Background

Nonspecific neck pain (NSNP) is a major health condition in society causing serious debility throughout the world. The NSNP is neck pain without any precise cause [1]. NSNP affects 30–50% of the general population and often causes severe disability [2]. According to the World Health Organization, musculoskeletal (MSK) disorders are problems of muscles, tendons, joints, intervertebral discs, peripheral nerves and the vascular system [3]. Neck pain is defined as a painful sensation in the neck region which is sometimes presented clinically as, tension, or fatigue that may radiate towards head, shoulder, elbow, and even wrist [4]. In terms of global burden, neck pain is the 4th most common MSK condition that causes disability and ranked 21st in a total of 291 conditions [5]. Less than half of the people at any point in their lifetime experience neck pain [6].

In the COVID-19 pandemic due to prolonged sitting, there is an increase in MSK pains with the highest percentage of neck pain at 32% [7]. There is also an increase in neck pain due to laptop and smartphone use in lockdown due to the pandemic [8]. It is commonly observed that neck pain is often associated with the forward head posture (FHP). A FHP commonly known as “hunched upper back” is characterized by rounded shoulders and upper back with an anteriorly inclined neck with hypo flexed lower cervical spine and hyperextended upper cervical spine. In FHP there is also recruitment of accessory muscle [9]. According to the Global Burden of Disease (GBD) Study, in people in their twenties neck pain and low back pain are the second most common causes of disability in a lifetime and prevalence is increasing day by day, with around 21% increase from 2006 to 2016 [10]. Women are more affected than men [11]. Evidence supports the use of neck stabilization exercises (NSE) to reduce the pain in people with insidious neck pain [12]. Stabilization exercises comprise exercises that activate the deep muscles and decrease the over-activity of the superficial muscles [13]. Studies have reported that muscle weakness leads to the activation of accessory muscles that disrupt the normal movement pattern, and neck stabilization exercises decrease the over-activity of these muscles, which restores and facilitates postural control [14]. Strength training and isometric exercises are found to be effective in decreasing neck pain symptoms. Conversely, NSE was introduced as a rehabilitation program for pain management, improved function, and injury prevention [15]. According to the American Physical Therapy Association, clinical practice guidelines exercise therapy like mobilizations and NSE, neck dynamic exercise (NDE) laser therapy, and stabilization with the short-term use of a cervical collar may be provided as treatment options [16]. Among MSK problems, neck pain and FHP stand foremost rising issues with the world moving to work from home and online. Furthermore, according to authors’ knowledge the NSE and NDE has been compared in literature but is not evident with limited comparison in neck pain associated with postural deficit. Therefore, identifying which particular exercise is effective in improving pain and posture is going to help patients get the best treatment. These exercises can be followed at home and workplace too so the patient can easily perform self-directed exercises which may reduce their hospital re-visit due to neck pain also, providing the most effective treatment is going to reduce the overall cost of treatment helping organization at a larger scale. This study also helps future researchers to focus on other aspects of treatment that were not explored in this study. So, this study was to compare the effects of NSE versus NDE among patients having NSNP with FHP in reducing pain, disability, FHP, and improving neck range of motion (ROM).

Methodology

Study design and setting

This is a two-arm, parallel-designed, and randomized clinical trial conducted at Sindh Institute of Physical Medicine and Rehabilitation, Karachi, Pakistan with a group allocation ratio of 1:1. The duration of the study was from April 2022 to January 2023.

Inclusion and exclusion criteria

Individuals included in the study were patients of age range from 18 to 40 years [16] having NSNP for more than 3 weeks to < 6 months [17] along with FHP on plumb line measurement tool and with moderate intensity pain on Visual analogue scale (VAS) 3.5–7.4 cm [18] and moderate disability on neck disability index (NDI) questionnaire score (50–64%) [19].

However, the participants with a history of any accident (whiplash), vertebral fracture, tumor, previous surgery, psychological disorders etc. and participants unwilling to participate are excluded.

Sampling technique and sample size estimation

A sample size of 60 patients (30 in each group) was considered on the basis of non-probability, purposive sampling. The sample size was calculated using PASS software version 11. Group sample sizes of 10 and 10 achieve 83% power to detect a difference of 1.8 and with a significance level (alpha) of 0.05 using a two-sided two-sample t-test. The mean ± SD of visual analogue scale scores of the relevant article used for sample size calculation were 4.48 ± 1.38 in the neck stabilization plus dynamic exercises group and 2.66 ± 1.27 in the NSE group [4].

Randomization and envelope concealment

A physician with more than 13 years of experience screened the patients for study criteria to enroll in the study. Randomization was done by a computer-generated online randomizer (https://www.sealedenvelope.com) for a sample size of 60 for NSE group and NDE group. An independent statistician performed this. The outcome assessor (physician) assessed study outcomes before and after the intervention and was blinded to the treatment allocation. The participants and intervention providers could not be blinded due to the nature of the treatment.

Data collection procedure

All the participants were randomized into two groups after screening for NSNP which was conducted by a consultant physician through detailed history taking, aided by a screening proforma. This process aimed to rule out potential causes of neck pain, through x-ray as diagnostic imaging, prior to enrolling patients. All participants filled informed consent before randomization. Group one received stabilization exercises and group two received dynamic exercises. Neck stretching exercises and pain modalities were given to both groups. Participants were assessed before and after treatment. VAS, NDI questionnaire, goniometry, and plumb line assessment were used for the assessment of pain intensity, functional disability, ROM and FHP respectively. The treatment was provided by a qualified physiotherapist with more than two years of clinical experience. The data was analyzed statistically for its significance. The CONSORT flow diagram is also given (Fig. 1).

Fig. 1
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The Consort flow diagram

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Consent form and questionnaire

A very concise consent form was provided to all participants before enrollment. It contains the possible harms and benefits of the study. The participants are informed about confidentiality and their voluntary participation and the treatment was free of cost. The participant was informed about the objective of the research and the treatment provided. English and Urdu versions of the NDI questionnaire were used for the assessment of participants. The licensed version is used by the investigator and permission was granted by the MAPI research trust.

Ethical considerations

The research was approved by the Institutional Review Board (IRB) of Dow University of Health Sciences (DUHS) ref: IRB-2391/DUHS/Approval/2022/731.

Intervention

Treatment group 1 was provided with NSE and treatment group 2 was provided with NDE along with Conventional treatment; transcutaneous electrical nerve stimulation (TENS) [20], Comfy Stim: Model EV-806 (10 min of electrical stimulation was given with a pulse rate of 80 to 120 Hz and pulse width of 200uS in normal mode). Electrode 1 A: right side of posterior neck. Electrode 1B: left side above scapula. Electrode 2 A: left side of posterior neck Electrode 2B: right side above scapula, MEDICARE reusable hot/cold pack (20 minutes of cryotherapy will be given after therapy) [20] on the posterior aspect of neck and shoulders, cervical muscle stretching was provided to both treatment groups. The patient sitting at the edge of the couch comfortably facing forward for all self-stretch. For trapezius participant performed contralateral lateral bending with the help of the opposite hand to touch the shoulder with the earlobe [21]. For the right side Pectoralis minor the participant’s right forearm was stabilized from the front by vertical plane the trunk is then rotated in the left direction. Movement was external rotation and abduction to 90°. For the right side sternocleidomastoid participant touched the left shoulder with the left ear by rotating the neck upward toward the ceiling and the stretch felt on the right side, applying pressure from the other hand. The movement was lateral flexion and rotation. For the right side levator scapulae, participant touched the left shoulder with the left ear by rotating the neck downward towards the ground and the stretch felt at the right side and applied pressure from the other hand. The movement was lateral flexion and rotation [22]. Participant kept each stretch for 10 s and 5 reps for each side of the muscle.

NSE included Chin tuck (patient pulled back the chin towards the body while maintaining gaze; Fig. 2), Cervical extension (patient extended the neck as far as possible while supporting the neck from the back with both hands; Fig. 3), Shoulder shrugs (patient shrugged the shoulders; bringing them up towards the ears; Fig. 4), Shoulder rolls (patient rolled the shoulders in the circle, clockwise and anticlockwise; Fig. 5), Scapular retraction (participant brings both scapulae towards the midline; Fig. 6) All exercises were performed in sitting a position with a frequency of 15 repetitions 1 set with relaxation [4].

NDE included the usage of a Thera band with increasing resistance. It included cervical extension-dynamic. The participant’s position was upright sitting. The participant extended their neck, then held it for 5 s and slowly returned to the neutral position, using a Thera band to maintain an erect posture throughout the exercise (Fig. 7). Cervical Flexion-Dynamic isometric in upright sitting the participant flexes their neck, then held it for 5 s and slowly returns to the neutral position (Fig. 8), using Thera band to maintain erect posture throughout the exercise and Chest flies exercises in standing position the participant grip the Thera-band at the level of his or her shoulders with the elbows in extension and pulled the bands with both hands toward each other hands and then returned slowly (Fig. 9). The frequency of exercise was 15 per 1 set [4].

Treatment group 1

Treatment group 2

• TENS, stretching exercises of the neck, cold packs.

• Stabilization exercises

1) Chin tuck

2) Cervical extension

3) Shoulder shrugs

4) Shoulder rolls

5) Scapular retraction

• TENS, stretching exercises of the neck, cold packs.

• Dynamic exercises.

1) Cervical extension-dynamic isometric.

2) Cervical Flexion-Dynamic isometric.

3) Chest flies exercises.

Treatment time per session: 45 min [4]

Duration of treatment: 3 weeks

3 visits per week total of 9 sessions [19].

Follow up

Results were evaluated before and after treatment for both treatment groups first initially at baseline and then after 3 weeks of treatment.

Fig. 2
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Chin tuck

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Fig. 3
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Cervical extension

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Fig. 4
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Shoulder shrugs

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Fig. 5
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Shoulder rolls

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Fig. 6
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Scapular retractions

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Fig. 7
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Cervical extension-dynamic isometric

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Fig. 8
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Cervical flexion-dynamic isometric

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Fig. 9
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Chest fly’s exercises

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Outcome measures

The VAS was used for pain intensity, NDI for disability, goniometry for ROM, and plumb line assessment for FHP. All the outcome measures were primary.

Neck disability index questionnaire (NDI)

It is a validated tool that has been widely used in assessing disability in individuals with neck pain. It is available in multiple languages. The NDI-Urdu version has also high reliability and validity [23]. It is also found to be effective with VAS and other pain scales. It is a ten-item questionnaire. Each item scores from 0 no disability to 5 complete disability (6 responses) total score of 0–50. 4 or less indicates no, 4–15 mild, 15–25 moderate, 25–35 severe and more than 35 is complete disability [18].

Visual analogue scale (VAS) for pain

VAS is a validated tool used for assessing pain. It is a subjective measure used for both acute and chronic pain. It is a 10 cm straight line. One side of the straight line is minimum/no pain and the other side is worst pain from left to right. The patient marks his/her pain on the line. The score is assessed by the therapist. 0–3.4 cm is mild, 3.5–7.4 cm is moderate and 7.5–10 cm on a 10 cm line is considered severe pain [24].

Goniometry

Goniometry has excellent intra-rater reliability for the measurements of ROM [18]. Measurements of all the ranges were assessed in a sitting position (for flexion and extension, the center of the goniometer was placed over the external auditory meatus stationary arm was placed straight point the toward ceiling and the moving arm moved in the direction of flexion and extension following the nose. For lateral flexion, the center of the goniometer was placed over the C7 spinous process stationary arm placed straight point toward the ceiling and the moving arm moved in the direction of side-flexion from the midline and for rotation, the center of the goniometer was placed over the center of the head from above and the moving arm moves in the direction of rotation following nose.) [25].

Plumb line measurement

The plumb line is an inexpensive and easy to use measurement tool. It has a high inter-rater reliability for measuring postural deviations. Head and shoulder landmarks are used for reference (mastoid process and auditory meatus). Head and shoulder alignment was assessed using a plumb line as a reference line for ideal head posture. Any forward Deviation of the tragus of the ear from the ideal plumb line is considered as FHP [26]. It was measured through the measuring scale in inches. This deviation can be subjectively assessed as a slight deviation, moderate deviation, or marked deviation in inches on the scale [27]. It is performed in both standing and sitting.

Harms and adverse events

No harm or any adverse event was reported during the period of trial.

Data analysis procedure

Data was entered and analyzed by IBM-SPSS 21, and mean and SD was calculated for quantitative variables like age (years), height (cm), weight (Kg), Body Mass Index (BMI) (Kg/m2), marital status (single, married, divorced), irritability (present/absent), severity (mild, moderate, severe). Counts with percentages given for gender (male, female), and occupations, means and SD were also given for studied parameter VAS (pain intensity), NDI questionnaire (functional disability), Goniometry (ROM) and plumb line assessment tool (FHP) scores in both groups NSE and NDE. Paired sample t-test is used to compare these parameters within groups and independent sample t-test is used to compare between-group outcomes post treatments. A P-value less than 0.05 is considered statistically significant. The normality of all outcome measures was measured with the Shapiro-Wilk test p-value > 0.05 is considered as significant. Graphical representation of the data set is by bar diagrams and pie charts.

Results

Among all study participants (n = 60), there were mostly females [47(78.33%)] and only 13(21.67%) were males with total mean age of 30.08 ± 6.35 years, mean height of 161.23 ± 9.09 cm, mean weight of 61.2 ± 13.19 kg and mean BMI of 23.63 ± 4.39 kg/m2. All the participants had moderate pain intensity. Most of the participants [57(95%)] had no irritability and only 3(5%) had irritability. About half of the participants [30(50%)] were married, 28(46.67%) were unmarried and only 2(3.33%) participants were divorced (Table 1).

Table 1 Frequency and percentages of the baseline characteristics (N = 60)
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The baseline data analysis for comparison of gender, irritability, marital status (Table 1), occupation, age, height, weight, body mass index, VAS, neck range of motions, plumb line and NDI between groups showed no statistically significant differences (p > 0.05) between both groups (Table 2).

Table 2 Mean and standard deviation of the baseline characteristics (N = 60)
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The within group analysis of both groups for mean VAS (0–10 cm) showed significant (p < 0.001) pain improvement after treatment with a very large effect size and no zero value in a 95% confidence interval there is almost approximately 2/3rd decrease in pain within both groups (Table 3).

Table 3 Comparison of pain intensity (VAS) within groups
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Table 4 shows significant (p < 0.001) improvement in all range of motions of the neck including flexion, extension, left and right lateral flexion and left and right rotation with a large effect size and no zero value in 95% confidence interval of difference.

Table 4 Comparison of neck range of motion within groups
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The within group analysis of both groups for the mean plumb line showed significant (p < 0.001) improvement after treatment with a very large effect size and no zero value in 95% confidence interval of difference, approximately 1/3rd decrease within both groups (Table 5).

Table 5 Comparison of forward head posture within groups
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Table 6 shows significant (p < 0.001) improvement in the neck disability index score with a very large effect size and no zero value in the 95% confidence interval of the mean difference. There is more than 1/3rd mean neck disability index score improvement.

Table 6 Comparison of neck disability within groups
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However, the between group analysis showed a non-significant difference (p > 0.05) for post-treatment mean VAS and all neck range of motions including flexion, extension, left and right lateral flexion and left rotation. The null hypothesis fell within the 95% confidence interval of the mean difference of all variables (Table 7).

Table 7 Comparison of post-treatment pain intensity and neck range of motions between groups
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The between group analysis for mean plumb line measurement and NDI also showed a non-significant difference (p > 0.05) after treatment. The null hypothesis fell within the 95% confidence interval of the mean difference of all variables (Table 8).

Table 8 Comparison of post-treatment plumb line and NDI between groups
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Discussion

The study was conducted to evaluate the effectiveness of the neck NSE and neck dynamic exercises in improving pain, neck ROM and functional ability in patients with neck pain it also evaluates the effect of exercises in normalizing forward head posture using VAS as a tool to assess pain improvement whereas NDI questionnaire, goniometry and plumb line measurement tool are used to assess the functional ability, ROM and forward head posture respectively.

The results of the study showed that in both groups NSE and NDE, There was a marked improvement in pain on VAS from baseline to after the 9th session and the functional status of the patient also improved after 3 weeks of treatment. ROM of the neck is increased in all ranges in both groups NSE and NDE as well as the head posture is normalized.

Numerous research has shown that females are more prone to head and neck pain and injury as compared to males due to their anthropometric differences like the anatomy of the neck (smaller head and shorter neck length), muscle strength (less than males), arthokinemetics (differences in vertebral dimensions) [28]. Due to the high prevalence of neck pain in females this study also has more females (78.33%) than males (21.67%).

Most of the participants in the study are housewives (30%) the second highest number of individuals consists of students (20%) due to the increased use of computers for online education during the COVID-19 pandemic. Their prolonged computer use and forward bending of the neck lead to the tightness of the anterior neck muscle causing neck pain, fatigue, and discomfort [29]. There was also a large number of physiotherapists (15%) participants. According to the literature, healthcare professionals especially physical therapists are at increased risk of work-related MSK disorder because of their work routine and among all kinds of WRMDs neck pain is very frequently reported (44.1%) [30]. The rest of the participants belong to multiple professions including teaching, government jobs, private jobs, etc.

VAS scoring is a subjective measurement of pain on a scale of 0–10 cm. In this study, a 2/3rd decrease in pain is found in the within-group analysis of both groups NSE and NDE. The mean difference of group 1 NSE is 4.23 and the mean difference of group 2 NDE is 4.56. MCID value of VAS for neck pain is 4.6 [31] the VAS is found to be clinically significant. This may be due to the mechanism through which exercises reduce pain i.e., it is believed that intense exercises enhance activity in the motor pathways causing an inhibitory effect on the pain center present in central nervous system (CNS). Also, the contraction of muscles strains different connective tissues stimulating mechanoreceptors thereby increasing the activity of sensory nerves which inhibits the pain mediating pathways [4]. Cervical NSE has also shown significant improvement in pain by enhancing the control of deep cervical muscles [32]. These results are the same as the previous studies but there is no statistical significance was found in between group analysis of VAS. The mean difference between groups is -0.1 which is contradictory to the previous evidence in which NSE are found to be more effective than dynamic exercises [4].

In this study, more than 1/3rd improvement in NDI is seen in within group analysis of both groups NSE and NDE. The mean difference of group 1 NSE is 44.25 and the mean difference of group 2 NDE is 47.44. This may be due to the effect of exercises on the MSK system, CVS, immune system, CNS, and other brain functions like mood, sleep, etc. Exercise is also beneficial in improving mobility and flexibility of different structures as well as increasing strength and endurance of muscles and also prevents injury by improving tensile strength of capsule and ligaments hence, providing both physical and mental benefits. Previous studies suggest that these benefits are more with stabilization exercises [4] but in this study, there is no statistical significance was found in between group analysis of NDI. The mean difference between groups is 1.73. That may be because dynamic exercises were also found to be much more effective in treating neck pain and disability as compared to other exercises i.e., isometric exercises [13].

Literature has suggested that ROM has a strong relation with neck disorders. Poor posture results in muscle imbalance and reduces the strength of cervical muscles. However, performing NSE leads to improved posture and restoring balance resulting in increased ROM [33]. In this study ROM improvement (in all ranges flexion, extension, left and right rotation, left and right lateral flexion) is seen in within group analysis of both groups NSE and NDE (p-value: <0.001) for all ranges which is consistent with previous literature that shows there is increased ROM in all ranges due to stabilization exercises [32, 33] This was thought to be due to normalization of straight neck and normalization of muscle asymmetry [33]. Dynamic exercises are also found to be effective in maintaining the flexibility of joints, muscles, ligaments, and capsules resulting in increased joint movement [13]. There is no statistical significance was found in between group analysis of ROM. there are limited studies that show the comparison between NSE and NDE exercises in improving ROM.

The FHP is associated with neck pain, stiffness, and fatigue because of overloading of the cervical spine these patients present with tightening of cervical extensors and weakness of scapular retractors [9]. There is a 1/3rd improvement seen in within group analysis of both groups NSE and NDE plumb line measurement. The mean difference of group 1 NSE is 0.46 and the mean difference of group 2 NDE is 0.47. This is consistent with the studies that show that the NSE affects deep cervical muscles of the neck restoring strength of the cervical muscles and improving postural alignment. The NSE is beneficial in improving the strength and endurance of spinal stabilizers which helps in reducing pain and improves cervical function [9] Also dynamic exercises affect pain and neck alignment by increasing the strength of deep neck flexor muscle [34]. There is no statistical significance found in the between-group analysis of plumb line measurement. The mean difference between groups is 0.12. However, there is a lack of composite research showing a comparison between NSE and NDE in treating FHD along with nonspecific neck pain.

Limitations:

This study is limited to only physical disability, and psycho-social aspects of disability were not considered. There was no control group in the study because the objective of the study is to compare the two different interventions however, all the confounding factors are controlled as per consort guidelines. The assessment is done manually by goniometry and plumb line assessment so there are chances of manual error however to overcome the chances of error average values were taken.

Conclusion

It is concluded no one of the two treatments is more beneficial than the other. Both NSE and neck dynamic exercises are equally efficient in alleviating pain, decreasing functional disability, and improving ROM and FHP. Therefore, both NSE and NDE are equally beneficial to use with conventional treatment for providing better results in patients with NSNP with FHP.