Can Suboccipital Release Followed by Cranio-Cervical Flexion Exercise Improve Shoulder Range of Motion, Pain, and Muscle Activity of Scapular Upward Rotators in Subjects With Forward Head Posture?원문보기
Background: For the treatment of forward head posture (FHP) and forward shoulder posture, methods for strengthening scapular retractors and deep cervical flexors and stretching pectoralis and upper cervical extensors are generally used. No study has yet assessed whether suboccipital release (SR) fol...
Background: For the treatment of forward head posture (FHP) and forward shoulder posture, methods for strengthening scapular retractors and deep cervical flexors and stretching pectoralis and upper cervical extensors are generally used. No study has yet assessed whether suboccipital release (SR) followed by cranio-cervical flexion exercise (CCFE) (SR-CCFE) will result in a positive change in the shoulders and neck, showing a "downstream" effect. Objects: The purpose of this study was to investigate the immediate effects of SR-CCFE on craniovertebral angle (CVA), shoulder abduction range of motion (ROM), shoulder pain, and muscle activities of upper trapezius (UT), lower trapezius (LT), and serratus anterior (SA) and LT/UT and SA/UT muscle activity ratios during maximal shoulder abduction in subjects with FHP. Methods: In total, 19 subjects (7 males, 12 females) with FHP were recruited. The subject performed the fifth phase of CCFE immediately after receiving SR. CVA, shoulder abduction ROM, shoulder pain, muscle activities of UT, LT, and SA, and LT/UT and SA/UT muscle activity ratios during maximal shoulder abduction were measured immediately after SR-CCFE. A paired t-test and Wilcoxon signed-rank test were used to determine the significance of differences in scores between pre- and post-intervention in the same group. Results: The CVA (p<.001) and shoulder abduction ROM (p<.001) were increased significantly post-versus pre-intervention. Shoulder pain was decreased significantly (p<.001), and LT (p<.05) and SA (p<.05) muscle activities were increased significantly post- versus pre-intervention. The LT/UT muscle activity ratio was increased significantly post- versus pre-intervention (p.05). Conclusion: SR-CCFE was an effective intervention to improve FHP and induce downstream effect from the neck to the trunk and shoulders in subjects with FHP.
Background: For the treatment of forward head posture (FHP) and forward shoulder posture, methods for strengthening scapular retractors and deep cervical flexors and stretching pectoralis and upper cervical extensors are generally used. No study has yet assessed whether suboccipital release (SR) followed by cranio-cervical flexion exercise (CCFE) (SR-CCFE) will result in a positive change in the shoulders and neck, showing a "downstream" effect. Objects: The purpose of this study was to investigate the immediate effects of SR-CCFE on craniovertebral angle (CVA), shoulder abduction range of motion (ROM), shoulder pain, and muscle activities of upper trapezius (UT), lower trapezius (LT), and serratus anterior (SA) and LT/UT and SA/UT muscle activity ratios during maximal shoulder abduction in subjects with FHP. Methods: In total, 19 subjects (7 males, 12 females) with FHP were recruited. The subject performed the fifth phase of CCFE immediately after receiving SR. CVA, shoulder abduction ROM, shoulder pain, muscle activities of UT, LT, and SA, and LT/UT and SA/UT muscle activity ratios during maximal shoulder abduction were measured immediately after SR-CCFE. A paired t-test and Wilcoxon signed-rank test were used to determine the significance of differences in scores between pre- and post-intervention in the same group. Results: The CVA (p<.001) and shoulder abduction ROM (p<.001) were increased significantly post-versus pre-intervention. Shoulder pain was decreased significantly (p<.001), and LT (p<.05) and SA (p<.05) muscle activities were increased significantly post- versus pre-intervention. The LT/UT muscle activity ratio was increased significantly post- versus pre-intervention (p.05). Conclusion: SR-CCFE was an effective intervention to improve FHP and induce downstream effect from the neck to the trunk and shoulders in subjects with FHP.
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가설 설정
The intervention, which included SR and deep neck flexor strengthening, obtained positive results with pain reduction. In this study, the resultant decrease in shoulder pain was considered that SR-CCFE lead to a downstream effect from neck to shoulders.
Thus, this is the first reported study to investigate the immediate effects of SR-CCFE on (1) CVA, (2) shoulder abduction range of motion (ROM) and shoulder pain, and (3) muscle activities of the UT, LT, and SA and LT/UT and SA/UT muscle activity ratios during maximal shoulder abduction in subjects with FHP. We hypothesized that SR-CCFE would (1) increase CVA, (2) increase shoulder abduction ROM and decrease shoulder pain, and (3) increase LT and SA muscle activities and LT/UT and SA/UT muscle activity ratios, and decrease UT muscle activity in subjects with FHP.
제안 방법
Prior to measurement, the subject was asked to identify their painful side for the shoulder and to show their upper body by taking off their top if male or wearing a tank top if female. The subject completed a familiarization session for the CCFE at each phase of the exercise (up to the fifth phase) to ensure optimal performance capability.
Inclusion criteria were (1) CVA<53° (Kim et al, 2015), (2) shoulder pain, and (3) limitation of abduction at the shoulder joint. The more painful side (greater visual analogue scale; greater VAS) was chosen to collect the data (18 right and 1 left side). Exclusion criteria were (1) medical/health care for low back pain over the past year (Harman et al, 2005), (2) dysfunction of the spine, (3) cervical, thoracic, or shoulder girdle fractures or anomalies (Peterson et al, 1997), and (4) obesity, as determined by body mass index >30 ㎏/㎡ (Hallman et al, 2011).
The purpose of this study was to investigate the effects of SR-CCFE on (1) CVA, (2) shoulder abduction ROM and shoulder pain, and (3) muscle activities of the UT, LT, and SA and LT/UT and SA/UT muscle activity ratios during maximal shoulder abduction in subjects with FHP. The results of the kinematic data partially supported our research hypothesis.
The shoulder abduction ROM was measured by two investigators using a universal goniometer (Baseline, Fabrication Enterprises, White Plains, New York, USA). While the PI measured the ROM, the other investigator prevented all compensatory movements.
Prior to measurement, the subject was asked to identify their painful side for the shoulder and to show their upper body by taking off their top if male or wearing a tank top if female. The subject completed a familiarization session for the CCFE at each phase of the exercise (up to the fifth phase) to ensure optimal performance capability. Then, the subject performed the fifth phase of CCFE immediately after receiving the SR.
In the first phase of the exercise, the PI taught the subject to perform controlled CCFE slowly in a supine position. The subject focused on sagittal rotation movement of the head slide in caudad and cephalad directions on the bed rather than a retraction movement. Once the first CCFE phase was achieved correctly, the subject performed the second phase using an air-filled pressure sensor (Stabilizer, Chattanooga Group Inc.
The VAS entails a 10 ㎝ line and a scale completed by the subject. The subject was asked to check on the VAS line to identify the present intensity of shoulder pain on the tested side. The scores, which begin from the zero point indicating “no pain” are marked by the subject using a ruler.
, Hixson, USA) placed between the back of the head and the bed. The subject was asked to perform progressive CCFE by increasing the amount of pressure, as shown by the feedback dial, thereby flattening cervical lordosis. Gradually, the subject performed CCFE, increasing the pressure in 2 ㎜Hg increments, to reach the fifth phase, with a target pressure level of 20∼30 ㎜Hg.
The subject held the extension of the elbow joint with the thumb directed up toward the ceiling to create the external rotation necessary to prevent shoulder impingement (Kolber and Hanney, 2012). The subject was instructed to maximally abduct the shoulder in the frontal plane with chin tucked for stabilization and to prevent lateral flexion of the neck. Once active end-range was accomplished, the angle of maximum shoulder abduction ROM was measured.
The subject completed a familiarization session for the CCFE at each phase of the exercise (up to the fifth phase) to ensure optimal performance capability. Then, the subject performed the fifth phase of CCFE immediately after receiving the SR. All variables were measured twice by the PI before and after the SR-CCFE.
No study has yet assessed whether SR followed by CCFE (SR-CCFE) results in a positive change in shoulder as well as neck posture, representing a “downstream” effect. Thus, this is the first reported study to investigate the immediate effects of SR-CCFE on (1) CVA, (2) shoulder abduction range of motion (ROM) and shoulder pain, and (3) muscle activities of the UT, LT, and SA and LT/UT and SA/UT muscle activity ratios during maximal shoulder abduction in subjects with FHP. We hypothesized that SR-CCFE would (1) increase CVA, (2) increase shoulder abduction ROM and decrease shoulder pain, and (3) increase LT and SA muscle activities and LT/UT and SA/UT muscle activity ratios, and decrease UT muscle activity in subjects with FHP.
대상 데이터
A power analysis was performed using results from a pilot study with five subjects. A total sample size of 17 subjects was required to satisfy a significance level of .
The CVA was recorded with a digital camera (PL150, Samsung, Seoul, Korea), and the ImageJ image analysis software (U.S. National Institutes of Health, Maryland, USA) was used to assess the kinematic data. The digital camera was placed perpendicular to the ground, with its lens 80 ㎝ from the lateral aspect of the subject and pointing directly at the subject’s shoulder to minimize parallax error (Yoo et al, 2008).
데이터처리
Paired t-tests were conducted to assess the significance of differences in the CVA, shoulder abduction ROM, muscle activities of the UT, LT, and SA, and LT/UT and SA/UT muscle activity ratios during maximal shoulder abduction in subjects with FHP between pre- and post-intervention. A Wilcoxon signed-rank test was used to assess the significance of differences in shoulder pain between pre- and post-intervention. The level of significance was set at .
All variables were measured twice by the PI before and after the SR-CCFE. The mean of the two measurements was used for statistical analysis. The other investigator was blinded to the experimental condition being tested during analysis of the variables.
성능/효과
This study has some limitations. First, because it was performed to investigate the immediate effects of SR-CCFE using a cross-sectional design, the long-term effects of the intervention could not be determined. Second, the findings of this study have limited generalizability to other patient populations with shoulder and trunk pathologies because only subjects who had FHP with shoulder pain and limitation of abduction were recruited.
Further studies are needed to exclude subjects with a dominant rhomboid. Fourth, because we used combination of SR and CCFE as an intervention, it was uncertain that the effects resulted from whether combined intervention or not. Finally, because our study was not a randomized controlled trial, the results could be influenced by other unrecognized factors.
Athletes with scapular dyskinesis often have dominance of the UT and perform a shoulder shrug motion during retraction, which is counterproductive (Kelly and Thomas, 2011). In this study, the LT/UT muscle activity ratio during maximal shoulder abduction was increased significantly, by 24.05%, post-intervention versus pre-intervention. The reduction in UT dominance relative to LT indicated improvement in the shoulder muscle imbalance during overhead activity.
Furthermore, Falla et al (2007) suggested that CCFE improved the ability to maintain a neutral cervical posture during prolonged sitting. In this study, we used SR-CCFE as an intervention in FHP, and our results indicate that SR-CCFE was effective in reducing FHP through increasing CVA immediately.
Gradually, the subject performed CCFE, increasing the pressure in 2 ㎜Hg increments, to reach the fifth phase, with a target pressure level of 20∼30 ㎜Hg. The PI confirmed that the subject could hold the target level consistently for 10 seconds without depending on retraction, dominant contraction of superficial neck flexor muscles, or a quick CCFE movement. Recruitment of the superficial muscles was monitored by the PI using palpation.
The intra-class correlation coefficients (ICC) for the MVIC of UT, LT, and SA were .98 (95% confidence interval; 95% CI=.94∼.99), .98 (95% CI=.96∼.99), and .98 (95% CI=.95∼.99), respectively.
후속연구
Second, the findings of this study have limited generalizability to other patient populations with shoulder and trunk pathologies because only subjects who had FHP with shoulder pain and limitation of abduction were recruited. Future studies should investigate the long-term effects of SR-CCFE in subjects with other medical histories, such as thoracic hyperkyphosis, FSP, winged scapula, or shoulder impingement syndrome. Third, we did not consider or exclude rhomboid muscle activity, which has a role in scapular downward rotation and could be variable among subjects.
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