The effectiveness of manual and exercise therapy on headache intensity and frequency among patients with cervicogenic headache: a systematic review and meta-analysis

Integrated manual therapies: IASP taskforce viewpoint

Introduction

Manual therapy refers to a range of hands-on interventions used by various clinical professionals, such as osteopaths, osteopathic physicians, chiropractors, massage therapists, physiotherapists, and physical therapists, to treat patients experiencing pain.

Objectives

To present existing evidence of mechanisms and clinical effectiveness of manual therapy in pain.

Methods

This Clinical Update focuses on the 2023 International Association for the Study of Pain Global Year for Integrative Pain Care. Current models of manual therapy and examples of integrative manual therapy are discussed.

Results

The evolution of concepts in recent years are presented and current gaps in knowledge to guide future research highlighted. Mechanisms of manual therapy are discussed, including specific and contextual effects. Findings from research on animal and humans in manual therapy are presented including on inflammatory markers, fibrosis, and behaviours. There is low to moderate levels of evidence that the effect sizes for manual therapy range from small to large for pain and function in tension headache, cervicogenic headache, fibromyalgia, low back pain, neck pain, knee pain, and hip pain.

Conclusion

Manual therapies appear to be effective for a variety of conditions with minimal safety concerns. There are opportunities for manual therapies to integrate new evidence in its educational, clinical, and research models. Manual therapies are also well-suited to fostering a person-centred approach to care, requiring the clinician to relinquish some of their power to the person consulting. Integrated manual therapies have recently demonstrated a fascinating evolution illustrating their adaptability and capacity to address contemporary societal challenges.

An Additive Effect of Instrument-Assisted Soft Tissue Mobilization with Spinal Manipulation in Cervicogenic Headache: a Randomized Controlled Trial

INTRODUCTION

There is a multitude of evidence supporting the use of manual and manipulative therapy techniques for patients with cervicogenic headache (CGH). However, evidence in finding and comparing the efficacy of instrument assisted soft tissue mobilization with manual therapy in unilateral cervicogenic headache is lacking. Therefore, the objective of the study is to find and compare the long term effects of instrument assisted soft tissue mobilization along with spinal manipulation therapy in patients with cervicogenic headache.

METHODS

It is a randomized, single-blinded controlled study conducted at University hospital. Overall, 64 participants with CGH were divided into spinal manipulation therapy group (SMT; n = 32) and spinal manipulation therapy with instrument assisted soft tissue mobilization (ISM) group (SMT + ISM; n = 32) and they received the respective treatment for 4 weeks. In addition, both groups received 10 min of heat therapy and neck isometric exercises three times a day. The primary (CGH frequency) and secondary (CGH pain intensity, CGH disability neck pain frequency, pain intensity, pain threshold, neck disability index and quality of life) scores were measured at baseline, after 4 weeks, and at 6 months.

RESULTS

The reports of the SMT and SMT + ISM group were compared. Following 4 weeks of training, and at 6 months follow up the SMT + ISM group showed more significant changes in the primary outcome (CGH frequency) with a -4.3 [(95% confidence interval (CI) -4.80 to -3.79] and -1.7 (95% CI -1.92 to -1.47), when compared with the SMT group alone (p = 0.001). The secondary outcomes (CGH pain intensity, CGH disability, neck pain frequency, neck pain intensity, neck disability index, and quality of life) also shows more significant changes in the SMT + ISM group than the SMT group (p = 0.001). The same gradual improvement can be seen in the above variables at 6 months follow up. At the same time, neck pain threshold level does not show any improvement at 4 weeks (p ≥ 0.05) but shows a statistical difference at 6 months follow up. No such adverse effects or consequences were noted during or after the intervention.

CONCLUSIONS

The study concluded that spinal manipulation therapy with instrument assisted soft tissue mobilization provided better long-term outcomes in patients with cervicogenic headache. This study provided a piece of sound physical therapy evidence for a widespread and costly clinical condition, such as cervicogenic headache.

CLINICAL TRIAL REGISTRATION

The trial was registered prospectively in the Indian clinical trial registry with CTRI/2020/06/026243 on 30/06/2020.

The safety and feasibility of transcranial direct current stimulation combined with conservative treatment for patients with cervicogenic headaches: A double-blinded randomized control study protocol

Background

Cervicogenic headaches (CGH) are common following concussion and whiplash injuries and significantly reduce patient quality of life. Conservative therapies such as ET (ET) and physiotherapy combined with injection-based therapies are cornerstones of treatment for CGH but have shown limited efficacy. Transcranial direct current stimulation (tDCS) over the primary motor cortex (M1) has shown promise in treating other chronic pain conditions. The primary aim of this trial is to evaluate the feasibility and safety of tDCS when combined with ET for the treatment of CGH.

Methods

Adults (aged 18-65), blinded to treatment arm, will be randomized into one of two groups: active tDCS followed by ET or sham tDCS followed by ET. Transcranial direct current stimulation will be applied over M1 three times per week for 6-weeks and ET will be performed daily. The primary outcomes of this trial will be the feasibility and safety of the intervention. Feasibility will be defined as greater than 30 % recruitment, 70 % protocol adherence, and 80 % retention rate. Safety will be defined as no severe adverse events. Secondary exploratory outcomes will assess improvement in pain, strength, function, and quality of life.

Conclusions

This trial aims to demonstrate the safety and feasibility of tDCS in combination with ET for the treatment of CGH. Cervicogenic headaches can be difficult to treat contributing to significant impairments function and quality of life. Transcranial direct current stimulation is a potential novel treatment to improve health outcomes in these patients.

Registration

ClinicalTrials.gov-NCT05582616.

Manual physical therapy for neck disorders: an umbrella review

INTRODUCTION

Neck pain is a common musculoskeletal disorder, with a prevalence rate (age-standardized) of 27.0 per 1000 in 2019. Approximately 50-85% of individuals with acute neck pain do not experience complete resolution of symptoms, experiencing chronic pain. Manual therapy is a widely employed treatment approach for nonspecific neck pain (NSNP), cervical radiculopathy (CR) and cervicogenic headaches (CGH). This umbrella review synthesized systematic reviews examining manual physical therapy for individuals with cervical disorders.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed with Prospero registration (CRD42022327434). Four databases were searched from January 2016 to May 2023 for systematic reviews with or without meta-analysis examining manual therapy for individuals with neck pain of any stage. Interventions included any manual physical therapy of the cervical or thoracic spine as well as neuromobilization of the upper quarter. Primary outcomes included pain and disability. Two reviewers screened for eligibility and completed data extraction. Methodological quality was assessed using the Assessment of Multiple Systematic Reviews (AMSTAR 2) tool.

RESULTS

A total of 35 SRs were included: 15 NSNP, 7 cervical radiculopathy, 9 CGH and 4 samples with combined diagnoses. AMSTAR 2 ratings of the SRs support high confidence in results for 10 reviews, moderate confidence in 12 reviews and low to critically low confidence in 13 reviews. For NSNP, there was high confidence in the results showing manual therapy combined with exercise was superior to either treatment in isolation. In cervical radiculopathy, neural mobilization, distraction, soft tissue treatment and mobilization/manipulation to cervical and thoracic spine were supported with moderate confidence in results. For CGH, there was high confidence in the results supporting the use of cervical spine mobilization/manipulation, soft tissue mobilization, and manual therapy combined with exercise. Original authors of SRs reported varying quality of primary studies with lack of consistent high quality/low risk of bias designs.

CONCLUSION

Manual therapy plus exercise, cervical or thoracic mobilization and manipulation, neuromobilization, and other types of manual therapy were supported as effective interventions in the management of pain and disability for individuals with NSNP, CGH, or CR in the short-term.

Practitioner characteristics of osteopaths who treat pregnant women and children: An Australasian perspective from two practice-based research networks

BACKGROUND

Although there is evidence supporting positive outcomes for osteopathic healthcare during pregnancy and post-natal phases, there is very little that describes the practice and management characteristics of osteopaths providing this healthcare. The aim of this study is to describe the specific characteristics of Australian and New Zealand osteopaths who often treat pregnant women and children.

MATERIAL AND METHODS

The study is a secondary analysis of data from osteopathy practice-based research networks (PBRN) in Australia and New Zealand. Chi-square tests were used to explore associations between practitioner and practice characteristics among osteopaths who report often providing care to children (aged up to 3 years, or between 4 and 18 years) and pregnant women, and those who do not. Backward logistic regression was used to identify significant predictors of Australian osteopaths who report often providing care to children (aged up to 3 years, or between 4 and 18 years) and pregnant women.

RESULTS

One third (33.4 %) of surveyed Australian and New Zealand osteopaths (n = 1269) indicated they treat pregnant patients often, while 18.3 % indicated they often treat children up to 3 years old, and 28.7 % indicated often treating children between 4 and 18 years old. Osteopaths who treated pregnant women and children were more likely to be female and to have 15 years or more of clinical experience. Osteopaths who treated pregnant women were more likely to often treat patients up three years old, compared to osteopaths who reported not often treating pregnant women.

CONCLUSION

These characteristics suggest osteopaths who provide care to pregnant women are more commonly female, and female osteopaths are more likely to treat children under 3 years old.

Effect of cervical traction on cervicogenic headache in patients with cervical radiculopathy: a preliminary randomized controlled trial

BACKGROUND

Cervical radiculopathy (CR) is a common condition, often associated with cervicogenic headache (CGH), a secondary headache arising from cervical spine disorders. Mechanical intermittent cervical traction (MICT) is frequently prescribed to treat CR symptoms. The purpose of the study was to make a preliminary estimate of efficacy of adding MICT to conventional rehabilitation on CGH in patients with cervical radiculopathy.

METHODS

A total of 36 CR patients with CGH were randomly allocated to 3 equally sized groups (A, B and C). The treatment consisted of twelve sessions of conventional rehabilitation (4 weeks) combined with MICT (2 kg for group A, 8 kg for group B and 12 kg for group C). Primary outcomes were CGH intensity (visual analog scale) and frequency (days per week). Secondary outcomes were radicular pain intensity (visual analog scale), cervical range of motion (cervical range of motion instrument), proprioception (cervical range of motion instrument) and muscle strength (MicroFET2 dynamometer), handgrip strength (handheld dynamometer), function (Neck Disability Index), kinesiophobia (Tampa Scale for KInesiophobia), anxiety and depression (Hospital Anxiety and Depresion questionnaire), and quality of life (World Health Organization Quality of Life). Patients were assessed at baseline, one, three and six months after the beginning of treatment. The post hoc Dunn testing was used to determine which traction load had the better effect on CGH symptoms.

RESULTS

At one, three and six months follow-ups, Group C exhibited the highest improvement in CGH intensity and frequency compared to the other groups (p = 0.021 and p = 0.023; p = 0.012 and p = 0.01; p = 0.005 and p = 0.005). Both groups C and B showed a significant improvement in radicular pain compared to group A at one month follow-up (p = 0.05).The improvement in group C was significantly better in terms of function (p = 0.049) and anxiety (p = 0.011) at three months and quality of life at six months (Psychological p = 0.046 and Environment p = 0.006).

CONCLUSIONS

The blend of conventional rehabilitation alongside 12 kg MICT seems to be efficacious in diminishing both the intensity and frequency of CGH in patients with CR. These advantages appear to last for up to six months following the treatment period, potentially leading to decreased CGH severity and occurrence rates, heightened functionality, reduced anxiety levels, and an overall enhancement in quality of life. These findings are preliminary and require confirmation in larger trials.

TRIAL REGISTRATION

The study protocol was retrospectively registered at the Pan African Clinical Trial Registry (PACTR202401838955948). Date of registration is 16/01/2024.

The Effects of cervical mobilization and clinical pilates exercises in cervicogenic headache: randomized controlled trial

OBJECTIVES

To investigate the effects of Cervical Mobilization (CM) and Clinical Pilates Exercises (CPE) in Cervigogenic Headache (CHA).

METHODS

The 37 patients were randomized into the 3 groups. The CM for 1st group, CPE for 2nd group and CM+CPE for 3rd group were applied 3 days/a week for 6 weeks. Pain frequency, pain intensity, number of analgesic, were recorded. The posture was measured by Posture Screen application, the cervical range of motion by the CROM device, deep neck flexor muscle endurance by the pressurized biofeedback device. Evaluations were applied 2 times as pre-post treatment.

RESULTS

In within-group comparison a decrease in pain parameters, neck-shoulder postural deviation and an increase DNFE and CROM were observed in all groups (p<0.05). In between-group comparison pain frequency, intensity and number of analgesics were significant changes in the CM and CM+CPE groups according to CPE (respectively p<0,001, p=0,001, p=0,018). Head and shoulder angulation were significant in the CPE and CM+CPE groups according to CM (respectively p=0.009, p=0,011). It was determined that the cervical right lateral flexion range of motion and right rotation were significant changes in the CM and CM+CPE groups according to CPE (respectively p=0,026, p=0,040). DNFE were significantly increased in CM+CPE according to CM and CPE (p=0.001).

CONCLUSION

This study suggests that it would be beneficial to add CM and CPE to the treatment plans of patients with CHA.

Mulligan manual therapy added to exercise improves headache frequency, intensity and disability more than exercise alone in people with cervicogenic headache: a randomised trial

QUESTION

What is the effect of a 4-week regimen of Mulligan manual therapy (MMT) plus exercise compared with exercise alone for managing cervicogenic headache? Is MMT plus exercise more effective than sham MMT plus exercise? Are any benefits maintained at 26 weeks of follow-up?

DESIGN

A three-armed, parallel-group, randomised clinical trial with concealed allocation, blinded assessment of some outcomes and intention-to-treat analysis.

PARTICIPANTS

Ninety-nine people with cervicogenic headache as per International Classification of Headache Disorders (ICHD-3).

INTERVENTIONS

Participants were randomly allocated to 4 weeks of: MMT with exercise, sham MMT with exercise or exercise alone.

OUTCOME MEASURES

The primary outcome was headache frequency. Secondary outcomes were headache intensity, headache duration, medication intake, headache-related disability, upper cervical rotation range of motion, pressure pain thresholds and patient satisfaction. Outcome measures were collected at baseline and at 4, 13 and 26 weeks.

RESULTS

MMT plus exercise reduced headache frequency more than exercise alone immediately after the intervention (MD between groups in change from baseline: 2 days/month, 95% CI 2 to 3) and this effect was still evident at 26 weeks (MD 4 days, 95% CI 3 to 4). There were also benefits across all time points in several secondary outcomes: headache intensity, headache duration, headache-related disability, upper cervical rotation and patient satisfaction. Pressure pain thresholds showed benefits at all time points at the zygapophyseal joint and suboccipital areas but not at the upper trapezius. The outcomes in the sham MMT with exercise group were very similar to those of the exercise alone group.

CONCLUSIONS

In people with cervicogenic headache, adding MMT to exercise improved: headache frequency, intensity and duration; headache-related disability; upper cervical rotation; and patient satisfaction. These benefits were not due to placebo effects.

TRIAL REGISTRATION

CTRI/2019/06/019506.

The Effects of Cervical Mobilization with Clinical Pilates Exercises on Pain, Muscle Stiffness and Head and Neck Blood Flow in Cervicogenic Headache: Randomized Controlled Trial

Background and Objectives: Physiotherapy approaches are used to eliminate the problems caused by cervicogenic headache (CHA), known as secondary headache associated with the structures of the upper cervical region. This study aimed to investigate the effects of cervical mobilization (CM) with clinical Pilates exercises (CPE) on pain, muscle stiffness and head-neck blood flow in CGH. Materials and Methods: A total of 25 patients participated in this randomized controlled study and were randomized into either the CM group or the CM+CPE group. All treatment methods were applied 3 days a week for 6 weeks. The outcome measure was headache intensity and frequency, the number of analgesics, muscle stiffness and vertebral artery (VA) and internal carotid artery (ICA) blood flow. Headache intensity was measured by a visual analogue scale, muscle stiffness by a myotonometer and blood flow by Doppler US. Evaluations were repeated after 6 weeks of treatment. Within-group comparisons were made by the Wilcoxon signed rank test, and between-group comparisons were made by the Mann-Whitney U test. Results: After treatments in the two groups, headache intensity and frequency and the number of analgesics decreased, the muscle stiffness of the suboccipital, upper trapezius and sternocleidomastoid (SCM) muscles decreased, and the blood flow of the ICA and VA increased (p < 0.05). There was a significant difference between the groups in terms of headache intensity (p = 0.025) and muscle stiffness in SKM (p = 0.044) in favor of the CM+CPE group. Conclusions: Non-pharmacological treatment approaches have an important role in CHA related to the upper cervical region. This study suggests that it would be beneficial to add CM in combination with CPE to the non-pharmacological treatment of patients with CHA.

Effectiveness of Nonpharmacological Measures on Improving Headache Score, Strength, Pain, and Quality of Life in Cervicogenic Headaches: A Systematic Review

Cervicogenic headache (CGH) is a common condition affecting a significant portion of the population and is effectively managed through various interventions, including nonpharmacological approaches. Physical therapy plays a crucial role in CGH management, with numerous studies supporting its effectiveness. This systematic review aimed to evaluate the effectiveness of specific nonpharmacological physical therapy interventions for CGH. A comprehensive search was conducted across various databases (PubMed, Medline, PEDro, and Cochrane Library) for randomized controlled trials (RCTs) published between January 2017 and January 2023 investigating the effectiveness of specific nonpharmacological physical therapy interventions for CGH. We employed manual searches to capture potentially missed studies. Independent reviewers screened all studies based on predefined eligibility criteria. Extracted data included methodology, specific interventions, outcome measures (headache score, strength, pain, and quality of life (QOL)), and study conclusions. Eight RCTs were identified as meeting all inclusion criteria and were thus included in the data synthesis. The findings from these trials revealed a diverse range of nonpharmacological physical therapy interventions, including but not limited to manual therapy, exercise therapy, and multimodal approaches. Specifically, the interventions demonstrated significant improvements in headache scores, strength, pain levels, and overall QOL among individuals with CGH. These results underscore the multifaceted benefits of physical therapy in managing CGH and highlight its potential as a comprehensive treatment option. This review identified eight relevant RCTs investigating nonpharmacological interventions for CGH. Despite the promising findings, this review acknowledges several limitations, including the limited sample size and the heterogeneity of interventions across studies. These limitations emphasize the necessity for further research to elucidate optimal intervention strategies and refine treatment protocols. Nevertheless, the comprehensive analysis presented herein reinforces the pivotal role of physical therapy in not only alleviating pain but also enhancing function and improving the QOL for individuals suffering from CGH.

Clinical Effectiveness of Craniosacral Therapy in Patients with Headache Disorders: A Systematic Review and Meta-analysis

OBJECTIVES

To analyze the effectiveness of craniosacral therapy in improving pain and disability among patients with headache disorders.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Physiotherapy Evidence Database, Scopus, Cochrane Library, Web of Science, and Osteopathic Medicine Digital Library databases were searched in March 2023.

REVIEW METHODS

Two independent reviewers searched the databases and extracted data from randomized controlled trials comparing craniosacral therapy with control or sham interventions. The same reviewers assessed the methodological quality and the risk of bias using the PEDro scale and the Cochrane Collaboration tool, respectively. Grading of recommendations, assessment, development, and evaluations was used to rate the certainty of the evidence. Meta-analyses were conducted using random effects models using RevMan 5.4 software.

RESULTS

The searches retrieved 735 studies, and four studies were finally included. The craniosacral therapy provided statistically significant but clinically unimportant change on pain intensity (Mean difference = -1.10; 95% CI: -1.85, -0.35; I2: 44%), and no change on disability or headache effect (Standardized Mean Difference = -0.34; 95% CI -0.70, 0.01; I2: 26%). The certainty of the evidence was downgraded to very low.

CONCLUSION

Very low certainty of evidence suggests that craniosacral therapy produces clinically unimportant effects on pain intensity, whereas no significant effects were observed in disability or headache effect.

Efficacy of the transcutaneous electrostimulation in treatment dysfunctions of the TMJ associated with occlusion distortions

BACKGROUND

The study evaluation of the effectiveness the method of electrostimulation in treatment TMJ associated with occlusion disorders with the use of a patches by the company "Aganyan''.

METHODS

The study included 54 patients with temporomandibular dysfunction syndrome who had previously undergone endodontic dental treatment. In patients temporomandibular disorders (TMD) determined on the basis of Diagnostic criteria for temporomandibular disorders(DC/TMD).All patients had occlusion disorders due to errors after dental filling restoration. To diagnose the TMJ, a CT scan was used. The complex therapy also included therapy and with the use of a patches by the company "Aganyan''. The wearable patch includes a flexible substrate, a binder an adhesive layer, with an electrode foil attached to it. Patients applied one patch behind each TMJ. The patches were applied for eight hours every third day for three months. All the patients were given full-fledged endodontic treatment and restoration of the crown part, taking into account anatomical features.

RESULTS

The dynamics of the complex treatment of patients diagnosed with TMJ dysfunction syndrome showed that after treatment, the clinical symptoms gradually decreased and disappeared at the end of treatment. CT scan a year after treatment showed a normal ratio of TMJ elements. Сomplex treatment was effective in 87% of patients, after 3-5 months gradually decreased pain, noise in the joints, restriction of opening and closing of the mouth disappeared. Patients recovered their chewing functions, psycho-emotional state.

CONCLUSION

The results of the studies revealed a positive effects for the complex treatment dysfunctions syndrome TMJ the using the patches by the company "Aganyan" through electrical stimulation with low intensity.

Effectiveness of thoracic spine manipulation for upper quadrant musculoskeletal disorders: protocol for a systematic review

INTRODUCTION

Upper quadrant musculoskeletal disorders (UQMD), comprising of cranial, cervical, shoulder and upper extremity disorders, are among the most frequently reported disorders in clinical practice. Thoracic high velocity low amplitude thrust (Tx-HVLAT) manipulation is a form of conservative management recommended in systematic reviews as an effective treatment option for aspects of UQMD disorders such headache, shoulder pain and lateral elbow pain. However, no recent systematic reviews have assessed the effectiveness across UQMD. Therefore, this systematic review aims to update the current evidence on the effectiveness of Tx-HVLAT for patients with UQMD on (1) patient-reported outcomes, (2) performance measures or (3) psychosocial outcomes.

METHODS AND ANALYSIS

The Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, PEDro and Index to Chiropractic Literature will be searched from inception using Medical Subject Headings (MeSH), Thesaurus and/or free-text words. Combinations will be made based on localisation, disorder, intervention and design. Following guidelines as advised by the Cochrane Back Review Group, published randomised controlled trials will be included. Two review authors will independently assess the risk of bias (ROB) using the Cochrane Back Review Group's recommended ROB2 tool and will independently extract the data using a standardised data extraction form. Overall quality of the evidence will be evaluated using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method. For continuous data, we will calculate standardised mean differences with 95% CIs. For dichotomous outcomes, relative risks and 95% CIs will be calculated. Where possible we will present a subgroup analysis by disorder. For pooling, a random-effects model will be used.

ETHICS AND DISSEMINATION

Ethics approval is not required for this systematic review. The study findings will be submitted to a relevant peer-reviewed journal for dissemination and presented at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42023429996.

Stretching and muscle-performance exercises for chronic nonspecific neck pain: who may benefit most?

BACKGROUND

Although exercise is the mainstay of treatment for neck pain (NP), uncertainty remains over optimal decision-making concerning who may benefit most from such, particularly in the long term.

OBJECTIVE

To identify the subgroup of patients with nonspecific NP most likely to benefit from stretching and muscle-performance exercises.

METHODS

This was a secondary analysis of treatment outcomes of 70 patients (10 of whom dropped out) with a primary complaint of nonspecific NP in one treatment arm of a prospective, randomized, controlled trial. All patients performed the exercises, twice weekly for 6 weeks, and a home exercise program. Blinded outcome measurements were collected at baseline, after the 6-week program, and at a 6-month follow-up. Patients rated their perceived recovery on a 15-point global rating of change scale; a rating of "quite a bit better" (+5) or higher was defined as a successful outcome. Clinical predictor variables were developed via logistic regression analysis to classify patients with NP that may benefit from exercise-based treatment.

RESULTS

NP duration since onset≤6 months, no cervicogenic headache, and shoulder protraction were independent predictor variables. The pretest probability of success was 47% after the 6-week intervention and 40% at the 6-month follow-up. The corresponding posttest probabilities of success for participants with all three variables were 86% and 71%, respectively; such participants were likely to recover.

CONCLUSION

The clinical predictor variables developed in this study may identify patients with nonspecific NP likely to benefit most from stretching and muscle-performance exercises in the short and long terms.