IMPACT OF STRETCHING WITH AND WITHOUT
STABILIZATION EXERCISES ON NECK PAIN
AND DISABILITY IN SUBJECTS WITH
UPPER CROSSED SYNDROME
Noha M. El-Badrawy* ; Yasser M. Aneis**
Hanaa K. Ata*** and A.E. El-Ganainy***
*Researcher of physical therapy for Basic Science Department, Faculty of Physical
Therapy,Cairo University, Egypt.
**Assistant Professor of Physical Therapy for Basic Science Department, Faculty of
Physical Therapy, Cairo University, Egypt.
***Lecturer of Physical Therapy for Basic Basic Science Department, Faculty of
Physical Therapy,Cairo University, Egypt.
****Department of Orthopedic surgery, Faculty of Medicine, Mansoura University,
Dakhlia, Egypt.
Key words: upper crossed syndrome, stabilization, stretching exercises,
neck pain
ABSTRACT
Objectives: Examine the effect of exercises in treating upper crossed
syndrome (UCS).
Methods: Eighteen patients aged from 25-40 years with UCS from both
populations. patients were randomly assigned into two equal groups;
Group A (n=9) stabilization exercises and stretching exercises for 30
minutes and Group B (n=9) received stretching exercises only for 15
minutes. Both groups received 1 session/ week for 12 weeks. pain
intensity level measured by visual analogue scale (VAS) and functional
activity measured by neck disability index (NDI), measurements taken
pre-treatment and after 12 weeks of treatment for both groups. Results:
VAS and NDI scores showed significant reduction in both groups, but
group A showed more improvement than group B. Conclusion:
Combined exercises showed considerable changes in treating UCS.
INTRODUCTION
Neck pain is an important problem affecting musculoskeletal
system (Szeto et al., 2005). Individuals with chronic neck pain have
altered abnormal postures for prolonged times. Chronic neck pain has the
potential to change the biomechanics of the spine (Kim et al., 2015).
Patients with neck disorders frequently have forward head posture (Yoo.
2013).
Forward head posture leads to shortening of the posterior neck
extensors and anterior neck and shoulder muscles (Lindstrøm et al.,
2011). Deep neck flexor stabilizing exercises, mobilization and electrical
therapy are considered traditional methods for treating neck pain
Egypt. J. of Appl. Sci., 36 (3) 2021 22-28
(Helgadottir et al., 2011). Upper cross syndrome (UCS) is a
combination of forward head posture and rounded shoulder (RS) (Lynch
et al., 2010). UCS leads to dysfunction along different multiple cervical
joints and shoulder joint (Kang et al., 2012).
Previous studies used stretching and strengthening exercises,
mobilization and manipulation for treating this syndrome (Lynch et al.,
2010). The aim of this study is to determine the effect of combined
exercise program on UCS patients.
MATERIALS AND METHODS:
Design, setting, methods, and population
This randomized controlled trial was conducted at general hospital,
Egypt. The study was conducted from March 2018 to August 2019. A
written informed consent was signed by all the participants. Eighteen
patients were selected to be enrolled into this study after they had
fulfilled the inclusion criteria which were participants of both gender
aging from 25 to 40 years who demonstrated chronic neck pain for more
than 3 months.
Exclusion criteria includes participants older than 40 or younger
than 25 years, BMI more than 30, functional or structural scoliosis,
psychosocial problem, cognitive impairment, tumor, inflammation and
congenital deformity and neurological diseases.
Patients who fulfilled the inclusion criteria of the study were
randomly assigned to either; group A, the intervention group (n= 9), who
received a combined treatment or Group B, the control group (n= 9), who
received stretching exercises.
Outcome measures
Pain intensity measured by VAS, and functional disability measured
by NDI.
Assessments
Pain intensity
VAS assesses the levels of pain intensity perceived by the patient
using a 10-point scale (varying from 0 to 10), in which 0 represents “no
pain” and 10 represents the “worst possible pain” (Guru et al., 2013).
Functional disability
The impact of neck pain on the patients‟ functional activities was
determined by the NDI. The index is a self-report questionnaire of the
subject‟s perceived disability (Vernon and Mior, 1991).
Intervention
The intervention group (group A) received a combination of
stretching and stabilization exercises for 30 minutes and Group B
received stretching exercises only for 15 minutes. Both groups received 1
session/ week for 12 weeks.
23 Egypt. J. of Appl. Sci., 36 (3) 2021
Stabilization exercise
Cervical stabilization exercise
The patient was lying in supine position, then asked to tuck his or
her chin in” and “hold her head up” as though he or she was saying „yes‟.
This exercise was repeated for 30 times for 3 sets (Asmaa et al., 2016).
Cervicothoracic stabilization exercise
The patient was lying prone with both upper limbs beside his/her
body, then asked to raise his/her head with chin tucked in. This exercise
was repeated for 30 times for 3 sets (Kisner and Colby, 2012).
Stretching exercises
Stretching was done for upper trapezius, and rhomboids. The
rhomboids and the upper trapezius muscles were engaged in selfstretching
exercsises. In the self-stretching exercise, the rhomboid was
stretched by pulling it laterally and the upper trapezius was stretched by
pulling it into cervical flexion. Each repetition was performed for 30
seconds, with a five-second break between each repetition. One exercise
set consisted of three repetitions (Evjenth and Hamberg, 1994).
Statistical Analysis
Multiple pairwise comparison tests were used for NDI
measurements and Wilcoxon Signed Ranked tests were used for VAS
measurements. For between-group analysis, multiple pairwise
comparison tests (post hoc tests) were used for NDI measurements and
Mann-Whitney U test was used for VAS measurements. The statistically
significant difference was accepted at p < 0.05.
RESULTS
In the baseline evaluation, results revealed that there were nonsignificant
differences between the two groups with regard to physical
characteristics where (P 0.05), results are given in table 1.
Table 1. Baseline demographic and clinical characteristics of patients
Variables
Group A
Mean ± SD
Group B
Mean ± SD
P-value
Age (year) 45.13±5.5 46.73±5.49 0.321
Height (cm) 156.8±7.45 158.4±7.7 0.568
Weight (kg) 105.13±10.32 107.66 ±9.8 0.190
BMI (Kg/m2) 34.98±2.21 35.18 ±2.79 0.388
Onset of neck pain (months) 5.15±1 5 ±1.5 0.591
SD = Standard Deviation; BMI = Body Mass Index; Level of significance at P ≤
0.05
Regarding NDI, and VAS, there were significant changes in the
two groups after 12 weeks of intervention relative to baseline, where (P <
0.001), with more improvements in group A Between-group variations
were remarkable where (P < 0.001), (see table 2).
Egypt. J. of Appl. Sci., 36 (3) 2021 24
Table 2. Changes in NDI and VAS.
Variable Group A (n=15) Group B (n=15) P value
NDI (%)
Baseline
4 weeks
P value
46.87(32.7-65.0)
4.31 (2.35-7.34)
0.0001
52.0 (39.6-67.4)
35.81(21.8-44.77)
0.0001
0.209
0.0001
VAS
Baseline
4 weeks
P value
8 (7.21-9.81)
2(1.21-6.11)
0.0001
7 (4.5-9.5)
3 (1.2-6.7)
0.0001
0.841
0.0001
NDI: neck disability index; VAS: visual analogue scale (p < 0.05).
DISCUSSION
The results are supported by other studies, some of them used
stretching and strengthening exercises for UCS (Lynch et al., 2010).
Others used stabilization exercises to restore normal posture of the neck,
scapula and shoulder joint (Im et al., 2015).
FHP puts the DNF in a lengthened position, creating a mechanical
disadvantage and abnormal motor control of the head and cervical spine.
Therefore, more specific training of the DNF through cervical
stabilization improves the ability to maintain upright posture of the
cervical spine (Chung et al., 2012).
In UCS patients, UT is overactive and we used stretching exercises
to normalize its tone while SA and lower trapezius are underactive
(Lynch et al., 2010).
Our findings revealed a significant decrease in pain intensity. This
improvement of pain seems attributable to the restoration of normal
posture of head, neck and shoulder. FHP and FSP could lead to an
increase in the stress imposed on articular, muscular, and neural tissues
of the neck and upper limb, which could lead to the development of pain
depending on the tolerance and adaptation capability of the central
nervous system (Kim and Kim. 2016). In addition, repetitive mechanical
stress over time could promote the appearance of algogenic substances
that could lead to tissue hyperalgesia (Martínez-Merinero et al., 2017).
Due to the abnormal positioning of the head and neck joints and
muscles in FHP, this postural disorder can affect neck proprioception
(Shaghayegh-Fard et al., 2015). Proprioception is necessary for proper
joint function in exercises, occupational and daily activities and helps
with motor control, dynamic restrains and increases muscle stiffness and
therefore provide joint dynamic stability. The loss of proprioception
feedback leads to functional disability (Armstrong et al., 2008). In fact,
it can be stated that increased FHP will have more side effects on deep
head and neck muscle function, muscle spindles and finally on reaction
time, postural control, and postural stability (Armstrong et al., 2005).
25 Egypt. J. of Appl. Sci., 36 (3) 2021
REFERENCES
Armstrong, B. ; P. McNair and D. Taylor (2008). Head and neck
position sense. Sports medicine; 38(2): 101-117.
Armstrong, B.S. ; P.J. McNair and M. Williams (2005). Head and
neck position sense in whiplash patients and healthy individuals
and the effect of the cranio-cervical flexion action. Clinical
Biomechanics; 20(7): 675-684.
Asmaa, M. ; H.O.G. El-Bandrawy and O. Ghareeb (2016). Efficacy of
neck stabilization exercises for neck pain complicating
pregnancy. IJTRR., 5(5): 122–128.
Chung, S.H. ; G.J. Her ; T Ko and et al., (2012). Effects of exercise on
deep cervical flexors in patients with chronic neck pain. J Phys
Ther Sci., 24(7): 629-632.
Evjenth, O. and J. Hamberg (1994). Muscle stretching in manual
therapy: a clinical manual. Sweden, Alfta Rehab Forlag.
Guru, K. ; N. Praveen and K. Selvamani (2013). Isometric endurance
of neck muscles and muscles for scapular positioning in
individuals with and without postural neck pain. Internet Journal
of Allied Health Sciences and Practice, 11(2): 1-11.
Helgadottir, H. ; E. Kristjansson; E. Einarsson and et al., (2011).
Altered activity of the serratus anterior during unilateral arm
elevation in patients with cervical disorders. J Electromyogr
Kinesiol, 21: 947–953. [Medline] [CrossRef]
Im, B. ; Y. Kim ; Y. Chung and et al. (2015). Effects of scapular
stabilization exercise on neck posture and muscle activation in
individuals with neck pain and forward head posture. Journal of
physical therapy science; 28(3): 951-955.
Kang, J.H. ; R.Y. Park; S.J. Leeand et al., (2012). The effect of the
forward head posture on postural balance in long time computer
based worker. Ann Rehabil Med., 36(1): 98-104.
Kim, D. ; M. Cho ; Y. Park and et al., (2015). Effect of an exercise
program for posture correction on musculoskeletal pain. J Phys
Ther Sci, 27: 1791–1794. [Medline] [CrossRef]
Kim, E.K. and J.S. Kim (2016). Correlation between rounded shoulder
posture, neck disability indices, and degree of forward head
posture. Journal of physical therapy science; 28(10): 2929-2932.
Kisner, C. and L.A. Colby (2012). Exercise Interventions by Body
Region, The Spine and Posture: Structure, Function, Postural
Impairments and Management Guidelines: Philadelphia, 398 –
400, 454.
Lindstrøm, R. ; J. Schomacher D. Farina and et al., (2011).
Association between neck muscle coactivation, pain, and strength
Egypt. J. of Appl. Sci., 36 (3) 2021 26
in women with neck pain. Man Ther, 16: 80–86. [Medline]
[CrossRef].
Lynch, S.S. ; C.A. Thigpen ; J.P. Mihalik and et al., (2010). The
effects of an exercise intervention on forward head and rounded
shoulder postures in elite swimmers. British Journal of Sports
Medicine, 44(5): 376-381.
Martínez-Merinero, P. ; E. Lluch ; T. Gallezo-Izquierdo and et al.,
(2017). The influence of a depressed scapular alignment on upper
limb neural tissue mechanosensitivity and local pressure pain
sensitivity. Musculoskeletal Science and Practice; 29: 60-65.
Shaghayegh-Fard, B. ; A. Ahmadi ; N. Maroufi and et al., (2015). The
Evaluation of Cervical Position Sense in Forward Head Posture
Subjects and Compares It with Normal Subjects. J Rehabil Med;
16(1): 48-57.
Szeto, G.P. ; L.M. Straker and P.B. O’Sullivan (2005). EMG median
frequency changes in the neck-shoulder stabilizers of
symptomatic office workers when challenged by different
physical stressors. J Electromyogr Kinesiol, 15: 544–555.
[Medline] [CrossRef]
Vernon, H. and S. Mior (1991). The Neck Disability Index: a study of
reliability and validity. Journal of Manipulative and
Physiological Therapeutics, 14(7): 409–415.
Yoo, W.G. (2013). Effect of the neck retraction taping (NRT) on forward
head posture and the upper trapezius muscle during computer
work. J Phys Ther Sci, 25: 581–582. [Medline] [CrossRef]
تأثير تمارين الإطالة مع وبدون تمارين التثبيت عمى آلام الرقبة والإعاقة في
الأشخاص المصابين بمتلازمة التقاطع العموي
نها محمد البد ا روي * ياسر محمد أنيس ** هناء قناوى عطا ***
عبد الرحمن احمد الجناينى***
* باحث العلاج الطبيعي بقسم العموم الأساسية بکمية العلاج الطبيعي، جامعة القاهرة ، مصر.
** استاذ مساعد العلاج الطبيعى لقسم العموم الاساسية بکمية العلاج الطبيعى، جامعة القاهرة ، مصر.
*** مدرس العلاج الطبيعي بقسم العموم الأساسية بکمية العلاج الطبيعي ، جامعة القاهرة ، مصر.
**** قسم ج ا رحة العظام ، کمية الطب ، جامعة المنصورة ، مصر.
خلاصة
.)UCS( الأهداف: فحص تأثير التمارين في علاج متلازمة الصميب العموي
84 عامًا يعانون من متلازمة الصميب - الطريقة: ثمانية عشر مريضًا تت ا روح أعمارهم بين 69
العموي من کلا المجموعتين. تم تقسيم المرضى بشکل عشوائي إلى مجموعتين متساويتين ؛
27 Egypt. J. of Appl. Sci., 36 (3) 2021
) المجموعة أ )ن = 9( تمارين التثبيت وتمارين الإطالة لمدة 74 دقيقة والمجموعة ب )ن = 9
تمقت تمارين تمدد لمدة 59 دقيقة فقط. تمقى کلا الفريقين جمسة واحدة في الأسبوع لمدة 56
والنشاط الوظيفي المقاس )VAS( أسبوعًا. يقاس مستوى شدة الألم بالمقياس التناظري البصري
القياسات اخذت قبل وبعد 56 أسبوعًا من العلاج لکلا ، )NDI( بمؤشر إعاقة الرقبة
انخفاضًا کبي اً ر في کلا المجموعتين ، لکن NDI و VAS المجموعتين النتائج: أظهرت درجات
الخلاصة: أظهرت التمارين المشترکة .B أظهرت تحسنًا أکبر من المجموعة A المجموعة
تغي ا رت کبيرة في علاج متلازمة الصميب العموي.
الکممات الدالة: متلازمة الصميب العموي ، التثبيت ، تمارين التمدد ، آلام الرقبة
Egypt. J. of Appl. Sci., 36 (3) 2021 28
