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RESEARCH ARTICLE Open Access
Does improvement towards a normalcervical sagittal configuration
aid in themanagement of cervical myofascial painsyndrome: a 1- year
randomized controlledtrialIbrahim M. Moustafa1,2* , Aliaa A. Diab2,
Fatma Hegazy1 and Deed E. Harrison3
Abstract
Background: There is a growing interest concerning the
understanding of and rehabilitation of the sagittalconfiguration of
the cervical spine as a clinical outcome. However, the literature
on the topic specific toconservative treatment outcomes of patients
with chronic myofascial cervical pain syndrome (CMCPS) has
notadequately addressed the relationship between cervical sagittal
alignment and improved pain, disability and rangeof motion.
Methods: A randomized controlled study with a 1-year follow-up.
Here, 120 (76 males) patients with chronic CMCPSand defined
cervical sagittal posture abnormalities were randomly assigned to
the control or an intervention group.Both groups received the
Integrated neuromuscular inhibition technique (INIT); additionally,
the intervention groupreceived the denneroll cervical traction
device. Alignment outcomes included two measures of sagittal
posture: cervicalangle (CV), and shoulder angle (SH). Patient
relevant outcome measures included: neck pain intensity (NRS),
neckdisability (NDI), pressure pain thresholds (PPT), cervical
range of motion using the CROM. Measures were assessed atthree
intervals: baseline, 10 weeks, and 1 year after the 10 week follow
up.
Results: After 10 weeks of treatment, between group statistical
analysis, showed equal improvements for both theintervention and
control groups in NRS (p = 0.36) and NDI (p = 0.09). However, at 10
weeks, there were significantdifferences between groups favoring
the intervention group for PPT (p
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(Continued from previous page)
Conclusion: The addition of the denneroll cervical orthotic to a
multimodal program positively affected CMCPSoutcomes at long term
follow up. We speculate the improved sagittal cervical posture
alignment outcomes contributedto our findings.
Trial registration: Pan African Clinical Trial Registry Clinical
Trial Registry: PACTR201801002968301, registered 11 January2018
(retrospectively registered).
Keywords: Randomized controlled trial, Cervical lordosis,
Cervical posture, Cervical pain, Myofascial pain, Traction
BackgroundChronic myofascial pain syndrome (CMPS) is a
muscu-loskeletal condition or syndrome that is typically
associ-ated myofascial trigger points (MTrP). CMPS has alifetime
prevalence of up to 85% with variations as lowas 15% for a point
prevalence [1, 2]. CMPS significantlyimpacts a patient’s health
related quality of life outcomeswith studies including: disability,
financial status, depres-sion, anxiety, and generalized neck pain
[3, 4].Myofascial pain syndrome remains one of the most
common sources of pain in chronic non-specific neckpain. Factors
commonly cited as predisposing to MPSamong subjects with chronic
non-specific neck paininclude abnormal postural, inadequate rest,
overstretch-ing, over-shortening or more generally, repetitive
mechan-ical stress [1, 2]. In clinical practice, different
approachessuch as massage, acupuncture and electro-thermotherapyare
quite commonly used in the treatment of CMPS [3, 4].However, the
effectiveness of many of these approachesdid not appear to be
superior to placebo [3]. A recent sys-tematic review found that
functional exercise protocolshave very low quality evidence for a
positive small-to-moderate effect on pain intensity in patients
sufferingfrom MPS [5].Identification of causative variables for
MTrPs is a first
step to prevent development and secondarily to developpotential
treatments preventing recurrence. Althoughthe exact mechanisms are
still unknown, [6, 7] it is ac-cepted that mechanical factors are
thought to be factorsassociated in the development of MTrPs [1, 2,
8]. In thisregard, various studies have confirmed that
prolongedabnormal postures have been regarded as one of thecauses
of MPS [9, 10].In the cervical region, various studies point to the
fact
that altered sagittal plane alignment of the cervical spinesuch
as straightened, s-curves, reversed curves, andanterior head
translation can result in abnormal stressesand strains leading to
premature and acceleration ofdegenerative changes in the muscles,
ligaments, bonystructures and neural elements [11–13].
Furthermore,preliminary randomized trials have demonstrated
improvedneck pain, dizziness, disability, positioning sense,
flexion /extension kinematics, arm pain, and somatosensory
evokedpotentials in patient groups receiving devices aimed at
restoration of the cervical curve and posture [14–17]. Onesuch
device for the rehabilitation of sagittal cervicalalignment is the
cervical denneroll spine orthotic out ofSydney, Australia. Two
previous clinical trials have dem-onstrated the denneroll is a
reliably placed three-pointbending extension traction device that
is relatively easy touse by both the patient and treating
therapist, and it iseffective at improving cervical lordosis
(10°-14° improve-ment) and reducing anterior head translation
(10-25 mmreduction) [15, 16].Although the previously mentioned
studies make a sig-
nificant contribution to understanding the important roleof a
normal cervical lordotic curve and rehabilitation toolsto enhance
correction, the literature on the topic specificto conservative
treatment outcomes of patients with MPShas not adequately addressed
the relationship betweencervical sagittal alignment and improved
pain and disabil-ity at short and at long term follow
up.Accordingly, the present randomized controlled trial
was undertaken to investigate the functional and painresponse
outcomes of denneroll cervical extension trac-tion compared to
standard care in patient cases withchronic MPS, with a verified
hypo-lordosis and anteriortranslation of the cervical spine. Two
primary hypoth-eses were tested: 1) that denneroll cervical
traction willimprove the sagittal alignment of the cervical spine.
2)The secondary hypothesis tested was whether restor-ation of
normal cervical sagittal alignment will improveboth short and
long-term outcomes in cervical myofas-cial pain syndrome
patients.
MethodsPatientsA prospective, investigator-blinded,
parallel-group, random-ized clinical trial was conducted at one of
our university’sresearch departments, the trial was registered with
the Clin-ical Trial Registry PACTR201801002968301. Cairo
univer-sity institutional review board approval was obtained
priorto the study and all subjects were recruited from our
insti-tutions local outpatient clinic. Patients with cervical
MPSwere recruited from our university’s rehabilitation
clinic.Patients were recruited and treated from March 2016
toOctober 2017 including a 1-year of follow-up.
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https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=2968
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Participants were screened prior to inclusion for alter-ations
in two primary cervical alignment variables: lossof the cervical
lordosis and anterior head translation. Aspart of our University’s
IRB approved protocol, each par-ticipant was only to receive
initial cervical spine radiog-raphy (with no follow up spine
radiography) because aprimary goal of the cervical denneroll
orthotic is to re-store the cervical lordosis, thus participants
were neces-sarily screened for hypo-lordosis. Participants
wereincluded if their cervical lordosis was less than 25°
asmeasured using the intersection of two lines drawnalong the
posterior body margins of C2 and C7 [12]. Ini-tial cervical
radiological assessment was important toidentify the cervical curve
apex to determine where asubject should properly place the apex of
the dennerollin their cervical spine [16, 18].Concerning anterior
head translation, the participant
had to have significant anterior head translation as mea-sured
by the craniovertebral angle (CVA). If the CVA wasless than 50°,
then a participant was referred to the study.Our selection of 50°
as a reference angle was guided bythe study of Yib et al. [19].
Consecutive patients were in-cluded if they had active, palpable
MTrPs on a single sideor both sides of the upper trapezius muscle.
Diagnosis wasmade according to Travell and Simons’ criteria,
wherebyfive major and at least one minor criteria are required
forclinical diagnosis [20]. The major criteria are (1)
localizedneck pain; (2) pain or altered sensations in expected
re-ferred pain area for given trigger point; (3) taut bandwithin
the muscle; (4) exquisite tenderness in a pointalong taut band; (5)
restricted range of motion. The minordiagnostic criteria for MPS
are (1) reproduction of thepatient’s chief pain complaint by manual
pressure onMTrP nodule; (2) a local twitch response; and (3)
painrelief obtained by muscular treatment. Participants
wereexcluded if any signs or symptoms of medical “red flags”were
present: tumor, fracture, rheumatoid arthritis, osteo-porosis, and
prolonged steroid use. Additionally, subjectswere excluded with
previous spine surgery and any examfindings consistent with
neurological diseases and vasculardisorders.An independent research
assistant performed a concealed
permuted block randomization using a
computer-generatedrandomization schedule with a random block
size.
RandomizationOur study design randomly assigned eligible
participantsto 1 of 2 groups: an intervention group (n = 60) or
controlgroup (n = 60). Examiner blinding was obtained throughan
independent research assist; not knowing the study de-sign and not
specifically involved in any aspect of the trial.This research
assistant created a concealed permutedblock randomization for
subject group allocation; where
equal numbers were placed in each group using a per-muted block
design of different sizes.
Treatment methodsBoth the control group and the intervention
groups re-ceived the treatment interventions including:
Integratedneuromuscular inhibition technique (INIT),
IschemicCompression, Strain Counterstrain (SCS), and muscleenergy
technique (MET). Additionally, the participantsin the intervention
group received the denneroll cervicaltraction. The control group
was treated also with a pla-cebo treatment using a small cervical
towel applied inthe supine position located in the mid cervical
spine asan intervention to mimic the denneroll traction time;but
without applying significant extension bending ofthe cervical
spine.Following 30 sessions, participants were re-evaluated a
minimum of 24 h after their last session and then eachsubject
was again followed for an additional 1-year timeframe with no
supervised treatment. The treating ther-apist (F.H), for both the
control and intervention groups,was un-blinded to the treatment
method but the sub-jects and assessor (A.I.M.M. and A.A.D.) who
conductedthe measurements were blinded.
Denneroll extension traction for the intervention groupThe
participants in the intervention group additionallyreceived the
denneroll cervical extension traction (Den-neroll Industries,
Sydney Australia; http://www.denner-oll.com) following previously
published protocols [18,21]. The patients were instructed to lie
supine and keeptheir legs extended. Based on the apex of each
partici-pant’s cervical curvature on the initial radiograph,
thetherapist positioned the apex of the denneroll in one oftwo
regions (mid cervical placement or lower cervicalplacement). The
duration of the traction session startedat 2–3 min and increased 1
min per session until reach-ing the goal of 20 min, the traction
was repeated threetimes per week for 10 weeks. See Fig. 1.
Integrated neuromuscular inhibition technique (INIT)The treating
therapist first identified the TrPs to betreated within the upper
trapezius muscle. The practi-tioner evaluated the fibers of the
upper trapezius, mak-ing note of any active TrPs, by firmly
pinching using thethumb and the forefinger. Ischemic compression
wasapplied by placing the thumb and index finger over theactive
TrP. The therapist applied slow, increasing levelsof sustained
pressure to the area until a relaxation of thetissue barrier was
felt. Following a release of pressure,the therapist again applied
increased pressure until anew barrier was felt. This process was
repeated until thepatient indicated the area was no longer tender
or until90 s had elapsed; whichever came first. All identified
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http://www.denneroll.comhttp://www.denneroll.com
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TrPs were treated in the above manner per generally ac-cepted
methodology reported in the literature [6–8].
Ischemic compression and strain Counterstrain (SCS)Here,
moderate pressure was applied by the therapist tothe identified
MTrP while each patient rated their levelof pain on a scale from 1
to 10. Once the patient’s painwas reproduced, the therapist
maintained pressure overthe active MTrP and located a position that
eased thepatient’s perception of pain. This position of ease
wasgenerally identified as positioning the affected muscle ina
shortened/relaxed state; where a reduction in pain in-tensity of
70% was indicated by the patient. Once identi-fied, the position of
ease was held for 20–30 s and thiswas repeated for three to five
repetitions by the therap-ist; similar to other generally accepted
methodology re-ported in the literature [6–8].
Muscle energy technique (MET)Following SCS, the participants
received MET applied tothe affected upper trapezius. Here, an
isometric contrac-tion was held for 7–10 s and was followed by
furthercervical spine contralateral side bending, flexion, and
ip-silateral rotation to maintain and increase the soft
tissuestretch as the muscle belly relaxes. The MET stretchposition
was repeated three to five times per treatmentsession and was
maintained for 30 s. This protocol issimilar to other generally
accepted methodology re-ported in the literature [6–8].All the
participant received the treatment by the same
physiotherapist, who had 15 years of experience in man-ual
therapy.
Home exercise protocolParticipants were advised to perform a
home exercise pro-gram once daily. The program included
strengthening
exercises for scapular retractors, deep cervical flexors,
andneck extensors. This protocol has been previously re-ported [18,
21]. The participants were instructed to prac-tice the same home
exercise program at least twice a weekduring the 1 year follow up
period. During the follow upperiod, participants were followed up
by telephone inter-views every 3 months.
Outcome measuresThe participants underwent a series of
assessments atthree time intervals: prior to treatment, after 10
weeksof intensive treatment, and at 1 year of follow-up. Theorder
of measurements was the same for all participants.
Primary outcome measure
� The Neck Disability Index (NDI), consisting of 10items related
to daily living activities, was ourprimary patient-reported outcome
measure. Thereliability, construct validity, and responsiveness
tochange of the NDI have all been assessed [18, 21].
Secondary outcome measures
� Cervical sagittal alignment, neck pain on anumerical rating
scale, cervical ROM and painpressure thresholds via an algometric
score weresecondary outcome measures.
Postural cervical sagittal alignmentStanding cervical and
shoulder posture was measuredwith photogrammetry, which provide
valid and reliableindicators of the spine [16]. Two angles of
measurementwere used cervical angle (CV), and shoulder angle
(SH)(Fig. 2) - and obtained in the sagittal view as follows:
Cervical angle - The cervical angle is highly reliable toassess
forward head translation [17]. It is defined as theangle between
the true horizontal line through thespinous process of C7 and a
line connecting spinousprocess of C7 with the tragus. In this
study, if the anglewas less than 50°, the participant was
considered tohave forward head posture; where subjects with FHPhave
a significantly smaller CV when compared withnormal subjects
[22].Shoulder angle - A line was drawn between themidpoint of the
humerus and spinous process of C7,and the angle of this line to the
horizontal line throughthe midpoint of the humerus was calculated
in degrees.In the present study, we considered 52° as the
referenceangle based on Brink et al. [23].
Pain intensity Neck pain intensity was measured usingthe
numerical pain rating scale (NPRS) [24]. The patients
Fig. 1 Denneroll cervical spine extension traction. ©Copyright
CBPSeminars, reprinted with permission
Moustafa et al. BMC Musculoskeletal Disorders (2018) 19:396 Page
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were asked to place a mark along the line indicating
theircurrent pain intensity; 0 reflecting “no pain” and
10reflecting the “worst pain”.
Pressure-pain threshold (PPT) algometric measurementA pressure
threshold algometer (Lutron electronic,FG5005, RS232) was used to
measure PPT in the mosttender point (MTP) of the upper trapezius
muscle beforeand after treatment. The average value of 3
repetitivemeasurements with an interval of 30 to 60 s (expressedas
kilograms per square centimeter) was taken for dataanalysis of the
PPT [25].
Cervical ROMCervical spine global range-of-motion was
measuredusing the valid and reliable cervical range-of-motion(CROM)
device [26]. The participant was instructed toperform flexion,
extension, right/left lateral flexion,right/left rotation in
upright sitting. The patient wasinstructed to perform each movement
when he/sheattained the maximum active range of motion. Three
tri-als were conducted for each direction of movement, andthe
average of the three measurements were recordedfor analysis. All
measurements were taken by the sameresearcher who has postgraduate
qualifications and15 years of clinical experience in
musculoskeletalphysiotherapy.
Data analysisDescriptive statistics were calculated including
mean ±standard deviation (SD) for age, height and weight.
Theoutcome measures of NDI, pain intensity, algometric
score, CROM, CV angle and SH angle were measuredusing repeated
measures one-way analysis of variances(ANOVA) to compare
measurements made before treat-ment, after the 10 weeks of
treatment, and at 1-year fol-low up. Tukey’s post-hoc multiple
comparisons wasimplemented when necessary. The baseline score
foroutcomes were used as covariates in a one-way analysisof
covariance (ANCOVA) when baseline differences aresubstantial enough
to influence the study outcomes. Weconsidered a mean difference of
more than 10.5 pointson the NDI as a MCID. Effect sizes measured
usingCohen’s d were calculated to examine the average impactof the
intervention [27]. According to the method of Co-hen, d ≈ 0.2
indicates a small effect and negligible clinicalimportance, d ≈ 0.5
indicates a medium effect and mod-erate clinical importance and d ≈
0.8 indicates a large ef-fect and high clinical importance [24].
For all statisticaltests the level of significance was set at p
< 0.05. Correla-tions (Pearson’s r) were used to examine the
relation-ships between the amount of changes in CV and SH (inthe
study group) and the amount of change in NDI, painintensity, ROM,
and pressure algometry.
Sample sizeA sample size of 100 patients provided a 90% power of
de-tecting minimal clinically important change (MCIC) onthe Neck
Disability Index (NDI) of 10.5 points (scale range0–50. To account
for possible participant drop-outs, thesample size was increased by
20% in each group.Missing values were addressed by using multiple
regres-
sion models. Model parameters were estimated with mul-tiple
regression applied to each imputed data setseparately. These
estimates and their standard errors werecombined into one overall
estimate using Rubin’s rules.
ResultsA diagram of patient flow and randomization for ourstudy
is shown in Fig. 3. Two hundred and fifteen pa-tients were
initially screened with 120 of them being eli-gible to participate
in the study. In total 120 (100%)completed the first study follow
up after 30 visits or10 weeks of treatment. At the 1-year follow
up, 102(85%) participants completed the entire study duration.At
baseline, both groups were comparable with regardto all variables
and had no statistically or clinically rele-vant differences,
except for the cervical rotation ROMand Algometric pressure (Table
1).
Primary outcome measureNDIThe difference between the
intervention group and thecontrol group was not significant after
10 weeks (p = .09;95% CI [− 1.59 to .131]), however, it was
significant at1-year follow up (< 0.001*; 95% CI [−
11.9–10.23]). The
Fig. 2 Adhesive marker placement and postural angles used
tomeasure anterior head translation. a. cervical angle; b. shoulder
angle
Moustafa et al. BMC Musculoskeletal Disorders (2018) 19:396 Page
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effect size (Cohen’s d) was 0.9 (Table 2). These findings
in-dicated a greater improvement in the interventional groupin the
NDI and a regression back to baseline-pre-treatmentvalues in the
NDI for the control subjects.
Secondary outcome measuresPain intensity and algometric
pressureSubsequent analyses depending on the presence of
inter-actions for main effects, revealed that after 10 weeks
oftreatment, the two arms of treatment (both interven-tional and
control groups) seemed roughly equally suc-cessful in improving the
pain intensity, and pressurealgometry outcome measures. At 10
weeks, the unpairedt test analysis revealed insignificant
differences betweenthe experimental and control groups for pain
intensity(p = 0.36), while there was a significant difference
foralgometry (p
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extension (p
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those reported in two earlier trials using this patient
pre-scribed orthotic device [15, 16]. Devices such as the
den-neroll, act as three-point-bending cervical extensiontraction
devices; where structures located anterior to theaxis of extension
rotation will be exposed to significanttension loads and structures
posterior will experiencecompression. The anterior tension loading
likely unloadsthe intervertebral disc, causing tension on the
anteriorcervical spine muscles, and anterior longitudinal
ligament,leading to visco-elastic creep deformation resulting in
in-creasing the cervical lordosis and reducing anterior
headtranslation [16, 18, 28].Anterior head translation and
protraction or rounding
of the shoulders are likely two postures that are
coupledtogether. In our current study, we identified that
theintervention group receiving the cervical denneroll wasfound to
have a reduction in both anterior head postureand a more retracted
shoulder / scapular position fol-lowing treatment. Reduction in
anterior head translationis likely responsible for the improvement
in shoulderalignment. Similarly, Diab et al., identified that
reductionin sagittal head posture was an effective means for
im-proving 3-D spinal posture of the thoracic region andpelvis
[29]. Collectively, the finding that rehabilitation ofcervical
sagittal posture may subtly improve full spineposture measures
indicates that there must exist a topdown neurophysiological
regulation of upright humanposture that is driven by the sagittal
alignment of thecervical lordosis and forward head posture [30,
31].
Forward head posture and neck disability indexIt is interesting
that the application of an integratedneuromuscular inhibition
technique alone or in con-junction with an intervention program for
forward head
posture reduction (denneroll orthotic) seem roughlyequally
successful in improving neck disability statusafter 10 weeks of
treatment. However, our 1-year followup data revealed a significant
decline in the neckdisability index for the control group. The
temporalimprovement in the control group may be attributed tothe
strong association between pain relief in bothgroups and functional
status. However, over time, thecontinuous increased and / or
asymmetrical loadingfrom forward head posture may be the possible
explan-ation for the decline in functional disability status forthe
control group at 12 months follow up. This conceptof biomechanical
dysfunction resulting from anteriorhead translation is supported by
predictions fromexperimental and biomechanical spine-posture
model-ing studies [15, 19, 32, 33] as well as from
post-surgicaloutcomes [34, 35] and large scale cross-sectional
inves-tigations [36].Specifically, Tang et al. [34] identified that
anterior
translation distance of C2 relative to C7 (termed the SVA)on
lateral cervical radiographs positively correlated withthe neck
disability index in 113 patients receiving poster-ior cervical
spine fusions. Similar results were identified ina prospective
sample of 49 patients by Roguski et al. [35].In a large cross
sectional analysis of 656 subjects, Oe et al.[36] identified strong
correlations between activities ofdaily living on the EuroQOL
questionnaire and theC2-C7 SVA. These three studies [34–36] are
supportedby the results of the current investigation where
weidentified a statistically significant correlation betweenour
experimental groups improvement in their anteriorhead translation
(CV angle) and their consequent im-provement in NDI 10-weeks post
treatment and at longterm follow up.
Table 3 The changes in secondary outcomes; pain intensity and
algometry in experimental and control groups vs time
Outcome Experimental group Control group Mean difference (95%
CI) P value effect size (Cohen’s d) Effect size r
Pain intensity
Baseline 5.3 ± .7 5.1 ± .8 [−.05 .5] .11
After 10 weeks 1.4 ± .9 1.6 ± .8 [−.5 .17] .36
1-year follow up .4 ± .4 4.2 ± .7 [−4.1-3.6] < 0.001 .6
.9
G < 0.001
T < 0.001
G*T < 0.001
Algometric pressure
Baseline 1.9 ± .2 1.71 ± .3 [.15.3] < 0.001
After 10 weeks 3.6 ± .3 3.3 ± .5 [.13.5] < 0.001 .7 .8
1-year follow up 3.9 ± .2 2 ± .4 [1.8 2.1] < 0.001 .9 .9
G < 0.001
T < 0.001
G*T < 0.001
G: group T: time G vs T: group versus time
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Table 4 Changes in secondary outcomes; cervical ROM and posture
parameters
Cervical angle (CV)
Experimental group Control group Mean difference (95% CI) P
value effect size (Cohen’s d) Effect size r
Baseline 44. 8 ± 3.5 45 ± 3.2 [−1.5 .94] .6
After 10 weeks 54.8 ± 2.5 45 ± 3.3 [8.8 10.9] < 0.001 5.2
.9
1-year follow up 54.2 ± 2.7 44.5 ± 3.1 [8.7 10.8] < 0.001 5.7
.9
G < 0.001
T < 0.001
G*T < 0.001
Shoulder angle
Baseline 48.2 ± 2.1 48.3 ± 1.7 [−.77 .6] .8
After 10 weeks 57.7 ± 2.9 48.06 ± 1.6 [8.7 10.4] < 0.001 4.1
.9
1-year follow up 56.9 ± 3.1 48.3 ± 1.4 [7.71 9.4] < 0.001 3.7
.9
G < 0.001
T < 0.001
G*T < 0.001
Flexion
Baseline 42.3 ± 2 41.9 ± 2.1 [−.31 1.2] .2
After 10 weeks 46.7 ± 1.5 43.3 ± 1.7 [2.8 4.1] < 0.001 2.5
.7
1-year follow up 46.3 ± 1.4 42.9 ± 2.3 [2.7 4.1] < 0.001 1.7
.7
G < 0.001
T < 0.001
G*T < 0.001
Extension
Baseline 68.1 ± 1.2 67.6 ± 2.5 [−.14 1.3] .1
After 10 weeks 75.2 ± 1.8 68.2 ± 2.4 [6.3 7.8] < 0.001 3.2
.9
1-year follow up 74.4 ± 1.7 67.6 ± 1.9 [6.2 7.3] < 0.001 3.8
.9
G < 0.001
T < 0.001
G*T < 0.001
Right rotation
Baseline 72.3 ± 2.4 73.7 ± 2.6 [−2.3 -.4] < 0.001
After 10 weeks 79.7 ± 1.4 74.8 ± 2.3 [4.2 5.5] < 0.001 2.6
.8
1-year follow up 78.8 ± .9 74.8 ± 2.1 [3.4 4.6] < 0.001 2.5
.8
G < 0.001
T < 0.001
G*T < 0.001
Left rotation
Baseline 72.3 ± 2.4 74.3 ± 2.8 [−2.94-1.05] < 0.001
After 10 weeks 79.6 ± 1.4 74.8 ± 2.3 [4.21 5.4] < 0.001 2.6
.8
1-year follow up 78.8 ± .9 74.8 ± 2.1 [3.4 4.6] < 0.001 2.5
.8
G < 0.001
T < 0.001
G*T < 0.001
Right tilt
Baseline 42.3 ± 2 41.9 ± 2.1 [−.31 1.18] .2
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Pain intensity and algometric pressureOverall, our findings
revealed a significant and stable de-crease in pain intensity for
the study group. This longlasting improvement of pain for the study
group seemsattributable to the restoration of normal posture. It
isgenerally accepted that spinal function is directly relatedto
spinal structure. Abnormal posture elicits abnormalstresses and
strains in many structures, including bones,intervertebral discs,
facet joints, musculotendinous tis-sues, and neural elements [13,
27, 32, 33], that can beconsidered as a predisposing factor for
pain from an al-teration in mechanical loading. Of interest, in
FHP, re-ciprocal postural compensation was observed in theupper and
lower cervical spine to maintain horizontalgaze. FHP caused flexion
in the lower segments andextension in the atlanto-occipital and
atlantoaxial seg-ments. The transition between flexion and
extension oc-curred in the C2–C4 region. These compensations
haveimplications towards increased abnormal stresses andstrains
[37]. Thus, restoring the normal sagittal configur-ation is likely
to minimize the abnormal stresses.This mechanical relationship
between prolonged ab-
normal postures and MPS has previously been identifiedin
different studies [9, 10]. However, few studies havedirectly
evaluated the relationship between forward headposture and MPS in
neck and shoulder. Sun et al., exam-ined the correlation between
the presence of MPS andabnormal cervical sagittal alignment
concluding that“there was no relationship between the forward
headposition and the presence, location, and number of trig-ger
points” [38]. While Penas et al., highlighted the posi-tive
relationship between forward head posture and thepresence of active
trigger points [39].The discrepancy and conflict regarding the
relation-
ship between abnormal forward head posture with MPS
identified by earlier authors cannot be directly comparedwith
our current study because earlier studies arecross-sectional
correlation studies without an ability toascribe cause and effect.
In the current study, the signifi-cant correlations between the
amount of change in theCV angle in the intervention group and neck
disability,pain intensity, and algometry outcomes indicates
thatforward head posture reduction improves the outcomesof
MPS.Concerning the pain level outcomes in the control
group, the temporal reduction of pain may be attributedto short
term effects of integrated neuromuscular inhib-ition technique. For
example, Hu et al. [40] reported thatpain reduction, improvement of
MTrP sensitivity, andincrease in ROM after various modalities for
cervicalmyofascial pain and trigger-point sensitivity may not
bemaintained long term. Similarly, the systematic review ofVernon
and Schneider [41] provides moderately strongevidence to support
the use of some manual therapies inthe immediate relief of TrP
tenderness. However, onlylimited evidence to support the use of
manual therapiesover longer courses of treatments in the management
ofTrPs and MPS was found.
Cervical ROMOne might speculate that the improvement of ROM
isattributed to a decrease of pain intensity. However,
thesignificant differences between our study and controlgroups at
the two measurement intervals favoring thestudy group indicate that
the loss in ROM is not or notonly driven by the presence of
myofascial pain [34, 42].Other factors associated with restricted
ROM besides in-creased muscle tension and pain need
considered.Mechanically though, forward head translation alters
theanatomic alignment of the cervical spine joints in the
Table 4 Changes in secondary outcomes; cervical ROM and posture
parameters (Continued)
Cervical angle (CV)
Experimental group Control group Mean difference (95% CI) P
value effect size (Cohen’s d) Effect size r
After 10 weeks 46.7 ± 1.5 43.3 ± 1.7 [2.8 4.05] < 0.001 2.5
.7
1-year follow up 46.3 ± 1.4 42.9 ± 2.3 [2.724 4.1] < 0.001
1.7 .7
G < 0.001
T < 0.001
G*T < 0.001
Left Right tilt
Baseline 42.5 ± 2.1 42.2 ± 2.1 [−.42 1.12] .3
After 10 weeks 46.7 ± 1.6 43.45 ± 1.8 [2.6 3.9] < 0.001 2.5
.7
1-year follow up 46.4 ± 1.4 43.15 ± 2.3 [2.5 3.9] < 0.001 1.7
.7
G < 0.001
T < 0.001
G*T < 0.001
G: group T: time G vs T: group versus time
Moustafa et al. BMC Musculoskeletal Disorders (2018) 19:396 Page
10 of 13
-
sagittal plane, alters the lever arms of the cervical
spinemuscles and thus this is the most plausible explanationfor
altered cervical spine ROM [35]. This statement isfurther supported
by the significant correlation betweenthe amount of change in the
CV angle in the interven-tion group and all ROM outcomes. The
current studyresults are logical and agree with those of four
otherstudies [35, 36, 43, 44], each of which investigated
theassociation between forward head and cervical ROM.
LimitationsThe current study has some potential limitations.
First,our study lacked blinding of participants and
treatmentproviders. Due to the nature of the interventions, it
wasnot be possible to blind participants and treatment pro-viders
to the interventions provided. Second, we used a
sample of convenience from 1 clinic; which may not
berepresentative of the entire population of patients withCMCPS.
Additionally, we chose selective but relevant pa-tient outcome
measures (NDI, pain scale, pain pressurethresholds, range of
motion) to identify if changes in sagit-tal plane posture
deviations are related to CMCPS im-provement. It is possible that
other measures of CMCPSoutcomes would have different relationships
(greater orless improved) with posture alignment changes and
thatdifferent interventions than those tested herein may im-prove
patients with CMCPS more considerably.Third, although the
correlations identified between
our postural measures and patient outcomes were statis-tically
significant, they would be classified in the moder-ate range. This
indicates that there are other variables,not accounted for in the
current study design, which
Table 5 Pearson’s r correlation matrix for outcome variables in
the intervention group
Δ cervical angle 0-10w Δ cervical angle 10-1Y Δ shoulder angle
0-10w Δ shoulder angle 10w -1Y
Δ pain 0-10 W −.2P = .05
−.2P = .015
Δ pain 10 W-1Y −.1P = .2
−.05P = .3
Δ NDI 0-10w −.24P = .032
−.11P = .196
Δ NDI 10 w-1Y .2P = .0
.07P = .2
Δ algometric 0–10 w .24P = .033
.29P = .012
Δ algometric 10w-1 Y −.027P = .4
−.002P = .4
ROM flexion 0–10 w .2P = .028
.15P = .1
ROM flexion 10w-1 Y −.16P = .1
−.007P = .4
ΔROM extension 0–10 w .34P = .003
−.06P = .3
ΔROM extension 10w-1 Y .06P = .3
.053P = .3
ΔROM RT rotation 0–10 w .25P = .026
.14P = .1
ΔROM RT rotation 10w-1 Y −.11P = .1
.033P = .4
ΔROM left rotation 0–10 w .4P = .036
.03P = .4
ΔROM rotation lt 10w-1 Y −.1P = .1
.013P = .4
ΔROM RT lateral flex 0–10 w .2P = .020
.12P = .1
ΔROM RT lateral flex 10w-1 Y .14P = .1
ΔROM left lateral flex 0–10 w .2P = .021
.05P = .3
ΔROM left lateral flex 10w-1 Y .04P = .3
−.1P = .2
Moustafa et al. BMC Musculoskeletal Disorders (2018) 19:396 Page
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-
have determining effects on neck disability, pain, andrange of
motion outcomes. Along this line, we were un-able to obtain
follow-up lateral cervical radiographs.Thus, we do not if know the
cervical lordosis was im-proved in the experimental group receiving
the denne-roll and if this may have added any significance to
thecorrelation to patient outcomes.Within these limitations, the
unique contribution of
this study is that it evaluated the independent effect
ofstructural rehabilitation of the cervical spine sagittal pos-ture
on the short and long term severity of the signs andsymptoms
associated with CMCPS; which to our know-ledge has not been
previously reported. A major strengthof the present study is the
information as to how longpain relief lasted after treatment; up to
1-year. Whereasadditional post-treatment measurements with
longerthan a 1-year interval might have identified a waning
ef-fectiveness of treatment.
ConclusionThis study identified that restoring a more normal
cervicalsagittal alignment with denneroll traction has a
strongpositive impact on pain, function, and ROM in patientswith
myofascial pain syndrome. Our one-year follow-uprevealed stable
improvement in all measured variables.The findings provide
objective evidence that biomechan-ical dysfunction in terms of
abnormal head and cervicalposture influences the outcome measures
of MPS. Theseobserved effects should be of value to clinicians and
healthprofessionals involved in the treatment of MPS where
cer-vical spine alignment rehabilitation can be added to
theinterventions for MPS patients who present with signifi-cant
posture abnormality.
AbbreviationsCMCPS: Chronic myofascial cervical pain syndrome;
CV: Cervical angle;INIT: Neuromuscular inhibition technique; NDI:
Neck disability index;NRS: Neck pain intensity; PPT: Pressure pain
thresholds; SH: Shoulder angle
AcknowledgementsWe thank the CBP NonProfit, Inc. for supplying
the Dennerolls used is this study.
FundingThis study was financially supported by funding from the
ChiropracticBiophysics Non-profit, Inc., Inc. The contribution in
terms of supplying theDennerolls used is this study.Chiropractic
Biophysics Non-profit, Inc. is anonprofit corporation dedicated to
the advancement of chiropracticprinciples through scientific
research.
Availability of data and materialsThe datasets used and analysed
in this study are available from thecorresponding author on
reasonable request.
Authors’ contributionsIMM and AAD, involved in study conception
and design, as well asimplementation, analysis and interpretation
of data, and manuscriptpreparation FH made substantial
contributions to the conception and designof the study and the
drafting of the article, DEH made substantialcontributions to the
conception and design of the study, the analysis andinterpretation
of the data and the revision of the article. All authors
havereviewed and approved the final manuscript.
Ethics approval and consent to participateThe study has received
ethical approval from the Research EthicsCommittee-Faculty of
Physical Therapy-Cairo University. All participatingsubjects have
signed an informed consent form before entering the study.
Consent for publicationWritten consent to publish the content of
this report along with theaccompanying images was obtained from all
patients.
Competing interestsDEH is the president of a company that
distributes the cervical Dennerollproduct to health care providers
in North America. IMM and AAD and FHhave no conflicts of interest
related to this project.
Publisher’s NoteSpringer Nature remains neutral with regard to
jurisdictional claims in publishedmaps and institutional
affiliations.
Author details1Department of Physiotherapy, College of Health
Sciences, University ofSharjah, Sharjah, United Arab Emirates.
2Basic Science Department, Faculty ofPhysical Therapy, Cairo
University, 7 Mohamed Hassan El gamal Street-AbbasEl Akaad, Nacer
City, Egypt. 3CBP Nonprofit (a spine research foundation),Eagle,
ID, USA.
Received: 12 February 2018 Accepted: 24 October 2018
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AbstractBackgroundMethodsResultsConclusionTrial registration
BackgroundMethodsPatientsRandomizationTreatment methodsDenneroll
extension traction for the intervention groupIntegrated
neuromuscular inhibition technique (INIT)Ischemic compression and
strain Counterstrain (SCS)Muscle energy technique (MET)Home
exercise protocolOutcome measuresPrimary outcome measureSecondary
outcome measuresPostural cervical sagittal alignmentPressure-pain
threshold (PPT) algometric measurementCervical ROM
Data analysisSample size
ResultsPrimary outcome measureNDI
Secondary outcome measuresPain intensity and algometric
pressureCervical angle and shoulder angleCervical range of
motion
Correlation of posture parameters to primary and secondary
outcomes
DiscussionForward head posture and neck disability indexPain
intensity and algometric pressureCervical ROMLimitations
ConclusionAbbreviationsAcknowledgementsFundingAvailability of
data and materialsAuthors’ contributionsEthics approval and consent
to participateConsent for publicationCompeting interestsPublisher’s
NoteAuthor detailsReferences