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How to cite this article: Heba Haider, Fakiha Farooqui, Vinod Kumar, Subbayal Shakeel, et al. Effectiveness of Manual therapy followed by Active
Exercises to improve the Functional Ability of Women with Neck Pain. J Yoga & Physio. 2019; 7(5): 555723. DOI: 10.19080/JYP.2019.07.555723
Objective: The purpose of this study was to observe the effectiveness of manual therapy followed by active exercises to improve the functional ability of working and non-working women with neck pain. The results of this study would indicate to physiotherapist about treatment plan, used for the treatment of neck pain that would potentially increase the cervical range of motion and / or decrease pain experienced by the patient, improving the functional ability to work for their activities of daily living and leading to a more effective treatment protocol. The outcome of the study will help physiotherapist to select more appropriate treatment for patients based on the outcomes and clinical findings.
Method: This was achieved by selecting 34 female subjects between the ages of 30 to 60 years were assessed through Muscle Length Test of Levator scapulae, Sternocleidomastoid, Upper Trapezius, Scalene (anterior, posterior, medius), Spurling’s test, Distraction test, Vernon Neck Pain Disability Index and Numeric Pain Rating Scale and a reassessment was taken after follow-up of 2 weeks. Patient received treatment session, 6 days of physical therapy visits in a week in which first rib depression manipulation was given 3 sessions in a week followed by 3 sessions of active exercise program which included stretching and strengthening exercises. Patients were classified as having successful or unsuccessful outcomes.
Result: From a randomly selected patients of working and non-working, 34 female patients,20 (14 acute & 6 chronic conditions which included 15 middle age and 5 old age women) patients received effective treatment and had NDI score less than 14%, with reduce sign and symptoms and improved strength of cervical muscles with greater functional ability so they were send back to their work while 12 (12 chronic condition which included 6 old age and 6 middle age women) patients did not receive more effective treatment as their NDI score was more than 15% with aggravating sign and symptoms and reduced strength of cervical muscles with lesser functional ability. 2 (chronic old age) patients did not receive any improvement after the course of 2-week treatment sessions.
Conclusion: The implications of the findings and outcomes of this study shows that there is affectivity of first rib depression manipulation with exercise program but in acute conditions rather than chronic conditions and it is a suggestion to increase the time duration of treatment sessions for patients in chronic conditions which might reduce their sign and symptoms and neck pain for better functional ability or different techniques of manual therapy can also be used for better results which is further discussed.
Keywords: Neck Pain; Cervical Spine; Flexion; Extension; Right Lateral Flexion; Left Lateral Flexion; Pinched Nerve; Anxiety; Stress; Sleeping in Awkward Position; Poor Posture; Heavy Physical Work; Degeneration; Mobilization; Manipulation Techniques; Sub-Acute Neck Pain; Massage; Stimulate; Static Contraction
Neck pain disorders remain a common problem in modern industrialized countries. Neck pain is a commonly reported
problem that affects 70% of individual at sometimes in their lives. Prevalence is generally higher in women, whether there is a working or non-working woman, higher in high-income countries compared with low- and middle-income countries
and higher in urban areas compared with rural areas. Many
environmental and personal factors influence the onset and
course of neck pain. A higher incidence of neck pain among
women and an increased risk of developing neck pain until the
35-49-year age group, after which the risk begins to decline
. It can be caused by a number of factors, including muscle
strain, ligament sprains, arthritis, or a «pinched» nerve, anxiety/
stress, sleeping in awkward position, poor posture, heavy
physical work, degeneration etc. Mobilization and manipulation
techniques are moderately effective in acute and sub-acute neck
pain at short term and intermediate term follow up . In the
long term, exercises alone or combined with manual therapies
were superior over manual therapies used alone .
In this respect, spinal manipulative therapy broadly defined
includes all procedures where hands are used to mobilize,
adjust, manipulate, apply traction, massage, stimulate, or
otherwise influence the spine or the paraspinal tissues with
the aim of influencing the patient’s health  These results
were confirmed by Parkin-Smith in his study on the efficacy of
manipulation in the treatment of mechanical neck pain, where
an increase in cervical range of motion and a decrease in neck
pain were also recorded .
The first rib is commonly fixated in flexion, when the rib is
palpated for motion it appears elevated and does not recede from
the palpating finger. The restriction of movement is common
following hyperextension injuries of the cervical spine, due to the
attachments of the cervical spine . As a result of the first ribs
involvement in cervical spine path mechanics, it has been noted
by Haley  that first rib dysfunctions are under diagnosed or
misdiagnosed due to a lack of assessment or focus of assessment.
However, it has been stated that a first rib dysfunction is one
of the most common and over-looked dysarthrodial conditions
. According to Douglas ,first rib manipulation had a positive
immediate and short-term effect on the following ranges of
motion of the cervical spine, flexion, extension, right lateral
flexion and left lateral flexion . The adjustment of the first rib
caused no immediate or short-term relief from pain itself, and so
is not an effective form of treatment for patients suffering from
mechanical neck pain if used in isolation . This is supported
by Johnson (1995:134)who found that the early detection and
treatment of a first rib dysfunction often leads to significant and
lasting relief from the condition for the patient . Therefore,
this research aims to investigate the effectiveness of first rib
manipulation as an adjunct to the treatment of neck pain.
It involves the static contraction of a muscle without any
visible movement in the angle of the joint. In simple terms
this means that in these exercises the length of the muscle
does not change. As it is continued for the cervical spine it will
gain strength in neck . Jonathan Bean  suggest that
performing specific muscle-strengthening exercises may be a
helpful strategy for many women with chronic neck pain. (The
researchers have investigated the effectiveness of each exercise
with electromyography, which measures muscle-generated
This is an observational, correlation study design. The study
was done in Baqai Institute of Diabetology & Endocrinology,
where working and non-working female patients were seen
more coming with neck pain in physiotherapy department
and were selected randomly. They were also informed, and
permission was taken from the female patients before starting
the research. The sample size consisted of thirty-four female
patients, which included working and non-working middle age
and old age women.
Thirty-four female patients with a diagnosis of neck pain with
acute and chronic conditions were required for the study were
obtained by the Baqai Institute of Diabetology & Endocrinology.
It was decided that all the patients will be manipulated in supine
position according to standardize treatment procedure. Only
participants between the ages of 30 to 60 years of age were
included into the study, Women working and non-working
women with complaint of neck pain with or without upper
extremity symptoms T1 Syndrome, cervical myofascial pain,
cervical disco-genic pain, cervical facet syndrome, cervical
spondylosis, Cervical strain and sprain, acute Whiplash Injury,
degenerative changes in cervical spine, Headache, Cervical
Muscle spasm, Cervical Joint stiffness, Fibromyalgia. Patients
were only accepted if they had read and signed the informed
consent form, undergone a full history and cervical examination.
Patients were requested to participate in the entire protocol in
order to avoid exclusion.
Any persons that at the time were currently taking either
anti-inflammatory or analgesic medication were required to
cease the intake 48 hours prior to consultation. Participants
with any contra-indications to manipulation were not included
into the study [12,13]. If any major lifestyle changes (e.g.
rigorous exercise) were made while involved with the study, that
participant was excluded from the study. Females, pregnant or
lactating, at the time of the study, were excluded. Patients were
excluded from the study if the allotted number of consultations
or the clinical protocol were not adhered to patients including
children and men were excluded from the study. Patients
including congenital deformity were excluded from study.
Patients with burn were excluded from study. Diagnosis was
made on the basis of following test. Distraction test foraminal
compression test, muscle length test for neck muscles.
In order to ensure that the patient’s completely understood
the research and to protect their interests, the patients were required to read and sign the Consent form and were asked to
fill a Questionnaire with closed ended questions (Appendix A)
Female Patients both working (included dentist, nurse, teacher,
housemaid, computer operator, car driving trainer and bank
employee) and non-working (house-wife), diagnose with acute
or chronic neck pain that fulfill the inclusion and exclusion
criteria were included in this study. Assessment of the patient
was done with spurling’s test, distraction test, Muscle length test
of trapezius, sternocleidomastoid, Levator scapulae and scalene
(anterior, posterior, medius) (Appendix B) were performed and
a closed ended questionnaire filled, pain intensity by numeric
pain rating scale (NRS) and functional ability was assessed by
Vernon Neck Disability Index (NDI) questionnaire (Appendix A).
Then the patient was treated by 1st rib manipulation depression
(Appendix C) followed by active exercises which included
stretching and strengthening exercises (Appendix D). After the
initial consultation, patients were required to attend 2-week
follow-up which required 6 days of physical therapy visits in
a week in which first rib depression manipulation was given
3 sessions in a week followed by 3 sessions of active exercise
program which included stretching and strengthening exercises.
The graphical representation shows that among 34 patients
the incidence of neck pain seen in 21 middle age patients was
found to be more as compared to 13 old age women patients.
(Graph 1) The graphical representation shows that among
34 patients, working women 18 were seen more effected
with neck pain as compared to housewife 16. (Graph 2). The
graphical representation shows that among 34 patients, 21
female patients were seen with radiating neck pain, which were
found more commonly present in both middle age and old age
women as compared to non- radiating pain present (Graph 3).
The graphical representation shows that among 34 patients
during the Muscle Length test was performed; most commonly
affected muscle seen was trapezius muscle which was seen
as mostly affected during neck pain (Graph 4). The graphical
representation shows that among 34 patients most commonly
neck pain in women were seen present in acute conditions (15
middle age& 5 old age) rather than chronic conditions (6 middle
age & 8 old age) (Graph 5). The graphical representation shows
that among 34 patients, effectiveness of treatment was seen in
middle age patients as compared to old age patients. 20 patients
were improved with effective treatment, 12 patients were
seen with slight recovery and 2 patients were not at all got any
effective treatment (Graph 6).
A study suggested that this finding may strengthen the
assumption that there is an association between working
conditions and the occurrence of neck and upper extremity
complaints . Alternatively, chronic disease and other
ailments may be more important in older people and be the
main reason for encountering them in general practice. Again,
additional (longitudinal) research is needed to establish the
association between work, age, and the occurrence of neck
and upper extremity complaints. Colin Douglas Brown study
researched on the effectiveness of first rib adjustment as an
adjunct to the treatment of mechanical neck pain and suggested
that there was limited evidence for any difference in treatment
effects between the three treatment groups . Only CMCC
score showed significant treatment differences between the
first rib group and cervical spine group (first rib was better) and
between the cervical spine group and first rib plus cervical spine
group (first rib plus cervical spine group was better).
Thus, it appeared that first rib manipulation was more
beneficial for CMCC score than cervical spine manipulation, in
terms of patients’ perception. In comparison with the placebo
treatment, there were many significant treatment effects.
Left lateral flexion was improved in the first rib group and the
first rib plus cervical spine group compared with the placebo.
Extension was improved in the cervical spine group compared
with placebo. CMCC was improved in the first rib group relative
to placebo, and NRS was significantly improved in all treatment
groups compared with placebo. Where the p value was not
significant, trends were demonstrated. Thus, any treatment was
better than placebo for most outcomes. This is evident that 1st
rib manipulation has an evidence based successful treatment for
neck pain, but different research suggest different techniques of
treatment. Miller et al.  suggested that, if manual therapy,
including manipulation or mobilization, combined with exercise
improves pain, function/disability, quality of life, global
perceived effect, and patient satisfaction for adults with neck
pain with or without cervicogenic headache or radiculopathy.
Kay TM  suggested with a background study that Neck
disorders are common, disabling and costly. The effectiveness
of exercise as a physiotherapy intervention remains unclear and
came with results that Moderate quality evidence demonstrates
patients are very satisfied with their care when treated with
therapeutic exercise. Low quality evidence shows exercise is of
benefit for pain in the short term and for function up to long-term
follow-up for chronic neck pain. After the 1st rib manipulation
patients were instructed in a stretching and strengthening
program. Recent guidelines and reviews have supported the
use of exercise to decrease pain, improve function and reduce
disability in a patient population with neck pain .
In Baqai Institute of Diabetology & Endocrinology where
the research is being performed does not have any heating
modalities, thera band, dumbbell’s, mechanical traction and
exercise ball, that’s why designing in treatment techniques
were limited so it was unable to select use of any equipment to
achieve any improvement or reduction in pain which is realized
at present time. A new approach is needed to solve the problem
and to progress towards the designing of better-quality clinical
Measurements of range of motion over the cervical spine
region should have been taken before and after treatment for
better results. This could have had an effect on the eventual
outcome of the results. Further research could be done in order
to compare the treatment given in seated, prone and supine
positions. Future efforts should focus on the study of noninvasive
interventions for patients with radicular symptoms and on
the design and evaluation of neck pain prevention strategies.
Further research can also be done on males and the effectiveness of treatment in males. Further research should be done with a
home exercise program and prevention tips should also been
given to the patient to reduce chances of increase in neck pain
so that the patient find less difficulty in their work and leisure
In this study, from a group of 34 female patients, 20 (14
acute & 6 chronic conditions which included 15 middle age and
5 old age women) patients received effective treatment and had
NDI score less than 14%, with reduce sign and symptoms and
improved strength of cervical muscles with greater functional
ability so they were send back to their work while 12 (12
chronic condition which included 6 old age and 6 middle age
woman) patients did not receive more effective treatment as
their NDI score was more than 15% with aggravating sign and
symptoms and reduced strength of cervical muscles with lesser
functional ability. 2 (chronic old age) patients did not receive
any improvement after the course of 2-week treatment sessions.
Treatment were seen to be effective but mostly in acute patients,
so it is suggested a new approach is needed to solve the problem
for chronic patients and to progress towards the designing
of better-quality clinical practice guidelines, long duration of
treatment, its techniques and better quality of exercises.
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