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The_Role_of_Physical_Activity_.pdf
Timişoara Physical Education and Rehabilitation Journal
Volume 7 ♦ Issue 14 ♦ 2015
17
DOI: 10.1515/tperj-2015-0003
The Role of Physical Activity and Physical Therapy on
Muscle Relaxation and Pain in Neck Disorders
Asuman SALTAN1, Yeşim BAKAR2, Eylem TÜTÜN YÜMİN3, Meral SERTEL4, Necati TATARLI5, Handan ANKARALI6
Abstract
Background: Musculoskeletal problems (neck, shoulder, back pain etc.) occur as a chronic pain or disability that reduces
quality of life and economic productivity. To test the hypothesis that, comparison of the effectiveness of one-session
application of two physiotherapy methods. The other aim is to investigation the relationship between physical activity and
pain, muscle relaxation. Method: This study was designed randomized trial and double blind. Participants (with neck pain)
divided into two groups (Classical Massage (CM), n=24 and Active Stretching, n=21) Pain were determined by the visual
analog scale (VAS), a digital pressure algometer was used to assess pain threshold (PT) level and muscle relaxation response
was measured by means of electromyography biofeedback (EMG_BF). Physical activity was determined by the physical
activity assessment questionnaire (PAAQ). Results: Only the EMG values on the right SCM muscles of the CM group was found
significantly higher than stretching group (p=0.003). The relationship between EMG-BF, PT values and PAAQ was examined.
Conclusions: Self-stretching is more effective than CM in providing muscle relaxation. Physical activities (especially steps,
sitting at home working and school activities) particularly affect neck pain and SCM muscle.
Keywords: stretching, massage, electromyography feedback, pain threshold.
Rezumat
Introducere: Problemele musculo-scheletale (gât, umăr, durerea de spate etc.) se manifestă ca durere cronică sau dizabilitate
care reduce calitatea vieții și productivitatea economică. Scopul acestui studiu este de a verifica eficiența aplicării unei
sesiuni unice a 2 metode fizioterapice; celălalt scop al acestui studiu este acela de a investiga relația dintre activitatea fizică și
durere, relaxarea musculară. Metodă: Acest studiu a fost conceput randomizat și dublu-orb. Participanții (cu durere la nivelul
gâtului) au fost împărțiți în 2 grupe (masaj clasic (CM), n=24 și stretching activ, n=21). Durerea a fost determinată cu scala
vizuală analogică (VAS), un algometru cu presiune digitală a fost utilizat pentru a determina pragul la durere (PT), iar
răspunsul privitor la relaxarea musculară a fost evaluat folosind biofeedback-ul electromiografic (EMG_BF). Activitatea fizică
a fost determinată cu chestionarul de evaluare al activității fizice (PAAQ). Rezultate: Doar valorile EMG la mușchiul
sternocleidomastoidian drept al grupului CM au fost semnificativ mai mari decât la grupul cu stretching (p=0.003). Relația
dintre valorile EMG-BF, PT și PAAQ au fost examinate. Concluzii: Auto-stretching-ul este mai eficient decât masajul clasic în
producerea relaxării musculare. Activitățile fizice (în special, urcatul scărilor, poziția șezând în activitățile casnice sau la
școală) afectează în mod particular regiunea gâtului și mușchii sternocleidomastoidieni.
Cuvinte-cheie: stretching, masaj, feedback electromiografic, pragul durerii.
1 Assistant Professor, PhD, PT, Yalova University Termal Vocational School,Yalova, TURKEY, e-mail: [email protected] 2 Associate Professor, PhD, PT, University of Abant İzzet Baysal, KD School of Physical Therapy and Rehabilitation, Bolu, Turkey. 3 Assistant Professor, PhD, PT, University of Abant İzzet Baysal, KD School of Physical Therapy and Rehabilitation, Bolu, Turkey. 4 Assistant Professor, PhD, PT, University Kırıkkale, Faculty of Health Sciences, Department of physiotherapy and rehabilitation, Kırıkkale, Turkey 5 Professor MD, University of Düzce, Faculty of Medicine,Department of Biyostatistic. Düzce, Turkey. 6 MD, Lütfi Kırdar Education and Research Hospital, İstanbul, Turkey
Timişoara Physical Education and Rehabilitation Journal
Volume 7 ♦ Issue 14 ♦ 2015
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Introduction
Musculoskeletal disorders are an important health
problem, common in both genders, affecting all age
groups and resulting in loss of strength.
Musculoskeletal problems (neck, shoulder and back
pain etc.) occur as a chronic pain or disability that
reduces quality of life and economic productivity
[1,2]. Cervical musculoskeletal disorders are
generally concomitant with back pain. The
complaints generally start with pain, tension and
induration and gradually turn into postural
disruption, restriction of normal body movements
and degeneration in the muscular and osseous
structure. This situation reduces the quality of life
and economic productivity of the individual.
Therefore, musculoskeletal problems constitute an
economic burden on society, both directly and
indirectly [3,4,5,6].
The impact of pain on daily living activies can be
defined as a patien's disability level or decreased
physical function. A decreased physical acivity level
in daily life (disuse) has been presented as a
perpetuating factor for chronicity in theoretical
research models on pain. Although there is no exact
results about physical activity in patients with
chronic neck pain, there is controversial results on
that physical activity must be increased or reduced
in studies for chronic low back pain [7,8].
Neck pain is a common complaint, with 0-18% point
prevalence and 30-50% lifelong prevalence [9].
Various methods such as medicines, physical
therapy, manual therapy, local or epidural injections
and patient education are frequently used in the
treatment of patients with neck pains [10]. Previous
systematic reviews have not provided conclusive
evidence on which of these methods is most
effective [11,12].
Massage and stretching exercises are two of the
practical applications used in the rehabilitation of
back pain [13]. Classical massage (CM), arterial
blood flow, venous connection and blood enzyme
concentrations have an impact on edemas, affect
connective tissues and reduce muscle spasms, thus
providing relaxation [14,15]. On the other hand,
stretching is known to have an effect on the muscle
fibril and provide relaxation and elasticity [16]. In
addition, measurements taken directly after
stretching applications show that it has neurological
and hypoalgesic effects [17].
According to Good, AP et al [3], neck pain may cause
absenteeism in working life as frequently as LBP.
While neck pain has become such a serious health
problem, little is known about the treatment of
chronic neck pain. The researchers are inclined to
treat their patients with evidence-based treatments
such as massage, manipulative therapy and
injection just because those treatments are easy to
apply even if those treatments are ineffective and
have less support in literature.3 In addition to the
above, another systematic review suggests that
massage is both a safe and widely used treatment
for neck pain and any side effects are temporary
and harmless. However, neither massage alone nor
massage combined with other treatments
(acupuncture, exercises, sham laser, transcutaneous
electrical nerve stimulation, manual traction,
mobilization, education and pain medication)
showed a significant advantage over other
comparison groups [18,19]. The European
Guidelines do not recommend the use of any
specific exercise programs such as stretching,
strengthening, flexion or extension exercises for
acute back pain. For subacute and chronic back pain
and neck pain, there is limited evidence for the use
of any specific exercise programs and in most
guidelines no program is recommended [11].
Most studies on physical activity in pain patients
have focused on people with chronic low back pain
[20]. Less is known about the activity of patients
with other types of chronic pain. Besides, not all
aspects of daily activity were investigated together.
Therefore, there is need a lot of study about
relationship physical activity and pain [20].
The main purpose of this study was to investigate
role of physical activity on neck pain and muscle
relaxation. Another aims to investigate the effects of
massage and exercise (active stretching), which are
two methods easily used for neck and back pain on
muscle relaxation and pain.
Materials and Methods
The study included 68 patients presenting to
Köroglu State Hospital Neurosurgery Polyclinic with
neck pain complaint, all of whom volunteered to
take part in the research. As randomized trials, we
divided two groups all participants. The CM group
comprised 24 participants, while the active
stretching group consisted of 21 participants.
Timişoara Physical Education and Rehabilitation Journal
Volume 7 ♦ Issue 14 ♦ 2015
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Diagnoses of the volunteers were carried out by a
neurosurgeon.
Each participant completed an Informed Consent
Form, which included an explanation of the purpose
of the study.
The study inclusion criteria were: 25–45 years of
age, having neck pain for 3 to 6 months. The
exclusion criteria were: disk hernia, stenosis,
trauma history, cancer, osteoporosis, hypermobility,
inflammatory rheumatologic diseases, severe
psychological disorders; and being pregnant. After
applying the inclusion and exclusion criteria, those
included were referred to the physiotherapy
department. Of the 68 patients, 23 patients did not
meet the inclusion criteria (13 patients were older
than 45 years, 7 patients had neck pain for more 6
months and 3 patients were not volunteers) (figure
1).
Figure 1. Flow diagram reflecting participants involvement in accordance with the CONSORT guidelines [30]
The study was designed as randomized and blind.
The volunteers were randomly separated into two
groups. Block randomization was by a computer-
generated random number list prepared by an
investigator with no clinical involvement in the trial.
Patients were assessed immediately before and
after each application by an independent (blinded)
investigator. The applications were carried out for
one session.
This study was approved by Bolu Clinic Research
Ethics Board (2010/26).
An assessment form was prepared to collect the
demographic data of the volunteers, such as age,
height, weight and information such as job, marital
status, and educational status.
A digital pressure algometer (JTECH MEDICAL,
MonsterMarketplace.com®, © 2006-2011) was
used to assess pain threshold (PT) levels. This
device is a digital pain threshold meter that
comprises a sensor connected to a hard edge with 1
cm diameter. The device measures PT as lb/cm2.
The instrument was applied to the patients’ bare
skin and the trigger motor point for
Sternocleidomastoideus (SCM) and Trapezius (TR)
muscles.
Measurement for the TR muscle was taken on the
upper border of the TR muscle half-away between
the midline and lateral border of the acromion.
Measurements for the SCM muscle were taken on
the SCM muscle between anterior, superior
Timişoara Physical Education and Rehabilitation Journal
Volume 7 ♦ Issue 14 ♦ 2015
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manubrium and superior medial third of clavicle
and lateral aspect of mastoid process, anterior half
of superior nuchal line.
These testing sites were chosen as they are known,
through clinical experience, to be sensitive in
patients with chronic non-specific neck pain. They
were also used in all trials, as only intratester
repeatability in reassessing pain sites qualitatively
has been shown to be fair [21].
To measure PT value, the edge of the algometer
was pressed on sensitive points until the maximum
level that patients could bear. The patients were
instructed to say “stop” at the point where the
pressure became painful. The measurement was
repeated three times, at 30-second intervals, and
the average of three measurements was taken; all
values were expressed as kg/cm2 unit [22].
The PT measurements were repeated in the same
order at the same time by the same tester to
evaluate the repeatability of the method. All
measurements were performed by the same
physiotherapist, who had several years’ experience
in testing. The algometer maintains the maximum
applied pressure until tared. Thus, the
measurements were performed blind, as the display
was not in view of the tester and the peak output
was read only after each measurement.
Muscle relaxation response was measured by
means of electromyography (Myomed 932 EMG
Biofeedback; Enraf Nanius, Rotterdam, Netherlans)
[23]. For EMG (Electromyography Biofeedback)
measurement from SCM, one of the active
electrodes was placed under the Proc. Mastoideus,
while the other was placed in the muscle’s origin.
For EMG measurement from TR muscle, the active
electrodes were placed on the right and left TR
muscle, along the lines connecting the spinous
process of the seventh cervical vertebra (C7) to the
right and left acromion, respectively. The passive
electrode was placed on the upper extremity.
Surface electrodes were used for the measurements.
While carrying out measurements, all the
volunteers were in a semi-horizontal position,
supported by pillows in the front, and with the
upper neck relaxed. During measurements, the
volunteers were instructed to relax and not to move
or talk.
The assessment form, PAAQ (Physical Activity
Assessment Questionnaire) and VAS were used only
at the beginning of the study, while PT and EMG-BF
measurements were taken before and immediately
after the application.
A visual analog scale (VAS) was used in subjective
assessment of volunteers’ pain. VAS is a simple and
effective pain measurement scale with established
validity and reliability. In order to determine body
pain, volunteers were required to mark their pain
levels on the 10 cm long scale, between “0” (no
pain) and “10” (unbearable pain). The patients were
instructed in how to use this scale [24].
Measure of physical activity: The PAAQ was
originally developed by Karaca et al [25] to measure
the physical activity level of individuals in the
Turkish population. The PAAQ consists of six sub-
scales of activities in which the individuals are
expected to engage during a week. These sub-scales
are related to activities involved in work, school,
hobbies, home, transportation, climbing stairs and
sports. For each subscale, participants were asked
to report frequency and duration of the given
activity. Total scores were calculated for each
individual by using the syntax prepared by the test
developer; the higher the scores, the more
physically active they are. The measurement unit
for the scale was MET/hour, in which MET stands
for "metabolic equivalent" and is defined as the
energy expenditure for sitting quietly. MET values
can be converted to kcal [26].
In the classical massage group: Classic “Swedish
massage” technique was applied to the upper back
area for 20 minutes, focusing especially on SCM and
TR muscles. The application was supported by
frontward pillows and carried out in a frontward
semi-horizontal position in which the upper back
was relaxed [27].
In the stretching group: Participants were given a
demonstration, by an examiner, on performing
active neck flexion, neck lateral flexion, and neck
rotation while seated near the edge of an armless
chair with both feet firmly planted on the floor.28
Participants performed each of the following
stretches, holding each movement for eight to 10
seconds; each exercise was repeated 10 times: R
(right)/L (left) upper TR: hold on to the edge of the
chair on the R/L side to keep the R/L shoulder from
elevating. Side bend your head to the L/R. Gently
pull your head over to the L/R with your L/R hand.
R/L SCM: Support your head from behind on the
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L/R side with your L/R hand to prevent your neck
flexors from having to work to keep your head up.
Side bend your head to the L/R. Rotate your head
slightly to the R/L. Extend your neck slightly until
you feel a mild stretch, letting the weight of your
head rest in your L/R hand [28,29].
Statistical Analysis
The Kolmogorov-Smirnov test was used to confirm
the conformity of digital measurements with the
normal distributions. The SPSS statistical package
(Version 11.0 for Windows) was used to analyze the
obtained data. Mean and standard deviations were
used in descriptive statistics. In the statistical
analysis, the t-test and the χ² test were used to
determine the differences between socio-
demographic characteristics. In the intra-group
comparisons, the paired samples t-test was used.
Also, the Mann Whitney U test was used in the inter-
group analyses.
In the comparison of demographic data and PAAQ
one-way analysis of variance was used. The
relationship between VAS, PT average values and
EMG-BF was detected with correlation analysis.
Results
Figure I shows the participant flow according to the
CONSORT guidelines [30]. The classical massage
group comprised 24 participants (53.3%), while the
active stretching group consisted of 21 participants
(46.6%).
Table I shows the socio-demographic information of
the participants. In comparisons between the
classical massage and stretching groups, statistically
significant differences were found in terms of age,
genders, BMI, VAS (relaxation/activity), occupation,
marital status and educational status (p<0.05). No
significant difference was found between these two
groups in terms of dominant hand and constipation
(p>0.05).
Table I. Socio-demographic data of the volunteers
Classical Massage
Active Stretching
p
Age (years, mean (SD)) 46.2 (9.7) 34.9(11.7) 0.001* Gender (n, %) Female 20 83.3 9 42.9
0.005* Male 4 16.7 12 57.1 BMI (kg/m2) 29.77±4.69 26.46±5.56 0.036* VAS (rest, cm, %) 4 2.73 1.83 2.46 0.002*
0.004* VAS (active, cm, %) 6.78 2.43 4.4 2.75
0.0001*
Occupation/Jobs (n, %) Official servant 2 8.3 7 33.3 Worker 1 4.2 6 28.6 House wife 17 70.8 2 9.5 Student 1 4.2 6 28.6 Diger 3 12.5 - Civil status (n, %)
Married 23 95.8 11 52.4
0.003* Single 1 4.2 9 42.9
Divorced - 1 4.8 Educational level (n,%)
Primary 18 75.0 6 28.6
0.018* Secondary 1 4.2 1 4,8
High 2 8.3 2 9.5 College 3 12.5 9 42.9
Graduate - 3 14.3 Constipation (n,%) Yes 5 20.8 3 14.3
0.596 No 19 79.2 18 85.7 Dominant Hand (n,%) Right 23 95.8 21 100
0.344 Left 1 4.2 - Abbreviations: SD - Standard deviation. * - p<0.05
Table III.Table III.Table III.Table III. Comparison of Physical Activity Assessment Questionnaire (PAAQ) values between two groups Physical activity Classical Active p
Table II. Comparison of Physical Activity Assessment Questionnaire (PAAQ) values between two groups
Physical activity
(MET/week)
Classical Massage
n %
Active Stretching n %
p
Work
>0.05 <3 2 66.7 3 23.1 3-6 9 69.2 >6 1 33.3 1 7.7 School <3 1 100 4 50.0
>0.05
3-6 - 2 25.0 >6 - 2 25.0 Transportati on
<3 9 39.1 19 95.0 0.000* 3-6 14 60.9 1 5.0
>6 - - House work <3 23 95.8 19 100
>0.05 3-6 1 4.2 - >6 House work while sitting <3 24 100 20 100
>0.05 3-6 - - >6 - - Leisure time activity <3 14 93.3 6 85.7
>0.05 3-6 1 6.7 1 14.3 >6 - - Sports <3 - 2 20
>0.05 3-6 7 70 7 70 >6 3 30 1 10 Steps <3 20 95.2 9 69.2
0.05* 3-6 1 4.8 3 23.1 >6 - 1 7.7 Abbreviations: MET - metabolic equivalent, * - p<0.05
Timişoara Physical Education and Rehabilitation Journal
Volume 7 ♦ Issue 14 ♦ 2015
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(kcal/week) Massage n %
Stretching n %
Work
>0.05 <1000 - - 1000-2499 - - >2500 3 100 13 100 School <1000 - 1 12.5
0.043*
1000-2499 1 100 - >2500 - 7 87.5 Transportation <1000 18 78.3 17 85
>0.05 1000-2499 4 17.4 2 10 >2500 1 4.3 1 5 Sleeping <1000 1 4.2 -
>0.05 1000-2499 3 12.5 2 9.5 >2500 20 83.3 19 90.5 House work <1000 2 8.3 6 31.6
0.05* 1000-2499 2 8.3 - >2500 20 83.3 13 68.4 House work while sitting <1000 7 29.2 4 20
>0.05 1000-2499 8 33.3 5 25 >2500 9 37.5 11 55 Leisure time activity <1000 8 53.3 2 28.6
>0.05 1000-2499 3 20 4 57.1 >2500 4 26.7 1 14.3 Sports
<1000 6 60 7 58,3 >0.05 1000-2499 2 20 3 25
>2500 2 20 2 16.7 Steps
<1000 24 100 13 100 0,05* 1000-2499 - -
>2500 - -
The results of the physical activity assessment
questionnaire are shown in Tables II and III. MET
analysis of the energy consumed by the
participants during a week shows a significant
difference in the activities of transportation and
climbing the stairs (respectively; p=0.000 and
p=0.05). There was a significant difference in the
amount of energy (in kcal) consumed by the
participants during a week between the groups in
the activities of school, housework and climbing
the stairs (respectively, p= 0.043, p=0.056 and
p=0.09).
Only the EMG values on the right SCM muscles of
the CM group were found to be significantly
higher than the stretching group (p=0.003). No
significant difference was found between these
two groups in terms of the PT average values of
right and left SCM and TR muscles and EMG_BF
average values of right and left TR and left SCM
muscles (p>0.05) (Table IV).
The correlation between VAS (activity/resting)
and PAAQ was evaluated (Table V). In addition,
we analyzed the relationship between VAS and
EMG-BF averages, and PT average values. The
pain was evaluated with VAS once more before
the applications (Table V). Between the PT and
BMI, only a significant positive relationship was
found (Table V).
Comparing the gender and EMG_BF values, only a
difference between SCM muscles and gender was
found. SCM Right (R)/Left (L) EMG_BF values
were found to be higher in women (p=0,005;
p=0,000) (Table VI). Comparing occupation and
EMG_BF values, a difference between SCM L
muscles and occupation was found (p=0,003). The
occupation with the highest mean was found to be
housewife (Table VI).
In the comparison conducted between marital
status and EMG-BF values it was observed that
only SCM muscle was affected and the mean
values of being married were found to have
significantly higher EMG_BF SCM R/L (p=0,50/
0,003) (Table VII).
Whether the physical activities in daily life are in
correlation with pain and relaxation was
evaluated in our study. In our study, the
relationship between EMG-BF and PT average
values and PAAQ was examined. It was detected
that in most cases hobi met values were in
correlation with PT values (Table VIII).
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Table IV. Comparisons of Electromyography (EMG), Pain Threshold (PT) average values on the left and right of
Sternocleidomastoideus (SCM) and Trapezius (TR) muscle between two groups
* - p <0.05, TR - Trapezius, SCM - Sternocloideumasteoideus, R/L - Right/Left, SD - Standard Deviation EMG_BF - Electromyography-Biofeedback
Table V. Compared Pain Threshold, Elektromyography Biofeedback average values and Age, Body Mass Index , Visuel Analog Scale (activity/resting) after and before application
Before application p After application p
Classical Massage
(n=24) Mean±SD
Stretching
(n=20) Mean ±SD
Classical Massage
(n=24) Mean±SD
Stretching
(n=20) Mean±SD
Algometre/ L SCM 14.60± 4.99 15.42± 6.15 0.629 15.97± 4.91 45.31± 111.28 0.203 Trapezius 14.37± 4.94 14.44± 6.51 0.966 14.81± 4.80 18.43± 19.67 0.391 Emg/ L SCM 9.04± 4.26 8.90± 5.6 0.926 9.16± 3.15 10.0± 17.40 0.819 Trapezius 6.04± 6.56 88.85± 375.8 0.286 7.58± 7.16 7.90± 18.03 0.936 Algometre/ R SCM 14.72± 4.46 15.60± 6.48 0.599 15.65± 8.37 9.38± 3.32 0.229 Trapezius 15.60± 4.78 14.92± 6.63 0.695 14.39± 4.71 18.79± 18.67 0.294 Emg/ R SCM 13.62± 4.65 11.76± 5.02 0.204 15.50± 8.71 9.11± 3.17 0.003* Trapezius 8.75± 6.46 28.76± 93.06 0.299 8.12± 4.14 6.71± 1.90 0.159
Missing data: The data contain extreme values were removed to reach the correct value.* - p<0.05
Table VI. Pain Threshold and Electromyography Biofeedback after application according to demographics characteristics (gender and occupations)
Pain threshol d
Gender Occupations Women n=29 Mean±SD
Men n=16 Mean±SD
P
Officer n=9 Mean±SD
Worker n=7 Mean±SD
Housewife n=19 Mean±SD
Other n=10 Mean±SD
P
TR R 13.49±4.4 16.16±6.9 .123 14.63±6.0 16.38±7.6 13.63±3.7 14.46±6.7 .748 TR L 13.70±4.7 15.95±7.0 .209 15.02±6.1 16.18±7.7 13.82±4.0 14.14±7.0 .816 SCM R 15.28±3.9 17.07±6.3 .251 15.56±5.4 18.25±5.6 15.64±3.7 15.13±6.2 .606 SCM L 16.47±4.3 16.68±7.0 .901 15.68±6.1 20.58±5.7 16.09±3.9 15.37±6.2 .188 EMG_BF TR R 7.44±2.81 7.50±4.22 .961 8.33±3.1 6.42±1.1 7.00±2.5 8.30±5.3 .530 TR L 6.37±5.5 5.18±5.9 .507 4.66±2.1 4.14±2.6 5.36±3.5 9.50±10.2 .151 SCM R 14.79±7.7 8.75±3.6 .005* 9.33±2.0 11.57±3.6 14.68±3.9 12.50±13.6 .311 SCM L 9.17±3.0 5.25±1.9 .000* 5.88±1.3 7.85±3.7 9.68±3.0 5.80±2.7 .003*
Legend: * - p <0.05, TR - Trapezius, SCM - Sternocloideumasteoideus, R/L - Right/Left, SD - Standard Deviation, EMG_BF - Electromyography-Biofeedback
Before application After application Pain Threshol d (n=45)
AGE
BMI VAS Resting
VAS Activit y
Pain Threshold (n=45)
AGE
BMI VAS Resting
VAS Activity
TR R r p
.169
.267 .388 .009*
.254
.093 .067 .660
TR R r p
.256
.090 .480 .001*
.272
.070 .087 .569
TR L r p
.183
.229 .373 .012*
.262
.082 .115 .453
TR L r p
.200
.187 .400 .007*
.147
.335 .038 .806
SCM R r p
.131
.391 .237 .116
.158
.300 .099 .519
SCM R r p
-.008 .958
.295
.050* .143 .350
-.008 .958
SCM L r p
.088
.566 .219 .148
.138
.366 .117 .444
SCM L r p
.044
.774 .295 .050*
.196
.254 .821 .067
EMG_BF (n=45) EMG_BF(n= 45) TR R r
p -.103 .500
-.022 .884
-.035 .821
.081
.597 TR R r
p -.139 .363
-.203 .181
-.132 .388
-.295 .050*
TR L r p
.070
.647 -.147 .334
-.062 .684
.141
.356 TR L r
p -.113 .461
-.316 .035*
-.021 .891
.213
.159 SCM R r
p .252 .094
.053
.731 .268 .075
.308
.040* SCM R r
p .175 .250
.086
.576 .151 .323
.204
.179 SCM L r
p .261 .083
.084
.581 .392 .008*
.254
.092 SCM L r
p
-.106 .487
-.173 .255
.007
.966 -.089 .559
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Table VII. Pain Threshold and Electromyography Biofeedback after application according to demographics characteristics (marital status and constipations)
Pain Threshol d
Marital status Constipation Married (n=34) Mean±SD
Single (n=11) Mean±SD
p Yes (n=8) Mean±SD
No (n=37) Mean±SD
p
TR R 14.47±5.0 14.35±7.0 .950 14.32±4.0 14.47±5.8 .946 TR L 14.54±5.2 14.36±7.2 .928 13.78±4.6 14.65±5.9 .701 SCM R 15.91±4.3 15.93±6.5 .719 15.62±2.2 15.98±5.38 .854 SCM L 16.71±5.0 16.03±6.5 .970 15.13±4.0 16.85±5.6 .418 EMG_BF TR R 7.41±2.82 7.63±4.73 .849 7.25±3.1 7.51±3.4 .842 TR L 5.91±5.2 6.09±7.0 .929 4.25±2.4 6.32±6.1 .355 SCM R 13.82±7.6 9.00±3.6 .050* 12.25±5.0 12.72±7.5 .866 SCM L 8.58±3.3 5.27±1.6 .003* 7.12±2.5 7.91±3.4 .544
Legend: * - p <0.05, TR - Trapezius, SCM - Sternocloideumasteoideus, R/L - Right/Left, SD - Standard Deviation EMG_BF - Electromyography-Biofeedback
Discussion This is the first study examining the acute effect of
classical massage and stretching exercises on pain
and relaxation. In addition to this study suggest that
physical activities (specially steps, sitting home
working and school activities) effects on neck pain
and SCM muscle, especially.
As a result of this study, we found that in a
comparison of the effectiveness of one-session
application of two physiotherapy methods, self-
stretching and CM, showed that self-stretching is
more effective than CM in providing muscle
relaxation. The role of conservative treatments for
managing neck pain is not clear. Health
professionals should attempt to identify possible
cognitive, behavioral, demographic, organizational
or practical barriers which may impact on patient
adherence to the treatment [31]. In the study, we
wanted to compare the two applications we
conducted while investigating the effect of physical
activity on the muscles and wanted to measure
EMG-BF and PT.
EMG-BF is influenced by a number of factors
including: Series elastic components, ability of the
action potential of propagate, and excitation-
contraction coupling. Elongation of decrease in EMG
BF values is believed to be due to mechanical stress
placed on the muscle and increased passive tension
on non-contractile structures [32,33]. Behm DG et
al.[32] (2013) studied how to evaluate changes in
neural and evoked muscle responses with massage
and static stretching. They found that static
stretching increased the duration of
electromechanical delay whereas massage had no
effect on this property. But the static stretching
induced Hreflex depression during and 30s
following massage and recovered rapidly once the
stretching ceased. Electromechanical delay was
generally prolonged when massage was combined
with stretching [32]. McBridge et al. [34] (2007)
investigated EMG activity during the proprioceptive
neuromuscular facilitation stretching method and
observed EMG activity. However, their results
should be considered with caution, since they
proposed that passive stretching may be safer than
active techniques. Indeed, 88% of their volunteers
reported that passive stretching procedures were
more comfortable [35].
According to Soysal M et al. [7] (2012), there is a
correlation between physical activity and neck pain.
Sleeping status of the individual, whether in
depression or not, affects the life quality. They
found that quality of life scores of outpatients were
significantly negatively correlated with physical
activity. Recent studies show that patients with
spinal pain have impaired daily activities
[7,36,37,38]. There are many studies [7,39,40,41] in
the literature about neck pain but few studies that
compare physical activity and its effectiveness on
muscles of areas of the neck in patients with neck
pain.
Among persons with neck pain little is known from
previous studies about the potential positive effects
of physical activity on the prognosis of neck pain,
and high-quality studies are scarce.41 A Dutch study
summarized that active time was associated
favorably with neck and shoulder symptoms and
with sickness in a working cohort [42]. This was
also found in two other studies [43,44] reporting
positive associations between physical activity level
Timişoara Physical Education and Rehabilitation Journal
Volume 7 ♦ Issue 14 ♦ 2015
25
and neck pain. Hildebrandt et al. [44] (2000)
suggested that in a sedentary working situation,
higher physical activity level seems to be positive
for spinal pain. According to Shan Z et al. [40]
(2013) in their study there is no association
between physical activity and neck/shoulder pain.
In our study, in parallel with the literature, some
demographic characteristics (being women, being
housewife, being married, BMI) had an effect on
neck pain. No relationship was found between age
and PT or EMG-BF values. According to Croft PR et
al [45]. (2001) there is no apparent link between
age and weight and neck pain but there is relative to
a past history of neck pain. Rasmussen Barr E et al.
[41] (2013) found that between levels of physical
activity and neck pain in active women compared to
those with sedentary leisure time, indicated a
positive prognostic effect, whereas BMI was not a
prognostic factor. No such associations were found
in men. Shan Z et al. [40] (2013) suggest that
prevalence of neck pain was significantly higher in
girls compared to boys, which is consistent with
adults.
Pedersen MM et al.[46] (2013) stated that problems
experienced frequently in the workplace involved
neck pains and that with slight and effective
exercises in the workplace neck pain complaints
decreased. In this study, we did not evaluate the
self-efficiency (the adaptation to exercise) of the
individuals. However, in our study with stretching
performed for a unique session the decrease in
EMG-BF values on the SCM muscle cannot be
ignored. The most important problems for
exercising in the workplace are time, other
employees and venue [46]. For this reason, we think
that muscle relaxation obtained through a unique
session will increase adaptation to the exercise.
Veiersted KB et al [47] (1993) used EMG-BF values
on TR muscle and stated that in workplace studies,
one of the muscles creating neck pain is the trapeze
muscle. In our study, no correlation was found
between workplace activities and trapeze muscle
EMG-BF and PT values. In conclusion, in all these
analyses, in almost all activities, it was observed
that mostly the SCM muscle was influenced.
In this study, we showed that the stretching group
consumed more energy during school and work
activities (desk work activities) and the classical
massage group consumed more energy during
housework and spare time activities (activities
including mass body movements) [48], while the
levels of energy consumed during sporting activities
were similar in both groups. As indicated in
previous studies, neck pain complaints are more
common in desk work activities [49]. As the
stretching group took place in desk work activities
in our study, neck and upper back muscles were
used more extensively compared to the CM group.
This may be the reason behind the higher success of
the treatment in the stretching group.
According to the results we obtained, it is
interesting that there are both positive and negative
relationships between physical activity and after
application PT and EMG-BF values.
Our prediction for negative correlation is as follows:
Generally after stretching and massage, a decrease
in EMG-BF values is expected indicating muscle
relaxation. Increased flexibility caused by the
viscoelastic properties of muscles may have led to a
reduced muscle spindle response, with a
consequent reduction of the EMG-BF signal [50].
Massage may produce an increase in peripheral
circulation, resulting in general relaxation and
relief.32,50 Especially after the application, the
positive correlation between the EMG-BF values
and physical activity found reveals the increase in
EMG-BF values of the applications performed. A
hypothesis explaining this could be based on
changes in the relationship between length and
tension. If stretching really induces
myofibrillogenesis, plastic changes in muscle
structure would alter the length-tension
relationship. Improved interaction between
actomyosin bridges may have led to better muscle
recruitment, increasing EMG-BF activity. As
massage techniques are transmitted to the muscle
through the skin, the activity of the cutaneous
afferents would be expected to play a role in the
excitation of the central nervous system [51]. Hence
muscle relaxation can be quite variable dependent
upon the type, duration and location of the
stimulation.32
With all of these factors, our hypothesis for negative
and positive relationships seen can be related to the
posture in the activities performed by the
individual. In our study, especially without looking
at the evaluations between PT and free time
activities (hobby), a positive correlation was found.
Timişoara Physical Education and Rehabilitation Journal
Volume 7 ♦ Issue 14 ♦ 2015
26
Tettamanti A et al. [52] (2013) found that the
characteristics of postural activity derive from the
mechanical characteristics of the body masses that
are moved. For example, during abduction of the
upper limb, the scapula has to be oriented upward
and must remain in contact with chest, whereas the
agonist muscles tend to produce a movement in a
downward direction. The muscles in postural
stabilization prevent unwanted movement of the
cervical-dorsal spine. The trunk is stabilized by
contra-lateral movement and rotational torque is
avoided. Along each ROM, if the action is done
wrongly by the upper extremity, it may cause
injuries with the effects of ground reactions. It may
cause pain [52]. In addition, in the activities made
again in the posture, it may cause pain by affecting
muscle balance [53,54]. In this study, the postures
of the individuals were not evaluated. This situation
may be seen as a limitation of our study. In future
studies, the correlation between PAAQ and posture
should be explored.
Besides this, we estimated that the correlation
between hobby and pain is due to the fact that while
the individuals are pursuing enjoyable activities
they like, they do not pay attention to their posture
and spend a lot of time in the wrong position
(spending a long time standing for fishing, watching
TV, knitting etc.). In our study, in accordance with
the information obtained from the participants,
most of the free time activities are sedentary. In the
literature, it is stated that sedentary activity in
leisure time is associated with higher prevalence
rates of low back symptoms and sick leave due to
low back symptoms [44].
There are some limitations to this study. The
investigation of whether the participants had taken
analgesia and muscle relaxants before the
applications could affect our results. In our study,
we did not ask whether the individuals had neck
pain or not. Cross sectional studies report that
recalled injury is more common in those with neck
pain [45]. The type or nature of injury may be
important. Road traffic related whiplash injury
cannot be assumed to be equivalent to occupational
trauma (overuse); sports injury and domestic
accidents are other possible causes. An important
limitation of this study was the small sample size.
It is known that the self-report method used in
physical activity evaluations and in BMI calculations
may result in faults [41,42]. Our study is important
in terms of investigating the correlation between
physical activity and musculoskeletal disorders via
physical evaluation survey and has validity and
reliability. In the literature only certain activities
(the activity conducted by sitting in the workplace55,
during computer activities40 were focused on the
correlation between physical activity and pain. In
our study, only the EMG-BF value of either the SCM
muscle [39] or TR muscle [47] were used. In our
study (as suggested by Gorman E et al. [55] (2013)),
all physical activities were mentioned and both SCM
and TR muscles were included. Findings are
discussed in light of the sense of coherence, physical
activity, and positive and negative effects, as in the
literature. Along with long term monitoring of neck
pain in the future, we suggest the evaluation of
EMG-BF values of the neck muscles.
Conclusions
Comparison of the effectiveness of one-session
application of two physiotherapy methods, self-
stretching and CM, showed that self-stretching is
more effective than CM in providing upper back
muscle relaxation. One-session application of self-
stretching showed its effectiveness on SCM muscle
relaxation. As individuals can easily apply self-
stretching within daily routines in the work place,
this may reduce clinical visits, thus helping to
reduce health expenses. Physical activities
(especially steps, sitting at home working and
school activities) particularly affect neck pain and
SCM muscle. Evaluation of parameters affecting the
level of physical activity is very important and
should be considered in planning the therapy
programs of patients so that they can return to their
normal daily lives.
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