Abstract. Med. J. Cairo Univ., Vol. 84, No. 2, December: , SAHAR A. ABDALBARY, Ph.D.

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1 Med. J. Cairo Univ., Vol. 84, No. 2, December: , The Manual Therapy and Exercise Program Compared with Postural Exercises for Mechanical Neck Pain in Female Computer Typists: A Randomized Clinical Trial SAHAR A. ABDALBARY, Ph.D. The Department of Orthopedic Physical Therapy and Its Surgery, Faculty of Physical Therapy, Modern Academy, El-Maadi University Abstract Background: Purpose of this study was to assess the effectiveness of manual physical therapy and s as compared to the postural s in the treatment of patients with mechanical neck pain with unilateral upper extremity symptoms in female patients worked as computer typists. Material and Methods: Patients were referred by the orthopedist to the outpatient physical therapy clinic to this controlled randomized study. Inclusion criteria were female patients working in computer office typing for at least 2 years. Patients were assessed for pain, neck pain disability, cervical range of motion and success of treatment. There were 2 groups, one group was treated with manual therapy and and the other group with postural s for 12 sessions. Results: There were significance differences between both groups at p<0.01. The improvement was in the group which treated with the manual therapy and program. Conclusion: The manual therapy and program was effective in the treatment of mechanical neck pain in female computer typists. Key Words: Mechanical neck pain Manual therapy Postural s Upper extremity. Introduction WORK-RELATED musculoskeletal disorders are common among computer users, especially affecting the neck and shoulder regions [1]. Typing and moussing are common office tasks, involving both fine motor control and associated postural activity of the muscles of the cervical spine. Physiotherapist treats patients with computer-related musculoskeletal disorders, and therefore an understanding of the mechanism underlying impairments is important to guide management [2]. Correspondence to: Dr. Sahar A. Abdalbary, The Department of Orthopadic Physical Therapy and Its Surgery, Faculty of Physical Therapy, Modern Academy, El-Maadi University Neck pain and Disability due to neck pain are major problems in public health. The prevalence of neck pain in general populations ranging from 4.8% to 79.5% and the economic impact of neck pain is immense [3]. Mechanical neck pain is a general term which covers pain originating from stress and strain of soft tissues around the vertebral column. Many interventions are useful in conservative management of mechanical neck pain. Physiotherapy interventions mainly deal with modalities, s, ergonomic advice and manual therapies [4]. Despite the prevalence, less than optimal prognosis, associated risk disability, and economic consequences of individuals suffering from mechanical neck pain, there remain significant gap in the literature, which fails to provide sufficient high-quality evidence to effectively guide the conservative treatment of this patient population. The purpose of this study was to determine the effectiveness of manual physical therapy and s as compared to postural s in the treatment of patients with mechanical neck pain with unilateral upper extremity symptoms in female patients worked computer typing. Material and Methods Prospective randomized clinical trial. Participants: 60 Patients were referred by the orthopedist to the outpatient physical therapy clinic at Al-Kasr El-Aini Hospital the time was since January 2014 till January 2016 to this controlled randomized study. Inclusion criteria were female patients working in computer office typing for at least 2 years, 149

2 150 The Manual Therapy & Exercise Program Compared with Postural Exercises a primary complaint of neck pain, with or without unilateral upper extremity symptoms, age greater than 20 years, neck pain disability score 10 points, and a composite Visual Analog Scale (VAS) pain score 30mm, as derived from 3 separate 100-mm pain scales measuring the patient s cervical, upper extremity, and average 24-hours pain scores. Exclusion criteria were patient s with whiplash injury within the past 12 weeks, history of spinal tumors, spinal infection, spinal fractures, or previous neck surgery, central spinal stenosis, or bilateral upper extremity symptoms. Patients were asked to stop taking medications for their neck pain and not to start any new medications during the clinic treatment from the first session till the 12 session. All eligible patients were informed of the potential risks and benefits of the study before obtaining their written informed consent. Randomization: Before the study, an assistant for the author used a random number generator to generate a randomization list. Sequentially numbered paper slips with the randomization assignments were prepared and placed into sealed envelopes. Baseline outcomes measures were collected by a blinded author assistant before referring the patients to the author for treating physical therapy. The author opened the next sealed envelopes to reveal the patient s group assignment. In this manner patients were randomized into 2 treatment groups 30 patients for every group: Manual physical therapy and or postural and postural modification. Interventions: The author assistant performed a standardized history and examination of the cervical spine and upper quarter before randomization. Demographic information and self-report measures for Neck Pain Disability (NDI) and (VAS) pain scales were collected. Physical examination measures included cervical Range of Motion (ROM) measurements with a gravity inclinometer [5]. Passive accessory motion testing to assess cervical spine segmental mobility and pain provocation [6], an upper quarter neurologic screening, and special tests commonly used to identify cervical impairments [7,8]. Patients in the manual therapy and group received manual physical therapy interventions specifically targeted to impairments identified during the physical examination. Each treatment session consisted of thrust and non-thrust joint mobilization, muscle energy and stretching techniques in all directions of the neck muscles and strengthening for flexors, lateral rotators and side bending [9,10]. Patients in the second group received a basic treatment plan consisted of general practitioner care [11]. Patients were provided with a basic regimen of postural advice, encouragement to maintain neck motion and daily activities, cervical rotation range of motion and instructions for continued maintaining good posture. The intervention period for both groups lasted 4 weeks with 3 sessions weekly treatment time was standardized for both groups during the initial evaluation and treatment sessions. Outcome measures: Patient outcomes were collected at baseline and after the last session completion for both groups. Primary outcome measures assessed disability, pain intensity, and perceived recovery. The 50-point NDI was used to measure patient-reported disability due to mechanical neck pain [12]. The NDI has high test-retest reliability [13], good concurrent validity with the McGill pain questionnaire and patient-perceived improvement [14], a minimal detectable change of 4.2 points [15], and a minimum clinically important difference of 5 points [16]. Cervical pain and upper extremity pain were assessed using the 100mm VAS, where 0 represented (no pain) and 100mm represented (worst pain). The VAS has test-retest reliability between 0.95 and 0.97 [17] and a minimum clinically important difference of 12 ±3mm [18]. Patient-perceived improvement was measured using the 15-point global rating of change scale ranging from 7 to +7, where 0 represents no change, 7 indicates( a very great deal worse), and +7 indicates (a very great deal better) [19,20]. It was proposed that patient global rating of change scale classifications: 0, 1 or 1 had no change, ±2 to 3 had minimal change, ±4 to 5 had moderate change, and ±6 to 7 had large change in their condition [21]. Post treatment outcome measures included treatment success rates for each group on treatment completion. Statistical analysis: Sample size determination was based on detecting a significant interaction effect between treatment groups and the NDI and VAS pain scores at an a-level of Power analysis for B=0.80 revealed the need for 30 patients per group to detect significant change of 4 points for the 50- point NDI and 15mm for the 100mm VAS. SPSS for windows software, version 15.0 (SPSS, Chicago, IL) was used for statistical analysis. Base line variables between groups were compared using independent t-test for NDI, VAS scores

3 Sahar A. Abdalbary 151 for cervical pain, and VAS for upper extremity pain and Mann-Whitney U-test for analyzing nonparametric data from global rating of change scores to compare perceived improvement between the groups. Results Sixty patients were randomized into 2 treatment groups: 30 patients in every group. Baseline Characteristics (Table 1) and outcome measures for the NDI and VAS pain scores did not differ significantly Table (1): Comparison between both groups at base line characteristics. Variables Manual therapy and (n=30) Postural (n=30) p Value Age (year) 30±9 30± Symptoms duration (year) 2.1 ± 1 2.2± Range of motion (degrees): Flexion 44± 13 45± Extension 42± ±9 0.1 Rotation 50.9± 11 50± Side bending 32±8 31 ± Upper extremity symptoms 21 (30) 20 (30) 0.16 NDI Score 25 ± 13 27± VAS 55±6 54± GRC Score 1.9± ± Data are Mean and ± Standard Deviations for variables. There were no significance differences between both groups before the treatment. Discussion The results of this randomized trial, in female patients working as typist in computer office suffering from mechanical neck pain, showed that both treatment programs were effective but, the treatment with manual therapy and showed significantly greater improvement. Several studies have shown that manual therapy and is more effective for patients with mechanical neck pain than general practitioner care and standard physical therapy [22], and than spinal manipulation or used alone [23]. Treatment efficacy has been demonstrated in terms of perceived improvement and pain reduction [24], similarly, the manual therapy and group reported significantly larger cervical pain reduction, improved cervical range of motion, and decreased upper extremity pain. The present study attempts to assess the effect of manual therapy and and postural exer- between the 2 treatment groups before the treatment. Table (2) shows the mean scores (95% confidence intervals) for all outcome measures and the mean differences in scores between the both groups. The manual therapy and group demonstrated statistically greater improvement in the NDI (p=0.001), the cervical pain VAS (p=0.001), the upper extremity pain VAS (p=0.004), the Global Rating of Change (GRC scale) ( p=0.001), and all directions of the range of motion after the treatment. Table (2): Comparison between both groups after the treatment. Variables Manual therapy and group Postural group p Value Range of motion (degrees): Flexion 60± ± * Extension 56± ± * Rotation 66±3 57± * Side bending 45±2 34± * NDI 6.2± ± * VAS 15± ± * GRC 4.9± ± * Upper extremity pain 7.1± ± * Treatment success rates, 25 (30) 13 (30) 0.001* No. (%) p-values were significant at all measurements for both groups after the treatment. cise on the upper extremity pain in patients with mechanical neck pain. The baseline pain scores for both groups were moderately range. The change in the VAS was significantly decreased for the manual therapy and group and this improvement reported in previous study [25]. The NDI which includes a standard set of activities specific to each patient was significantly different after the treatment between both groups. The program used in our study differed from previous study [26] in addition to cervical strengthening s to address regional muscle imbalances, we included patient-specific s to target impairments and reinforce the effects of our manual interventions. A concern when using a multimodal treatment approach is the inability to assess the contribution of each modality towards patient improvement. In using impairment-based approach, every manual

4 152 The Manual Therapy & Exercise Program Compared with Postural Exercises intervention was followed by an immediate reassessment of the patient s impairments to increase our confidence that observed changes were a direct result of the intervention. There was study has reported that within session changes in range of motion and pain intensity can be used to predict between session changes in patients with cervical and low back pain [27]. Several studies have demonstrated significant improvement in patient outcomes when using an impairment-based manual therapy and s treatment approach [28,29]. The changes in the cervical range of motion in the manual therapy and were large and might then be explained by the neurophysiological effect of this procedure, it has been demonstrated that the s of the cervical spine could produce an increase in mechanical pain threshold [30]. Neck posture was also, found to be problematic in terms of duration, particularly for a subset of participants. Traditionally, work design methods aim to reduce required motion to conserve energy and avoid waste [31]. The treatment plan for manual therapy and group consisted of interventions (patient education, mobility ) typically found in general practitioner care. There were several limitations with our study. Our patients were female only and computer typist was used in this study. We need further research to apply the program of treatment on it with large number and different professions. Conclusion: This study demonstrated that the treatment program of manual therapy and is effective for the conservative management of patients with mechanical neck pain, with or without unilateral upper extremity symptoms. The benefits of this intervention are the reduction of cervical and upper extremity pain, neck disability, and increase the perceived recovery and treatment success. References 1- SZETO G., STRAKER L.M.O. and SULLIVAN P.B.: During computing tasks symptomatic female office workers demonstrate a trend towards higher cervical postural muscle load than symptomatic office workers: An experimental study, Aust. J. Physiother., 55: , COOPER A. and STRAKER L.: Mouse versus keyboard use: A comparison of shoulder muscles load, Int. J. Indust. Orgono., 22: , CORE P., CASSIDY J.D. and CARROLL L.: The Saskatchewan health and back pain survey, the prevalence of neck pain and related disability in Saskatchewan adults. Spine, 23: , BERTOZZI L., GARDENGHI I. and TUROI F.: Effect of therapeutic on pain and disability in the management of chronic nonspecific neck pain: Systematic review and meta-analysis of randomized trials, Phys. Ther., 93 (8): , SARIG-BAHAT H.: Evidence for therapy in mechanical neck disorders, Maual Ther., 8 (1): 10-20, WANNIER R.S., FRITZ J.M., IRRANGANG J.J., et, al.: Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy, Spine, 28: 52-62, MAITLAND G. and MAITLAND S.: vertebral mobilization, 6th ed. Oxford Butter Worth Heinemann, MAGEE D.J.: Orthopaedic physical assessment, 4 th ed. Canada: Elsevier Sciences, JULL G., EVANS R., NELSON B., et al.: A randomized controlled trial of and manipulative therapy for cervicogenic headache, Spine, 27: , FLYNN T.: Orthopadic manual physical therapy management of the cervical-thoracic spine and ribcage. Minneapolis: OPTP, HARRIS K.D., HEER D.M., ROY T.C., et al.: Reliability of measurement of neck flexor muscle endurance. Phys. Ther., 85: , VERNON H. and MIOR S.: The neck disability index a study of reliability and validity. J. Manipulative Physical Ther., 14: , STATFORD P.W., RIDDLE D.L., BINKELY J.M., et al.: Using neck pain disability index to make decision to individual patients. Physiother Can., 51: , WESAWAY M.D., STATFORD P.W. and BINKLY J.M.: The patient-specific functional scale: Validation of its use in persons with neck dysfunction. JOSPT, 27: , McCORMACK H.M., HORNE D.J. and SHEATHER S.: Clinical application of visual analogue scale: A critical review. Psychol. Med., 18: , KELLY A.M.: The minimum clinically significance difference in visual analogue scales pain score does not differ with severity of pain. Emerge. Med. J., 18: , JAESCHKE R., SINGER J. and GUYATT G.H.: Measurement of health status. Ascertaining the minimal clinically important difference. Control Clin. Trials, 10: , JUNIPER E.F., GUYATT G.H., WILLAN A., et al.: Determining a minimal important change in a diseasespecific quality of the questionnaire, J. Clin. Epidemiol., 47: 81-87, BORGOUTS J.A., KOES B.W., BOUTTER L.M.: The clinical course and prognostic factors of non-specific neck pain: A systematic review. Pain, 77: 1-13, 1998.

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