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Research Review By Dr. Jeff Muir©


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Date Posted:

July 2021

Study Title:

Combining targeted instrument-assisted soft tissue mobilization applications and neuromuscular exercises can correct forward head posture and improve the functionality of patients with mechanical neck pain: a randomized control study


Mylonas K, Angelopoulos P, Billis E, Tsepis E & Fousekis K

Author's Affiliations:

Human Evaluation and Rehabilitation Laboratory, Physical Therapy Department, School of Health Rehabilitation Sciences, University of Patras, Greece

Publication Information:

BMC Musculoskeletal Disorders 2021; 22: 212.

Background Information:

Cervical pain syndrome (CPS) remains a significant and prevalent condition (1, 2) (note: this is another label for what many refer to as ‘mechanical neck pain’). Several contributing factors are associated with CPS, including pathological postural changes, which are associated with increased stress and pain in the cervical spine. Postural changes – the most common of which is forward head posture (FHP) – have been shown to be a chronic contributor to CPS and are thought to begin at puberty (3, 4).

Treatment for cervical spine pathologies traditionally includes manual therapy, massage, stretching, soft-tissue techniques and therapeutic exercise (4, 5). Manual therapy is a broad category which itself includes the use of therapeutic equipment, such as stainless-steel tools (6, 7), plus therapeutic exercise including neuromuscular retraining, which can improve mobility, increase strength, and prevent tendon injuries (8, 9).

Despite these known treatments and their clinical impact, little research has been completed examining the use of these two therapeutic approaches to correct postural changes such as FHP. To address this gap in the literature, the authors sought to evaluate the short- and intermediate-term effects of postural correction on cervical pain syndrome. To do this, they assessed the effectiveness of a combined treatment approach, featuring instrument-assisted soft tissue techniques and a therapeutic exercise program for correcting the posture and functionality of patients with mechanical neck pain syndrome and accompanying FHP.

Pertinent Results:

Significant improvements in FHP while sitting were noted, with greater improvements noted in Group A (IASTM + neuromuscular exercise) vs. Group B (classical massage + neuromuscular exercise). Group A improvements were maintained at 2 (p = 0.397) and 4 weeks (p = 0.08) post-treatment. FHP improvements in Group A were noted in the upright position (p = 0.0005), which were also maintained at 2 (p = 0.01) and 4 weeks (p = 0.004) post-treatment.

ROM (flexion/extension) improvements were noted immediately following treatment in both groups (A: p = 0.002; B: p = 0.0005) and were maintained after 2 (p = 0.151 and p = 1.000, respectively) and 4 weeks (p = 0.064 and p = 1.000, respectively) in both groups.

Cervical flexion strength increased significantly post-treatment in Group A (p = 0.017), which was greater than Group B. This improvement was not maintained at 2 weeks (p = 0.019) post-treatment but was significantly improved at 4 weeks (p = 1.00).

Pain (VAS) improved significantly in both groups immediately after treatment (p = 0.0005), which was maintained in both groups after 2 (p = 0.0005) and 4 weeks (p = 0.008). NDI also improved significantly in Group A vs. Group B after the 8th session (p = 0.004) and after 2 weeks (p = 0.001) and 4 weeks (p = 0.0005) post-treatment.

No adverse events were reported in this study.

EDITOR’S NOTE: As you may have noticed, some of the p values relating to the observed differences between groups crept higher (in some cases way higher) than the 0.05 (5%) threshold, indicating that some of these changes may have due to chance. In a smaller study like this, it is not unusual to see this and if they had a much larger sample size, these discrepancies may have been resolved (or, the treatment differences may be shown to be nil). The results are promising, but bigger, higher powered studies are required to further investigate this relationship.

Clinical Application & Conclusions:

IASTM techniques combined with neuromuscular exercise improved pain and function (including reducing FHP) in patients with cervical pain syndrome when compared with classical massage and neuromuscular exercise. These results, while promising, require support from larger studies in future. These techniques could also be investigated when targeted to lumbar postural dysfunctions.

Study Methods:

20 female patients (aged 43-65) with a diagnosis of mechanical neck pain and accompanying FHP participated in this study.

Inclusion criteria:
  • Female
  • Diagnosed by a medical orthopaedic doctor
  • Duration of pain symptoms of > 3 months
  • Forward head posture (FHP) defined as a craniovertebral angle (CVA) of < 50° (10)
Exclusion criteria:
  • Lack of FHP
  • Minor neck injury
  • Intervertebral disc herniation
  • Spondylolisthesis
  • Accompanying neurological, musculoskeletal or mental problems
  • Currently taking medication.
Patients were randomized to receive either targeted instrument-assisted soft tissue mobilization (IASTM) techniques and neuromuscular exercises (group A) or the same exercise program accompanied by classical massage (group B). Reflective markers at the tragus of the ear and the spinous process of C7 were used to track and measure FHP.

Outcomes and Measurements:
An inclinometer was used to assess cervical ROM and strength. ROM (flexion/extension) was assessed with the patient in a seated position while rotation and strength were assessed in the supine position. Pain was assessed via the visual analog scale (VAS). Functional ability was assessed via the Neck Disability Index (NDI). Eight treatment sessions (2x/week for 4 weeks) were provided for each patient. FHP, ROM and strength were assessed before and after each session; NDI was evaluated five times: before the 1st, 4th and 8th sessions, plus at 2- and 4-weeks post-treatment.

Group A: ERGON IASTM (11) targeted to the cervical and thoracic spine including myofascial release of shortened muscles. Group B: classical massage in the same area(s). Participants in both groups received specialized neuromuscular exercises to correct FHP following the soft-tissue treatment. Exercises included: neck curl with chin tuck; cervical rotation and lateral flexion strengthening; and trapezius and rhomboid activation in the prone position through horizontal abduction of the shoulder blades.

Statistical Analysis:
Univariate analysis was conducted via the mixed ANOVA method.

Study Strengths / Weaknesses:

  • Appropriate randomization methods and study group comparisons were employed.
  • Valid outcome measures reflecting pain, function and mobility were utilized.
  • The sample size, while small, was validated by appropriate sample size calculation.
  • Participants, while randomized to treatment groups, were recruited consecutively.
  • Pathologies causing neck pain were not standardized nor homogenous.
  • Patients’ physical conditioning and experience with exercise programs was variable.
  • There was no pure control (no treatment) group used for comparison.

Additional References:

  1. Andersson HI, Ejlertsson G, Leden I, Rosenberg C. Chronic pain in a geographically defined general population: studies of differences in age, gender, social class, and pain localization. Clin J Pain 1993; 9(3): 174–82.
  2. Côté P, van der Velde G, Cassidy JD et al. The burden and determinants of neck pain in workers: results of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders. Spine 2008; 33(4): 60–74.
  3. Kim MH, Yi CH, Kwon OY, Cho SH, Yoo WG. Changes in neck muscle electromyography and forward head posture of children when carrying schoolbags. Ergonomics 2008; 51(6): 890–901.
  4. Schwanke NL, Pohl HH, Reuter CP et al. Differences in body posture, strength and flexibility in schoolchildren with overweightand obesity: a quasi-experimental study. Man Ther 2016; 22: 138–44.
  5. Gross AR, Goldsmith C, Hoving JL et al. Cervical overview group. Conservative management of mechanical neck disorders: a systematic review. J Rheumatol 2007; 34(5): 1083–102.
  6. Portillo-Soto A, Eberman LE, Demchak TJ, Peebles C. Comparison of blood flow changes with soft tissue mobilization and massage therapy. J Altern Complement Med 2014; 20(12): 932–6.
  7. Fousekis K, Eid K, Tafa E et al. Can the application of the Ergon® IASTM treatment on remote parts of the superficial back myofascial line be equally effective with the local application for the improvement of the hamstrings’ flexibility? A randomized control study. J Phys Ther Sci 2019; 31(7): 508–11.
  8. Falla D, Jull G, Russell TR, Vicenzino B, Hodges P. Effect of neck exercise on sitting posture in patients with chronic neck pain. Phys Ther 2007; 87(4): 408–17.
  9. Roddey TS, Olson SL, Grant SE. The effect of pectoralis muscle stretching on the resting position of the scapula in persons with varying degrees of forward head/rounded shoulder posture. J Man Manip Ther 2002; 10(3): 124–8.
  10. Yip CHT, Chiu TTW, Poon ATK. The relationship between head posture and severity and disability of patients with neck pain. Man Ther 2008; 13(2): 148–54.
  11. Simatou M, Papandreou M, Billis E et al. Effects of the Ergon® instrument-assisted soft tissue mobilization technique (IASTM), foam rolling, and static stretching application to different parts of the myofascial lateral line on hip joint flexibility. J Phys Ther Sci 2020; 32(4): 288–91.

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