This study aims to investigate the effectiveness of low-load endurance exercise as compared to stretching exercise on upper trapezius on pain, pressure pain and muscle stiffness in patients with chronic neck-shoulder pain. The hypothesis is that endurance exercise of the upper trapezius should result in significantly better improvement in terms of neck-shoulder pain, pressure pain threshold and muscle stiffness than stretching exercise.
Participants with unilateral neck-shoulder pain will either perform low-load endurance exercise or stretching exercise of the upper trapezius muscle of the affected side in a 5-week period. Before and after the 5-week training, outcomes will be assessed by investigators in order to compare the effectiveness of two exercises on pain, pressure pain, muscle stiffness, and muscle endurance. Secondary outcomes include Neck Disability Index (NDI) to assess various aspects of daily living impacted by neck pain, and Disabilities of Shoulder, Arm and Hand (DASH) Questionnaire to evaluate the ability to perform various upper limb activities.
Findings to be obtained from this study will help inform the clinical management in particular for self-care of this chronic neck pain group of participants, by refining the exercise prescription for promoting the clinical outcomes for individuals suffering from neck-shoulder pain. In addition, results of this study will also inform physiotherapists the possible mechanisms underlying the improvement of neck-shoulder pain by examination of the relationship between biomechanical properties of muscles, such as muscle endurance or muscle stiffness, and neck-shoulder pain.
(1) are between 20 and 60 years of age;
(2) have worked with Display Screen Equipment (DSE) for a minimum of 20 hours per week;
(3) are presenting persistent, non-specific pain over unilateral neck-shoulder region for more than 3 months, with at least 30 days of pain during the last year;
(4) have average pain rating of Visual Analogue Scale (VAS) larger than 3.4 centimeter out of 10 (moderate level of pain) during the week before data collection;
(1) have regular strength training of the neck and upper limbs during the year before the study;
(2) have neck-shoulder pain with specific diagnosis or known cause, for instance cervical radiculopathy, prolapse of intervertebral disc or disc herniation, or with neurological deficits and symptoms;
(3) have previous cervical spine or upper limb surgery;
(4) have comorbidity which includes but is not limited to neurological disease such as stroke, Parkinson's disease or spinal cord injury, mental illness, heart disease, diagnosis of carpal tunnel syndrome or fibromyalgia; or
Parallel
Upper trapezius low-load endurance exercise
Other interventionParticipants in the EE group will perform the overhead shrug exercise for the affected side using a green Thera-Band Elastic Band. To perform this exercise, the subject will stand and place one arm of the affected side in an overhead position against the wall. The middle portion of the theraband will be placed on the floor, and the subject will stand on the middle portion of the theraband to fixate it in place with both feet shoulder-width apart. Then, the subject grasp both tails of the theraband and perform the shoulder shrug movement for the affected side with a 3-second elevation, hold at the end range for 5 seconds, and then return back to the starting position with a 3-second depression. The subject will perform this exercise for 20 repetitions per set, 3 sets a day with 1-minute rest between sets, 3 alternate days a week, for 5 weeks. They will be instructed to record all training sessions in a diary.
Upper trapezius stretching exercise
Other interventionParticipants in the SE group will perform static upper trapezius stretching exercise for the affected side. To perform the stretch, participants will be asked to sit upright on a chair and look straight ahead. To reduce scapular elevation and upward rotation, the ipsilateral hand should be placed below the buttock. The subject will then be asked to perform deep neck flexion, neck rotation towards the affected side, and contralateral side flexion using the opposite hand in a diagonal direction until the position of 'mild discomfort' is attained. They should maintain the deep neck flexion when performing the stretch. The stretch will be held for 30 seconds each set, 3 sets a day, daily for 5 weeks.
Pain
The average neck-shoulder pain will be indicated by a mark on a 10-cm VAS scale with the leftmost value representing 'no pain (0)' and rightmost value representing 'the worst pain (10)'. The VAS is the most commonly used method to assess neck-shoulder pain intensity, and its test-retest reliability for neck pain is very high, with an intraclass correlation coefficient (ICC) of 0.97.
Muscle stiffness of upper trapezius
Muscle stiffness of the upper trapezius will be measured using a handheld myotonometer device, MyotonPRO. MyotonPRO is a non-invasive, portable device that uses superficial mechanical deformation to assess the biomechanical characteristics of soft tissues. The subject will be tested in a seated position in a chair with back support. The myotonometer will be positioned vertically on the 2 designated points of the upper trapezius. The probe will apply a compression force of 0.18 N, followed by a 5-time mechanical impulse (0.4 N for 15 ms). Stiffness (N/m) will be measured. The measurement will be done on each spot for 3 times in order to obtain an average stiffness (N/m). The stiffness of upper trapezius on both sides will be measured.
Pressure Pain Threshold (PPT)
PPT, the minimum pressure force (kPa) required to evoke pain, will be assessed using a handheld electronic pressure algometer over the upper trapezius. Pressure algometry is a reliable tool for assessing chronic neck pain, with an ICC ranging from 0.78 to 0.93. After the myotonometry measurement is completed, the subject will lie prone on a plinth for the PPT measurement. The same 2 designated points used for the myotonometry measurement will be assessed. During the test, the algometer will be placed perpendicular to the skin and apply an increasing pressure at a constant rate. The subject will press a handheld button when the pressure exerted turns to pain. The measurement will be done on each spot for 3 times in order to obtain an average (N/cm square), and it will be performed on both sides.
Upper Trapezius Endurance
The muscle endurance of upper trapezius will be measured objectively utilizing a 5-minute electrical stimulation protocol, which was adopted in a previous study. Two silicon electrodes will be placed at two points: one point just lateral to C7 spinous process and the other point medial to acromion, with ultrasound gel applied underneath the electrodes. A tri-axial accelerometer will be positioned between the two electrodes. The upper trapezius will be stimulated with a current level that produces a visually noticeable and comfortable contraction in the subject. Then, the intensity will be adjusted to achieve a vigorous contraction ranging from 25mA to 30mA, with a pulse duration of 200μs. The electrical stimulation will last for 5 minutes at a frequency of 5Hz. The endurance index (EI) will be calculated by dividing the peak twitches at the end of the acceleration by the peak twitches at the start, expressed as a percentage.
Neck Disability Index (NDI)
The NDI is a self-report questionnaire consisting of 10 items that assess various aspects of daily living impacted by neck pain, with each item scored on a scale from 0 (no disability) to 5 (greatest disability). The total score will then be converted to a percentage. The scoring of NDI is as follow: 0-4 points (0-8%) indicates no disability; 5-14 points (10-28%) indicates mild disability; 15-24 points (30-48%) indicates moderate disability; 25-34 points (50-64%) indicates severe disability; and 35-50 points (70-100%) indicates complete disability. The NDI is a valid and reliable tool for assessing neck-shoulder pain and is frequently used to assess functionality in the workplace. Previous studies have reported ICCs ranging from 0.50 to 0.98. A 5-point change in NDI score is deemed clinically significant.
Disabilities of Shoulder, Arm and Hand (DASH) Questionnaire
The DASH questionnaire consists of 30 items that evaluate the ability of the subject to perform various upper limb activities, with each item scored on a scale from 0 (no difficulty) to 5 (unable). The scoring formula of DASH questionnaire will be \[(sum of n responses)/n\]\*25. The total score ranges from 0 (no disability) to 100 (most severe disability). The DASH questionnaire is a valid tool for assessing individuals with neck-shoulder complaints. The test-retest reliability of the DASH is excellent (ICC model 2,1 = 0.93), and an 11-point change is deemed clinically significant.
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