PRACA ORYGINALNA

ORIGINAL ARTICLE

NON-PHARMACOLOGICAL TREATMENT OF CHRONIC NECK−SHOULDER MYOFASCIAL PAIN IN PATIENTS WITH FORWARD HEAD POSTURE

Niefarmakologiczne metody leczenia przewlekłego zespołu bólowego mięśniowo-powięziowego szyi i barku u pacjentów z postawą głowy przodującej

Oleksandr A. Iaroshevskyi, Olga G. Morozova, Anna V. Logvinenko, Yana V. Lypynska

Kharkiv Medical Academy of Postgraduate Education, Kharkiv, Ukraine

Abstract

Introduction: Today, chronic pain remains a pressing medical and socio-economic problem, despite the rapid development of medical technologies, the presence of a vast arsenal of drug and non-drug treatments. Estimates for chronic pain prevalence ranged from 8% to 60%. At the same time, about 40% of patients report insufficient effectiveness in the treatment of chronic pain syndrome.

The aim of the study was to compare the effectiveness of MTrPS management by biomechanical correction of the musculoskeletal system combined with therapeutic exercises, DN and TrPs−pressure release with the effectiveness of MTrPS management by therapeutic exercises combined with DN and TrPs−pressure release in patients with chronic neck−shoulder myofascial pain and FHP.

Materials and methods: 87 patients (mean age − 39±4,9 years) with chronic neck−shoulder myofascial pain and FHP were randomly assigned to 2 treatment groups. Group 1 received a biomechanical correction, DN, TrPs−pressure release. Group 2 − therapeutic exercises, DN, TrPs−pressure release. Study protocol included CVA-measurement, assessment of pain intensity with VAS, assessment of QoL using MOS SF-36.

Results: increase of CVA (59,07°±1,41 in the 1st group, and 51,2°±2,01 in the 2nd group (p=0,036)), decrease of pain and decrease of influence of neck pain in performance of everyday activities, the improvement of QoL immediately after treatment occurred in both groups. However, after 3 months of therapy, 1-st group revealed more improvement than the 2-nd.

Conclusion: Comparison of the effectiveness of MTrPS management by biomechanical correction of the musculoskeletal system combined with therapeutic exercises, DN and TrPs−pressure release with the effectiveness of MTrPS management by therapeutic exercises combined with DN and TrPs−pressure release in patients with chronic neck−shoulder myofascial pain and FHP demonstrated no significant differences between the therapeutic approaches in the short term. In the medium term, the inclusion of biomechanical correction in the treatment protocol demonstrated higher efficiency compared with the combination of therapeutic exercises, DN and TrPs−pressure release.

Key words: Myofascial pain; Trigger point; Forward head posture; Biomechanical correction, Dry needling

Wiad Lek 2019, 72, 1, 84-88

INTRODUCTION

Today, chronic pain remains a pressing medical and socio-economic problem, despite the rapid development of medical technologies, the presence of a vast arsenal of drug and non-drug treatments. Estimates for chronic pain prevalence ranged from 8% to 60%. At the same time, about 40% of patients report insufficient effectiveness in the treatment of chronic pain syndrome [1, 2].

Chronic pain significantly impairs the quality of life of patients, negatively affecting their physical, mental and cognitive functioning, causing the development of anxiety and depressive disorders. Emotional stress arising from chronic pain has a detrimental effect on the fulfillment of professional, domestic responsibilities, relationships with family and friends, often leading to social isolation of patients [2, 3]. Economic losses associated with loss of productivity, job absenteeism, early retirement due to chronic pain, according to various estimates, in Europe range from three to 10% of gross domestic product [2, 4].

A special place in the structure of chronic pain belongs to musculoskeletal pain, the prevalence of which in the population is up to 68% [4, 5]. One of the most common causes of chronic non-specific neck pain is myofascial pain syndrome (MPS) [6−9], often developing due to biomechanical disorders of the musculoskeletal system, causing uneven distribution of the load on the muscles and, as a result, overloading of some and functional weakness of other muscles [11, 12].

One of the most common biomechanical disorders is the displacement of the regional center of gravity at the cervical level forward with the formation of the forward head posture, which is due to the peculiarities of the modern lifestyle: driving a car, using smartphones, tablets, working at a computer. The development of the forward head posture results in the chronic functional overload of the muscle-extensors with the formation of myofascial trigger points (MTrPs) in them and development of myofascial pain syndrome (MPS) and myofascial pain dysfunction (MPD) of cervical – brachial localization [13].

Standard treatments which are employed in the management of MPS, include stretching the affected muscle using aerosol fluoromethane, therapeutic exercises, massage, therapeutic ultrasound, injection of local anesthetics, steroids or botulinum toxin into TrPs, TrPs−pressure release, dry needling (DN) and taking nonsteroidal anti-inflammatory drugs for the relief of pain [10, 14]. At the same time, in some researches the positive immediate effect of biomechanical correction of the musculoskeletal system, based on the use of manual therapy techniques in MPS−treatment have been reported [11, 12, 15].

THE AIM

The aim of our study was to compare the effectiveness of MTrPS management by biomechanical correction of the musculoskeletal system combined with therapeutic exercises, DN and TrPs−pressure release with the effectiveness of MTrPS management by therapeutic exercises combined with DN and TrPs−pressure release in patients with chronic neck−shoulder myofascial pain and forward head posture.

MATERIALS AND METHODS

87 patients (43 male & 44 female) aged 18−44 years with chronic neck−shoulder myofascial pain and forward head posture participated in the study. Their mean age was 39±4,9 years. The diagnosis of MPS was based on the diagnostic criteria of myofascial pain [16]. The mean duration of pain syndrome was 14 ± 2,43 months.

Inclusion criteria were: age ranges from 18 to 44 years old, presence of chronic neck−shoulder myofascial pain and FHP.

Exclusion criteria were: less than 4 months duration of MPS, damaged skin or infection in the MTrPs area, specific neck pain, cervical radiculopathy, history of previous neck surgery or whiplash injury, fibromyalgia, bleeding disorders, autoimmune connective tissue diseases, rheumatism, cardiopulmonary disease with decreased activity tolerance, renal disorders, pregnancy, receiving other treatment (drug or non-drug treatment of pain syndrome). All patients were informed about the nature of the study, procedures, risks benefits, treatment schedules and were asked to sign an Informed consent document, which corresponds to International Ethical Guidelines for Biomedical Research.

Patients participating in the study were randomly assigned to two treatment groups. Group 1 included 43 patients (22 women, 21 men), group 2 included 44 patients (22 women, 22 men). The groups were similar for age, sex and duration of pain syndrome. Study protocol included clinical–neurological, vertebro–neurological examination (visual assessment of violations of statics of the musculoskeletal system, manual diagnostics) and measurement of craniovertebral angle (CVA) using the photogrammetric method. The CVA measurement is considered to be a valid and reliable assessment tool to assess the FHP. The CVA ≥55° were considered normal. Subjects with FHP had the CVA <55° [13, 17].

The mobility of the vertebral motor segments (VMS) of the cervical spine, the presence of their functional blocking, pain and swelling of the surrounding tissues were determined using manual diagnosis. The presence of MTrPs was detected using flat palpation techniques. The Visual analogue scale (VAS) was used to measure the intensity of pain (Huskisson E. C. (1974)). Neck Disability Index (NDI) (H. Vernon, S. Mior, 1991) was used to evaluate the influence of neck pain in performance of everyday activities. The quality of life of patients was assessed using the Russian version of MOS SF-36 (Medical Outcomes Study-Short Form) (1998). Patients were assessed prior to the study, immediately after the end of therapy and 3 months after the end of therapy.

The treatment of patients of the first study group included biomechanical correction of the musculoskeletal system combined with therapeutic exercises, DN and TrPs−pressure release. Biomechanical correction of the musculoskeletal system based on the use of manual therapy techniques (joint mobilization and joint manipulation) which mechanically eliminate functional blockade of VMS and restore the physiologic range of motion in them, improve venous outflow, microcirculation, reduce soft tissue swelling and eliminate pathological afferentation from the affected VMS; musculoskeletal techniques (post-isometric, post-reciprocal, anti-gravity relaxation of the muscles, myofascial release and post-isometric spinal automobilization techniques) with the help of which the pathological consequences of functional blocking of VMS in muscles and fascia are eliminated [11, 15]. Patients received a biomechanical correction session combined with DN and TrPs−pressure release one time in 2 days. Duration of treatment: 5 sessions. Sessions of manual therapy were supplemented with individually selected therapeutic exercises aimed at consolidating the static and dynamic stereotype achieved during manual therapy, stretching the affected muscles, which contributed to the inactivation of MTrPs and the relief of pain. The number of exercises was gradually increased after deactivating the MTrPs and reducing the pain syndrome.

The treatment of patients of the 2−nd study group included therapeutic exercises combined with DN and TrPs−pressure release. The course of DN and TrPs−pressure release was five treatments over the course of 10 days. Therapeutic exercises were performed by patients daily for 10 days.

Statistical analyses were carried out in STATISTICA 10 soft−ware (Statsoft Inc., USA). The results were considered statistically significant when p<0,05.

RESULTS АND DISCUSSION

The main complaints of patients of both studied groups before the start of therapy were pain and stiffness in the neck and shoulder girdle, the increase of which they attributed to the presence of long-term static loads (e.g. computer work or driving a car). Visual diagnosis of biomechanical disorders in patients of both groups revealed: displacement of the regional center of gravity at the cervical level forward with the formation of the forward head posture, compensatory enhancement of thoracic kyphosis with internal rotation of the shoulder joints, elevation of the clavicle and the entire shoulder girdle.

The mean value of the CVA in the 1-st group was 49,4°±2,02, in the 2-nd group − 49,6°±1,98. There were no statistically significant differences between groups (р=0,093).

Muscular hypertonicity and active MTrPs causing the appearance of a typical pain pattern in patients of both groups were detected in the superior and inferior oblique muscles of the head, large and small posterior rectus muscles, sternocleidomastoid muscles, anterior scalene muscles, in the upper portions of trapezius muscles, levator scapulae, in the supraspinatus, subscapularis, infraspinatus, and deltoid muscles.

An average value of pain syndrome according to VAS in the 1-st group was 43,1±6,8, in the 2-nd group − 42,9±5,7. There were no statistically significant differences between groups (р=0,071). Mean NDI score was 34,7±9,3 in the 1-st group and 34,1±8,7 in the 2-nd group (р=0,067).

The results of the study of quality of life (QoL) using the MOS SF-36 scale before therapy starting showed a decrease in the quality of life in both groups (Table І). Both the mental and physical scores of the SF-36 quality of life scale were reduced. There were no statistically significant differences between groups.

The main factors leading to a decrease in QoL in patients of both groups were: chronic neck−shoulder myofascial pain, chronic daily headaches, sleep disturbances caused to chronic pain, presence of affective disorders (anxiety and depression), fatigue. Both groups of observation demonstrated positive dynamics after the end of therapy. Patients noted a decrease in the severity of pain, sleep disturbances, a decrease in the severity of emotional disturbances and fatigue.

A visual diagnosis, carried out 10 days after the start of therapy, revealed in both groups a decrease in the severity of biomechanical changes in the cervical-thoracic region (reducing of the severity of FHP and thoracic spine kyphosis). Objectification of the degree of FHP using the measurement of CVI by photogrammetric method revealed a more significant positive dynamics in the regression of biomechanical disorders in patients of the 1-st study group. (Fig.1).

The CVI, measured by the photogrammetric method on the 11th day was 59,07°±1,41 in the 1st group, and 51,2°±2,01 in the 2nd group (p=0,036). Manual diagnosis carried out after the end of treatment revealed a significant decrease in the severity of hypertonicity and active MTrPs in the muscles of the neck and shoulder region in patients of both groups. An average value of pain syndrome according to VAS on the 11th day was 6,1±1,03 in the 1-st group and 6,4±1,08 in the 2-nd group. There were no statistically significant differences between groups (р=0,09). Mean NDI score on the 11th day was 6,2±0,97 in the 1-st group and 6,4±0,86 in the 2-nd group (р=0,087).

The analysis of the MOS SF-36 questionnaire, carried out on day 11, demonstrated an improvement in the physical and mental health component in both of the studied groups with no statistically significant differences between groups (Table ІІ). All patients reported increased work ability, improved sleep quality and mood.

The analysis of complaints of patients 3 months after the treatment showed that 11/25,58 % of patients of the 1-st and 36/81,82 % of patients of 2-nd group suffered from pain and stiffness in the neck and shoulder girdle. An average value of pain syndrome according to VAS 3 months after treatment was 7,3±1,05 in the 1-st group and 37,7±5,4in the 2-nd group (p=0,021). Mean NDI score 3 months after treatment was 6,8±1,1 in the 1-st group and 23,9±2,08 in the 2-nd group (p=0,0007). Evaluation of QoL after 3 months showed significantly higher rates of both physical and mental health in patients of group 1 (Table II).

Thus, our clinical observations have shown that the application of drug-free treatment ensures high efficiency of therapy, which corresponds to the world trends in treating patients with myofascial pain syndrome [17]. In accordance with the recommendations of the American Physiotherapeutic College, non-pharmacological methods in treating myofascial pain must go before pharmacological ones, and a combination of as many adequate techniques of drug-free therapy as possible is very important.

Manual therapy is essential for restoring muscle functions. Our research has completely confirmed this claim, since the treatment of patients without application of biomechanical correction of the vertebrae has had a lesser effect in a long-term perspective.

CONCLUSION

Comparison of the effectiveness of MTrPS management by biomechanical correction of the musculoskeletal system combined with therapeutic exercises, DN and TrPs−pressure release with the effectiveness of MTrPS management by therapeutic exercises combined with DN and TrPs−pressure release in patients with chronic neck−shoulder myofascial pain and forward head posture demonstrated no significant differences between the two therapeutic approaches in the short term. At the same time, in the medium term, the inclusion of biomechanical correction in the treatment protocol for chronic neck−shoulder myofascial pain and forward head posture demonstrated higher efficiency compared with the combination of therapeutic exercises, DN and TrPs−pressure release.

References

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Authors’ contributions:

According to the order of the Authorship.

Conflict of interest:

The Authors declare no conflict of interest.

CORRESPONDING AUTHOR

Olga G. Morozova

Department of Reflexology,

Kharkiv Medical Academy of Postgraduate Education

58 Amosova str., 61176, Kharkiv, Ukraine

e-mail: morozova.olga.0201@gmail.com

Received: 23.09.2018

Accepted: 17.12.2018

A. B.

Fig.1. Patient G., 27 years old, with chronic neck−shoulder myofascial pain and FHP.

A. − before treatment (CVA=50°), B. – after treatment (CVA=60°).

Table І. Study of QoL (MOS SF-36) before therapy starting in both groups

Subscale

1 group (n=43)

2 group (n=44)

Р

Physical Functioning (PF)

39,03±3,57

38,97±3,96

0,092

Role-Physical Functioning (RP)

39,4±4,77

39,21±4,67

0,071

Bodily Pain (BP)

34,17±4,98

33,98±4,81

0,67

General Health (GH)

36,3±4,23

35,9±4,75

0,072

Vitality (VT)

37,45±3,46

37,73±3,27

0,069

Social Functioning (SF)

39,4±3,91

39,12±3,82

0,63

Role-Emotional (RE)

39,3±3,24

39,6±3,51

0,082

Mental Health (MH)

39,8±5,12

39,11±5,09

0,54

Table ІІ. Study of QoL (MOS SF-36) after therapy starting in both groups

Subscale

1 group (n=43)

2 group (n=44)

Р

On the 11th day

Physical Functioning (PF)

91,7±4,21

91,03±4,11

0,87

Role-Physical Functioning (RP)

90,32±4,63

90,11±4,71

0,69

Bodily Pain (BP)

92,4±2,77

91,9±2,7

0,52

General Health (GH)

94,8±3,11

94,6±3,2

0,91

Vitality (VT)

93,42±2,4

93,21±2,36

0,738

Social Functioning (SF)

92,7±2,18

92,64±2,21

0,56

Role-Emotional (RE)

94,1±2,32

93,9±2,19

0,098

Mental Health (MH)

93,6±3,08

93,09±3,1

0,54

3 months later

Physical Functioning (PF)

91,2±3,74

76,1±5,09

0,027

Role-Physical Functioning (RP)

90,09±3,87

74,23±4,89

0,03

Bodily Pain (BP)

90,9±1,15

72,3±4,5

0,042

General Health (GH)

92,35±2,8

79,4±4,1

0,031

Vitality (VT)

92,67±3,02

78,04±3,62

0,02

Social Functioning (SF)

90,86±1,92

76,64±2,21

0,033

Role-Emotional (RE)

92,6±2,71

73,82±3,14

0,021