 2013), CINAHL (1982 to 31 May 2013), AMED (1985 to 31 May 2013), PsycINFO (1806 to 31 May 2013), the Physiotherapy Evidence Database (PEDro; inception to 31 May 2013) and the Occupational Therapy Systematic Evaluation of Evidence Database (OTseeker; inception to 31 May 2013). We did not apply any language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-randomised controlled trials evaluating conservative interventions for work-related complaints of the arm, neck or shoulder in adults. We excluded trials undertaken to test injections and surgery. We included studies that evaluated effects on pain, functional status or work ability.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted data and assessed risk of bias of the included studies. When studies were sufficiently similar, we performed statistical pooling of reported results.

MAIN RESULTS

We included 44 studies (62 publications) with 6,580 participants that evaluated 25 different interventions. We categorised these interventions according to their working mechanisms into exercises, ergonomics, behavioural and other interventions.Overall, we judged 35 studies as having a high risk of bias mainly because of an unknown randomisation procedure, lack of a concealed allocation procedure, unblinded trial participants or lack of an intention-to-treat analysis.We found very low-quality evidence showing that exercises did not improve pain in comparison with no treatment (five studies, standardised mean difference (SMD) -0.52, 95% confidence interval (CI) -1.08 to 0.03), or minor intervention controls (three studies, SMD -0.25, 95% CI -0.87 to 0.37) or when provided as additional treatment (two studies, inconsistent results) at short-term follow-up or at long-term follow-up. Results were similar for recovery, disability and sick leave. Specific exercises led to increased pain at short-term follow-up when compared with general exercises (four studies, SMD 0.45, 95% CI 0.14 to 0.75)We found very low-quality evidence indicating that ergonomic interventions did not lead to a decrease in pain when compared with no intervention at short-term follow-up (three studies, SMD -0.07, 95% CI -0.36 to 0.22) but did decrease pain at long-term follow-up (four studies, SMD -0.76, 95% CI -1.35 to -0.16). There was no effect on disability but sick leave decreased in two studies (risk ratio (RR) 0.48, 95% CI 0.32 to 0.76). None of the ergonomic interventions was more beneficial for any outcome measures when compared with another treatment or with no treatment or with placebo.Behavioural interventions had inconsistent effects on pain and disability, with some subgroups showing benefit and others showing no significant improvement when compared with no treatment, minor intervention controls or other behavioural interventions.In the eight studies that evaluated various other interventions, there was no evidence of a clear beneficial effect of any of the interventions provided.

AUTHORS' CONCLUSIONS

We found very low-quality evidence indicating that pain, recovery, disability and sick leave are similar after exercises when compared with no treatment, with minor intervention controls or with exercises provided as additional treatment to people with work-related complaints of the arm, neck or shoulder. Low-quality evidence also showed that ergonomic interventions did not decrease pain at short-term follow-up but did decrease pain at long-term follow-up. There was no evidence of an effect on other outcomes. For behavioural and other interventions, there was no evidence of a consistent effect on any of the outcomes.Studies are needed that include more participants, that are clear about the diagnosis of work-relatedness and that report findings according to current guidelines.

Psychological Care, Patient Education, Orthotics, Ergonomics and Prevention Strategies for Neck Pain: An Systematic Overview Update as Part of the ICON Project

OBJECTIVES

To conduct an overview on psychological interventions, orthoses, patient education, ergonomics, and 1⁰/2⁰ neck pain prevention for adults with acute-chronic neck pain.

SEARCH STRATEGY

Computerized databases and grey literature were searched (2006-2012).

SELECTION CRITERIA

Systematic reviews of randomized controlled trials (RCTs) on pain, function/disability, global perceived effect, quality-of-life and patient satisfaction were retrieved.

DATA COLLECTION & ANALYSIS

Two independent authors selected articles, assessed risk of bias using AMSTAR tool and extracted data. The GRADE tool was used to evaluate the body of evidence and an external panel to provide critical review.

MAIN RESULTS

We retrieved 30 reviews (5-9 AMSTAR score) reporting on 75 RCTs with the following moderate GRADE evidence. For acute whiplash associated disorder (WAD), an education video in emergency rooms (1RCT, 405participants] favoured pain reduction at long-term follow-up thus helping 1 in 23 people [Standard Mean Difference: -0.44(95%CI: -0.66 to -0.23)). Use of a soft collar (2RCTs, 1278participants) was not beneficial in the long-term. For chronic neck pain, a mind-body intervention (2RCTs, 1 meta-analysis, 191participants) improved short-term pain/function in 1 of 4 or 6 participants. In workers, 2-minutes of daily scapula-thoracic endurance training (1RCT, 127participants) over 10 weeks was beneficial in 1 of 4 participants. A number of psychosocial interventions, workplace interventions, collar use and self-management educational strategies were not beneficial.

REVIEWERS' CONCLUSIONS

Moderate evidence exists for quantifying beneficial and non-beneficial effects of a limited number of interventions for acute WAD and chronic neck pain. Larger trials with more rigorous controls need to target promising interventions.

Effects of a 12 week self-managed stretching program among Korean-Chinese female migrant workers in Korea: a randomized trial

AIM

The purpose of this study was to assess the efficacy of a 12 week, self-managed, community-based stretching program on musculoskeletal fitness, musculoskeletal symptoms, and acculturative stress, in Korean-Chinese female migrant workers in Korea.

METHODS

This was a randomized controlled trial with random assignment of eligible full-time Korean-Chinese female migrant workers to a stretching exercise intervention (n=40) or an enhanced stretching exercise intervention (n=40) condition. Both conditions received a 6 min stretching exercise program that included an orientation and three work-related musculoskeletal disorder (WMSD) educational classes. Between educational classes, the enhanced stretching exercise condition also received mobile phone text messaging and telephone counseling to increase self-efficacy (confidence in overcoming barriers) and provide social support. Flexibility, muscle strength, musculoskeletal symptoms, and acculturative stress were assessed at baseline and 12 weeks.

RESULTS

Significant increase in flexibility was noted for both conditions, but acculturative stress was significantly reduced only in the standard intervention condition. Muscle strength and WMSD symptoms had no significant changes at the 12 week follow up in both conditions.

CONCLUSION

The 12 week, self-managed, community-based, stretching exercise program was effective to increase flexibility. The standard stretching intervention without any enhancements may be a more cost-effective way to increase flexibility. Longitudinal studies, however, are needed to see if the long-term effects are greater in the enhanced intervention for the migrant worker population.

Identification of proteins from interstitium of trapezius muscle in women with chronic myalgia using microdialysis in combination with proteomics

Background

Microdialysis (MD) of the trapezius muscle has been an attractive technique to investigating small molecules and metabolites in chronic musculoskeletal pain in human. Large biomolecules such as proteins also cross the dialysis membrane of the catheters. In this study we have applied in vivo MD in combination with two dimensional gel electrophoresis (2-DE) and mass spectrometry to identify proteins in the extracellular fluid of the trapezius muscle.

Materials and Methods

Dialysate from women with chronic trapezius myalgia (TM; n = 37), women with chronic wide spread pain (CWP; n = 18) and healthy controls (CON; n = 22) was collected from the trapezius muscle using a catheter with a cut-off point of 100 kDa. Proteins were separated by two-dimensional gel electrophoresis and visualized by silver staining. Detected proteins were identified by nano liquid chromatography in combination with tandem mass spectrometry.

Results

Ninety-seven protein spots were identified from the interstitial fluid of the trapezius muscle; 48 proteins in TM and 30 proteins in CWP had concentrations at least two-fold higher or lower than in CON. The identified proteins pertain to several functional classes, e.g., proteins involved in inflammatory responses. Several of the identified proteins are known to be involved in processes of pain such as: creatine kinase, nerve growth factor, carbonic anhydrase, myoglobin, fatty acid binding protein and actin aortic smooth muscle.

Conclusions

In this study, by using in vivo microdialysis in combination with proteomics a large number of proteins in muscle interstitium have been identified. Several of the identified proteins were at least two-fold higher or lower in chronic pain patients. The applied techniques open up for the possibility of investigating protein changes associated with nociceptive processes of chronic myalgia.

Exercises for mechanical neck disorders

BACKGROUND

Neck disorders are common, disabling and costly. The effectiveness of exercise as a physiotherapy intervention remains unclear.

OBJECTIVES

To improve pain, disability, function, patient satisfaction, quality of life and global perceived effect in adults with neck pain.

SEARCH METHODS

Computerized searches were conducted up to February 2012.

SELECTION CRITERIA

We included single therapeutic exercise randomized controlled trials for adults with neck pain with or without cervicogenic headache or radiculopathy.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted selection, data extraction, 'Risk of bias' assessment, and clinical relevance. The quality of the body of evidence was assessed using GRADE. Relative risk and standardized mean differences (SMD) were calculated.  After judging clinical and statistical heterogeneity, we performed meta-analyses.

MAIN RESULTS

Six of the 21 selected trials had low risk of bias. Moderate quality evidence shows that combined cervical, scapulothoracic stretching and strengthening are beneficial for pain relief post treatment (pooled SMD -0.35, 95% confidence interval (CI): -0.60, -0.10) and at intermediate follow-up (pooled SMD -0.31, 95% CI: -0.57, -0.06), and improved function short term and intermediate term (pooled SMD -0.45, 95% CI: -0.72, -0.18) for chronic neck pain. Moderate quality evidence demonstrates patients are very satisfied with their care when treated with therapeutic exercise. Low quality evidence shows exercise is of benefit for pain in the short term and for function up to long-term follow-up for chronic neck pain. Low to moderate quality evidence shows that chronic neck pain does not respond to upper extremity stretching and strengthening or a general exercise program.Low to moderate quality evidence supports self-mobilization, craniocervical endurance and low load cervical-scapular endurance exercises in reducing pain, improving function and global perceived effect in the long term for subacute/chronic cervicogenic headache. Low quality evidence supports neck strengthening exercise in acute cervical radiculopathy for pain relief in the short term.

AUTHORS' CONCLUSIONS

Low to moderate quality evidence supports the use of specific cervical and scapular stretching and strengthening exercise for chronic neck pain immediately post treatment and intermediate term, and cervicogenic headaches in the long term. Low to moderate evidence suggests no benefit for some upper extremity stretching and strengthening exercises or a general exercise program.  Future trials should consider using an exercise classification system to establish similarity between protocols and adequate sample sizes. Factorial trials would help determine the active treatment agent within a treatment regimen where a standardized representation of dosage is essential. Standardized reporting of adverse events is needed for balancing the likelihood of treatment benefits over potential harms.

Update on the relation between pain and movement: consequences for clinical practice

It is generally thought that exercise is beneficial to alleviate pain. However, prolonged movement may lead to the development of painful injuries, because of the overload of low-threshold motor units. Especially in individuals with a pain condition, exercise prescription and the impact of fatigue is less clear. This may be because of the dual effects, aggravation and relief, which fatigue has on pain. The purpose of this review is to ascertain the relation between pain and the motor system, both in the development and management of pain. Recent studies show that fatigue alters pain-induced increases in corticomotor excitability and leads to within and between-muscle adaptations. Studies of acute pain have shown complex adaptations such as increased movement variability, which may be because of a search for motor solutions to prolong overall task performance. In contrast, chronic pain seems to limit movement duration, speed, and variability which could be protective in the short term but also counterproductive over time. Owing to these adaptations in movement strategies, pain chronicity may help to dictate exercise prescription. For example, the correct dosage of multimuscle, dynamic exercises would act to promote movement variability. Thus, it seems that exercise involving the use of different movement strategies could be effective in helping people to obtain exercise-induced benefits while avoiding injury and pain reaggravation.

Prognostic factors for intervention effect on neck/shoulder symptom intensity and disability among female computer workers

INTRODUCTION

It has been suggested that treatments may be more effective when they are matched to patient characteristics. This study aimed at investigating potential prognostic factors for clinically relevant improvement in symptom intensity and symptom-related disability among employees with symptoms in the neck/shoulder area, receiving either ergonomics counseling or such counseling in combination with myofeedback training.

METHODS

A randomized controlled study was performed among female computer users aged 45 or older (n = 36). A clinical examination and a questionnaire survey were performed before inclusion in the study. Symptom intensity and disability was assessed using questionnaires before the start of the interventions (baseline) and at follow-ups directly after the end of the interventions (T0) and after 3 (T3) and 6 (T6) months. Logistic regression analyses were performed in order to assess prognostic factors for clinically relevant improvement in symptom intensity and disability.

RESULTS

Improvement in symptom intensity was consistently predicted by symptom intensity at baseline. Diagnosis and stress-induced lack of muscular rest were prognostic factors for improvement in symptom intensity at short term follow-up. Baseline disability and passive coping consistently served as prognostic factors for outcome in disability. Few substantial differences were found between the interventions in terms of prognostic factors.

CONCLUSIONS

Myofeedback training in combination with ergonomics counseling seem to be an especially beneficial tool for secondary prevention among employees with moderate levels of symptom intensity and symptom-related disability, who respond to work-related stress by increased/sustained muscle activation, and who tend to employ passive coping to deal with their neck/shoulder symptoms.

WITHDRAWN: Ergonomic and physiotherapeutic interventions for treating work-related complaints of the arm, neck or shoulder in adults

BACKGROUND

Conservative interventions such as physiotherapy and ergonomic adjustments (such as keyboard adjustments or ergonomic advice) play a major role in the treatment of most work-related complaints of the arm, neck or shoulder (CANS).

OBJECTIVES

This systematic review aims to determine whether conservative interventions have a significant impact on outcomes for work-related CANS in adults.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2005) and Cochrane Rehabilitation and Related Therapies Field Specialised Register (March 2005), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2005), PubMed, EMBASE, CINAHL, AMED and reference lists of articles. The date of the last search was March 2005. No language restrictions were applied.

SELECTION CRITERIA

We included randomised controlled trials studying conservative interventions (e.g. exercises, relaxation, physical applications, biofeedback, myofeedback and work-place adjustments) for adults suffering CANS.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials from the search yield, assessed the methodological quality using the Delphi list, and extracted relevant data. We pooled data or, in the event of clinical heterogeneity or lack of data, we used a rating system to assess levels of evidence.

MAIN RESULTS

For this update we included six additional studies; 21 trials in total. Seventeen trials included people with chronic non-specific neck or shoulder complaints, or non-specific upper extremity disorders. Over 25 interventions were evaluated; five main subgroups of interventions could be determined: exercises, manual therapy, massage, ergonomics, and energised splint. Overall, the quality of the studies was poor.In 14 studies a form of exercise was evaluated, and contrary to the previous review we now found limited evidence about the effectiveness of exercises when compared to massage and conflicting evidence when exercises are compared to no treatment. In this update there is limited evidence for adding breaks during computer work; massage as add-on treatment on manual therapy, manual therapy as add-on treatment on exercises; and some keyboard designs when compared to other keyboards or placebo in participants with carpal tunnel syndrome.

AUTHORS' CONCLUSIONS

There is limited evidence for the effectiveness of keyboards with an alternative force-displacement of the keys or an alternative geometry, and limited evidence for the effectiveness of exercises compared to massage; breaks during computer work compared to no breaks; massage as an add-on treatment to manual therapy; and manual therapy as an add-on treatment to exercises.

The effectiveness of a work style intervention and a lifestyle physical activity intervention on the recovery from neck and upper limb symptoms in computer workers

This study assessed the effectiveness of a single intervention targeting work style and a combined intervention targeting work style and physical activity on the recovery from neck and upper limb symptoms. Computer workers with frequent or long-term neck and upper limb symptoms were randomised into the work style group (WS, n=152), work style and physical activity group (WSPA, n=156), or usual care group (n=158). The WS and WSPA group attended six group meetings. All meetings focused on behavioural change with regard to body posture, workplace adjustment, breaks and coping with high work demands (WS and WSPA group) and physical activity (WSPA group). Pain, disability at work, days with symptoms and months without symptoms were measured at baseline and after 6 (T1) and 12 months (T2). Self-reported recovery was assessed at T1/T2. Both interventions were ineffective in improving recovery. The work style intervention but not the combined intervention was effective in reducing all pain measures. These effects were present in the neck/shoulder, not in the arm/wrist/hand. For the neck/shoulder, the work style intervention group also showed an increased recovery-rate. Total physical activity increased in all study groups but no differences between groups were observed. To conclude, a group-based work style intervention focused on behavioural change was effective in improving recovery from neck/shoulder symptoms and reducing pain on the long-term. The combined intervention was ineffective in increasing total physical activity. Therefore we cannot draw conclusions on the effect of increasing physical activity on the recovery from neck and upper limb symptoms.

Repetitive strain injury

Repetitive strain injury remains a controversial topic. The term repetitive strain injury includes specific disorders such as carpal tunnel syndrome, cubital tunnel syndrome, Guyon canal syndrome, lateral epicondylitis, and tendonitis of the wrist or hand. The diagnosis is usually made on the basis of history and clinical examination. Large high-quality studies using newer imaging techniques, such as MRI and ultrasonography are few. Consequently, the role of such imaging in diagnosis of upper limb disorders remains unclear. In many cases, no specific diagnosis can be established and complaints are labelled as non-specific. Little is known about the effectiveness of treatment options for upper limb disorders. Strong evidence for any intervention is scarce and the effect, if any, is mainly short-term pain relief. Exercise is beneficial for non-specific upper limb disorders. Immobilising hand braces and open carpal tunnel surgery release are beneficial for carpal tunnel syndrome, and topical and oral non-steroidal anti-inflammatory drugs, and corticosteroid injections are helpful for lateral epicondylitis. Exercise is probably beneficial for neck pain, as are corticosteroid injections and exercise for shoulder pain. Although upper limb disorders occur frequently in the working population, most trials have not exclusively included a working population or assessed effects on work-related outcomes. Further high-quality trials should aim to include sufficient sample sizes, working populations, and work-related outcomes.

Interventions for the prevention and management of neck/upper extremity musculoskeletal conditions: a systematic review

Considered from medical, social or economic perspectives, the cost of musculoskeletal injuries experienced in the workplace is substantial, and there is a need to identify the most efficacious interventions for their effective prevention, management and rehabilitation. Previous reviews have highlighted the limited number of studies that focus on upper extremity intervention programmes. The aim of this study was to evaluate the findings of primary, secondary and/or tertiary intervention studies for neck/upper extremity conditions undertaken between 1999 and 2004 and to compare these results with those of previous reviews. Relevant studies were retrieved through the use of a systematic approach to literature searching and evaluated using a standardised tool. Evidence was then classified according to a "pattern of evidence" approach. Studies were categorised into subgroups depending on the type of intervention: mechanical exposure interventions; production systems/organisational culture interventions and modifier interventions. 31 intervention studies met the inclusion criteria. The findings provided evidence to support the use of some mechanical and modifier interventions as approaches for preventing and managing neck/upper extremity musculoskeletal conditions and fibromyalgia. Evidence to support the benefits of production systems/organisational culture interventions was found to be lacking. This review identified no single-dimensional or multi-dimensional strategy for intervention that was considered effective across occupational settings. There is limited information to support the establishment of evidence-based guidelines applicable to a number of industrial sectors.

Effects of ambulant myofeedback training and ergonomic counselling in female computer workers with work-related neck-shoulder complaints: a randomized controlled trial

OBJECTIVE

To investigate the effects of ambulant myofeedback training including ergonomic counselling (Mfb) and ergonomic counselling alone (EC), on work-related neck-shoulder pain and disability.

METHODS

Seventy-nine female computer workers reporting neck-shoulder complaints were randomly assigned to Mfb or EC and received four weeks of intervention. Pain intensity in neck, shoulders, and upper back, and pain disability, were measured at baseline, immediately after intervention, and at three and six months follow-up.

RESULTS

Pain intensity and disability had significantly decreased immediately after four weeks Mfb or EC, and the effects remained at follow up. No differences were observed between the Mfb and EC group for outcome and subjects in both intervention groups showed comparable chances for improvement in pain intensity and disability.

CONCLUSIONS

Pain intensity and disability significantly reduced after both interventions and this effect remained at follow-up. No differences were observed between the two intervention groups.

Exercise proves effective in a systematic review of work-related complaints of the arm, neck, or shoulder

OBJECTIVE

Interventions such as physiotherapy and ergonomic adjustments play a major role in the treatment of most work-related complaints of the arm, neck, and/or shoulder (CANS). We evaluated whether conservative interventions have a significant impact on outcomes for work-related CANS.

STUDY DESIGN AND SETTING

A systematic review was conducted. Only (randomized) trials studying interventions for patients suffering from work-related CANS were included. Interventions may include exercises, relaxation, physical applications, and workplace adjustments. Two authors independently selected the trials, assessed methodological quality, and extracted data.

RESULTS

We included 26 studies (in total 2,376 patients); 23 studies included patients with chronic nonspecific complaints. Over 30 interventions were evaluated and 7 main subgroups of interventions could be determined, of which the subgroup "exercises" was the largest one. Overall, the quality of the studies appeared to be poor.

CONCLUSION

There is limited evidence for the effectiveness of exercises when compared to massage, adding breaks during computer work, massage as add-on treatment to manual therapy, manual therapy as add-on treatment to exercises, and some keyboards in people with carpal tunnel syndrome when compared to other keyboards or placebo. For other interventions no clear effectiveness could be demonstrated.

The (cost-)effectiveness of a lifestyle physical activity intervention in addition to a work style intervention on the recovery from neck and upper limb symptoms in computer workers

Background

Neck and upper limb symptoms are frequently reported by computer workers. Work style interventions are most commonly used to reduce work-related neck and upper limb symptoms but lifestyle physical activity interventions are becoming more popular to enhance workers health and reduce work-related symptoms. A combined approach targeting work style and lifestyle physical activity seems promising, but little is known on the effectiveness of such combined interventions.

Methods/design

The RSI@Work study is a randomised controlled trial that aims to assess the added value of a lifestyle physical activity intervention in addition to a work style intervention to reduce neck and upper limb symptoms in computer workers. Computer workers from seven Dutch companies with frequent or long-term neck and upper limb symptoms in the preceding six months and/or the last two weeks are randomised into three groups: (1) work style group, (2) work style and physical activity group, or (3) control group. The work style intervention consists of six group meetings in a six month period that take place at the workplace, during work time, and under the supervision of a specially trained counsellor. The goal of this intervention is to stimulate workplace adjustment and to improve body posture, the number and quality of breaks and coping behaviour with regard to high work demands. In the combined (work style and physical activity) intervention the additional goal is to increase moderate to heavy physical activity. The control group receives usual care. Primary outcome measures are degree of recovery, pain intensity, disability, number of days with neck and upper limb symptoms, and number of months without neck and upper limb symptoms. Outcome measures will be assessed at baseline and six and 12 months after randomisation. Cost-effectiveness of the group meetings will be assessed using an employer's perspective.

Discussion

This study will be one of the first to assess the added value of a lifestyle physical activity intervention in addition to a work style intervention in reducing neck and upper limb symptoms of computer workers. The results of the study are expected in 2007.

Ergonomic and physiotherapeutic interventions for treating work-related complaints of the arm, neck or shoulder in adults

BACKGROUND

Conservative interventions such as physiotherapy and ergonomic adjustments (such as keyboard adjustments or ergonomic advice) play a major role in the treatment of most work-related complaints of the arm, neck or shoulder (CANS).

OBJECTIVES

This systematic review aims to determine whether conservative interventions have a significant impact on outcomes for work-related CANS in adults.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2005) and Cochrane Rehabilitation and Related Therapies Field Specialised Register (March 2005), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2005), PubMed, EMBASE, CINAHL, AMED and reference lists of articles. The date of the last search was March 2005. No language restrictions were applied.

SELECTION CRITERIA

We included randomised and non-randomised controlled trials studying conservative interventions (e.g. exercises, relaxation, physical applications, biofeedback, myofeedback and work-place adjustments) for adults suffering CANS.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials from the search yield, assessed the methodological quality using the Delphi list, and extracted relevant data. We pooled data or, in the event of clinical heterogeneity or lack of data, we used a rating system to assess levels of evidence.

MAIN RESULTS

For this update we included six additional studies; 21 trials in total. Seventeen trials included people with chronic non-specific neck or shoulder complaints, or non-specific upper extremity disorders. Over 25 interventions were evaluated; five main subgroups of interventions could be determined: exercises, manual therapy, massage, ergonomics, and energised splint. Overall, the quality of the studies was poor. In 14 studies a form of exercise was evaluated, and contrary to the previous review we now found limited evidence about the effectiveness of exercises when compared to massage and conflicting evidence when exercises are compared to no treatment. In this update there is limited evidence for adding breaks during computer work; massage as add-on treatment on manual therapy, manual therapy as add-on treatment on exercises; and some keyboard designs when compared to other keyboards or placebo in participants with carpal tunnel syndrome.

AUTHORS' CONCLUSIONS

There is limited evidence for the effectiveness of keyboards with an alternative force-displacement of the keys or an alternative geometry, and limited evidence for the effectiveness of exercises compared to massage; breaks during computer work compared to no breaks; massage as an add-on treatment to manual therapy; and manual therapy as an add-on treatment to exercises.

Cervicocephalic kinesthetic sensibility in young and middle-aged adults with or without a history of mild neck pain

Previous research has shown that there is no significant relationship between the degree of structural degeneration of the cervical spine and neck pain. We therefore sought to investigate the potential role of sensory dysfunction in chronic neck pain. Cervicocephalic kinesthetic sensibility, expressed by how accurately an individual can reposition the head, was studied in three groups of individuals, a control group of 20 asymptomatic young adults and two groups of middle-aged adults (20 subjects in each group) with or without a history of mild neck pain. An ultrasound-based three-dimensional coordinate measuring system was used to measure the position of the head and to test the accuracy of repositioning. Constant error (indicating that the subject overshot or undershot the intended position) and root mean square errors (representing total errors of accuracy and variability) were measured during repositioning of the head to the neutral head position (Head-to-NHP) and repositioning of the head to the target (Head-to-Target) in three cardinal planes (sagittal, transverse, and frontal). Analysis of covariance (ANCOVA) was used to test the group effect, with age used as a covariate. The constant errors during repositioning from a flexed position and from an extended position to the NHP were significantly greater in the middle-aged subjects than in the control group (beta=0.30 and beta=0.60, respectively; P<0.05 for both). In addition, the root mean square errors during repositioning from a flexed or extended position to the NHP were greater in the middle-aged subjects than in the control group (beta=0.27 and beta=0.49, respectively; P<0.05 for both). The root mean square errors also increased during Head-to-Target in left rotation (beta=0.24;P<0.05), but there was no difference in the constant errors or root mean square errors during Head-to-NHP repositioning from other target positions (P>0.05). The results indicate that, after controlling for age as a covariate, there was no group effect. Thus, age appears to have a profound effect on an individual's ability to accurately reposition the head toward the neutral position in the sagittal plane and repositioning the head toward left rotation. A history of mild chronic neck pain alone had no significant effect on cervicocephalic kinesthetic sensibility.

Measurement of cervical flexor endurance following whiplash

AIM

To investigate measurement properties of a practical test of cervical flexor endurance (CFE) in whiplash patients including inter-rater reliability, sensitivity to clinical change, criterion related validity against the Neck Disability Index (NDI), and discriminant validity for injured versus uninjured populations.

METHODS

Two samples were recruited, 81 whiplash patients, and a convenience sample of 160 subjects who were not seeking treatment and met criteria for normal pain and range of motion. CFE was measured using a stopwatch while the subject, in crook lying, held their head against gravity to fatigue.

RESULTS

Inter-rater reliability in whiplash patients was in a range considered 'almost perfect' (Intraclass Correlation=0.96). CFE had greater inter-subject variability than the NDI or range of motion in any of three planes. However, the effect size for improvement in CFE over treatment was as large as the effect sizes for all of those measures. In multivariate regression, CFE changes accounted for changes on the NDI better than the three ranges of motion. CFE discriminated whiplash patients who were within six months of injury (n=71) from age and gender matched normals with high effect size (ES=1.5).

CONCLUSIONS

These findings provide evidence of reliability and validity for CFE measurement, and demonstrate that CFE detects clinical improvements. Variance on CFE emphasizes the need to consider inter-, and intra-subject standard deviations to interpret scores.

Different types of variant muscle nociception after intermittent and continuous neuromuscular stimulation in rats

Critical assessment of experimental muscle-pain models resulting from maximal muscle contraction may provide a means of assessing hypersensitivity and the central nociceptive mechanisms involved in diffused muscle pain. The aim of the present study was, therefore, to investigate the patterns of nociceptive behavior and neuronal changes in the rat spinal cord after two modes of maximal muscle contraction. The gastrocnemius muscle of adult male Sprague-Dawley rats was subjected to continuous (10 min) or intermittent (60 min, 10/50 s on/off ratio) premodulated electrical stimulation of median frequency. Similar peak forces but different patterns of contraction output were generated by these two stimulation modes. Nociceptive behavioral scores and hind-leg oedema were significantly greater in the continuous group compared to the controls; however, significant difference was not demonstrated for either parameter comparing the intermittent and control groups. The sensory threshold was slightly reduced after the intermittent stimulation, and elevated after the continuous modality. The elevation of sensory threshold could be reversed by naloxone administration. More Fos-labeled nuclei were noted for both of the stimulation groups relative to the controls. The Fos-labeled nuclei were larger for the intermittent group than for the continuous and control analogs. The results of the present study suggest that prolonged contraction from continuous stimulation results in specific nociceptive neuron activation, muscle lesion and endogenous opioid release causing exaggerated nociception.

Exercises for mechanical neck disorders

BACKGROUND

Neck disorders are common, limit function, and are costly to individuals and society. Exercise therapy is a commonly used treatment for neck pain. The effectiveness of exercise therapy remains unclear.

OBJECTIVES

To assess the effectiveness of exercise therapy to relieve pain, or improve function, disability, patient satisfaction, and global perceived effect in adults with mechanical neck disorders (MND).

SEARCH STRATEGY

Computerised bibliographic databases including CENTRAL, MEDLINE, EMBASE, MANTIS, CINAHL, and ICL were searched, without language restrictions, from their beginning up to March 2004, and reference lists of articles were scanned.

SELECTION CRITERIA

Selected studies were randomised [RCTs] or quasi-randomised trials and investigated the use of exercise therapy as a treatment in adults with MND with or without headache or radicular signs and symptoms.

DATA COLLECTION AND ANALYSIS

Two reviewers independently conducted citation identification, study selection, data abstraction, and methodological quality assessment. Using a random effects model, relative risk and standardized mean differences were calculated. The reasonableness of combining studies was assessed on clinical and statistical grounds. In the absence of heterogeneity, pooled effect measures were calculated. When trials were considered homogenous, results were summarised using a rating system of five levels of evidence.

MAIN RESULTS

Thirty-one trials were selected, 19% (van Tulder criteria) to 35% (Jadad scale) had high quality. There is limited evidence of benefit that acute range of motion (AROM) may reduce pain in acute MND (whiplash associated disorder (WAD)) in the short term. There is moderate evidence of benefit that neck strengthening exercises reduce pain, improve function and global perceived effect for chronic neck disorder with headache in the short and long term. There is unclear evidence regarding the impact of a stretching and strengthening program on pain, function and global perceived effect for MND. However, when this stretching and strengthening program focuses on the cervical or cervical and shoulder/thoracic region, there is moderate evidence of benefit on pain in chronic MND [pooled SMD -0.42 (95%CI: -0.83 to -0.01)] and neck disorder plus headache, in the short and long term. There is strong evidence of benefit favouring a multimodal care approach of exercise combined with mobilisation or manipulation for subacute and chronic MND with or without headache, in the short and long term. A program of eye fixation or proprioception exercises imbedded in a more complete program shows moderate evidence of benefit for pain [pooled SMD -0.72 (95% CI:-1.12 to -0.32)], function, and global perceived for chronic MND in the short term, and on pain and function for acute and subacute MND with headache or WAD in the long term. There is limited evidence of benefit on pain relief in the short term for a home mobilisation program with other physical modalities over a program of rest then gradual mobilisation for acute MND or WAD. There was evidence of no difference between the different exercise approaches.

AUTHORS' CONCLUSIONS

The evidence summarised in this systematic review indicates that specific exercises may be effective for the treatment of acute and chronic MND, with or without headache. To be of benefit, a stretching and strengthening exercise program should concentrate on the musculature of the cervical, shoulder-thoracic area, or both. A multimodal care approach of exercise, combined with mobilisation or manipulation for subacute and chronic MND with or without headache, reduced pain, improved function, and global perceived effect in the short and long term. The relative benefit of other treatments (such as physical modalities) compared with exercise or between different exercise programs needs to be explored. The quality of future trials should improve through more effective 'blinding' procedures and better control of compliance and co-intervention. Phase II trials would help identify the most effective treatment characteristics and dosages.

Neck/shoulder disorders in a general population. Natural course and influence of physical exercise: a 5-year follow-up

STUDY DESIGN

A 5-year follow-up study was conducted of men and women seeking care for new incidents of neck/shoulder disorders (NSD).

OBJECTIVES

To study the natural course of pain and disability caused by NSD during a 5-year follow-up and to investigate the possible influence of regular physical exercise on recovery.

SUMMARY OF BACKGROUND DATA

NSD are a major health problem, but their natural course is not very well studied. Several studies have investigated the role of physical exercise on NSD, with inconsistent results.

METHODS

At baseline, a total of 439 subjects seeking care for NSD completed a questionnaire, and were interviewed about personal, medical, and occupational history, as well as physical exercise during leisure time. Over 5 years, 4 follow-up assessments were made by postal questionnaire. At all measuring points, pain intensity ratings and disability scores were compared between men and women, and between 3 exercise categories.

RESULTS

The highest improvements in pain and disability, both in men and in women, were seen after 3 months. After that, only minor improvements were seen. In some cases, there was deterioration. However, after 5 years, both men and women had significant improvements, men more than women. Only the women were analyzed concerning physical exercise and were pooled into 3 categories according to intensity of exercise. There were no differences in changes in pain intensity and disability scores from baseline between the groups.

CONCLUSIONS

A gender difference was seen in the change of pain and disability, with men having higher improvement than women over 5 years. Self-reported physical exercise of any intensity was not associated with higher recovery in women.

Regional musculoskeletal conditions: shoulder pain

About half the population has at least one episode of shoulder pain yearly. History and clinical examination are cornerstones in the evaluation of the patient. Shoulder pain at the work place is associated with job strain: lack of control and work with elevated arms and hand tools. Clinical skills and knowledge about red and yellow flags and biomechanics are essential to perform a systematic and reliable evaluation. The diagnostic validity of clinical tests for rotator cuff tear, impingement syndrome and superior labral tears is equal or better than ultrasound and magnetic resonance imaging. Non-steroidal anti-inflammatory drugs and cortico-steroidal injections have documented short-term pain relief. Additionally, the physician should attempt to give the patient simple advice and reinforce active coping strategies. One randomized study suggests that a proper physiotherapy regimen and surgery are equally effective for the impingement syndrome. Further research should address the cost-effectiveness of diagnostic methods and treatments.