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Rapid Responses: Rapid Responses published:
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Dynamic exercise?
- Carole J Murphy (2 September 2003)
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Response from the Manipulation Association of Chartered Phsyiotherapists
- Jane Greening, DA1 1SA (3 September 2003)
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And the JAMA-study?
- Maurice Vanbellinghen (4 September 2003)
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Relaxation method
- Eyal Lederman (23 September 2003)
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Specific neck muscle training is effective treatment in chronic neck pain.
- Jari Ylinen (26 September 2003)
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Not all solutions are necessarily simple ...
- Mark K. Frobb (15 October 2003)
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Carole J Murphy, Senior Physiotherapist Carlow, Ireland
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Current physiotherapy management of chronic neck pain promotes the activation of the deep neck flexor muscles to improve core central stability to relieve pain and improve posture. Although the article fails to mention the specific dynamic exercises chosen I am unsure how the deep flexor muscles can be strengthened using dumbbells held, presumably, in the hands. If the exercises chosen were simply upper limb or global muscle strengthening exercises I would expect there to be little overall change in symptoms as concluded by the authors. In any chronic condition it is important to directly retrain the specific musculature involved, in this case the deep flexor muscles, and not just indirectly through peripheral/global muscle strength work. In addition no rehabilitation is complete without re-educating posture and improving body awareness/proprioception. In the case of chronic neck pain there is usually muscle imbalance around the cervical spine therefore activating the large muscle groups in the neck and shoulder region in isolation would not be expected to be beneficial.The conclusions of the authors should be that dynamic peripheral muscle strengthening in isolation is ineffective in the treatment of chronic neck pain rather than being dismissive of all dynamic exercise programmes. In clinical practice I would aim to redress the muscle imbalance by improving the core stabilising muscles as well as posture re-education with or without peripheral strengthening. Competing interests: None declared |
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Jane Greening, Chair of the Manipulation Association of Physiotherapists Physiotherapy Department, Livingstone Hospital, Dartford, Gravesend and Swanley PCT, Dartford. Kent, DA1 1SA
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Dear Sir, Re: Effectiveness of dynamic muscle training, relaxation training, or ordinary activity for chronic neck pain: randomised controlled trial. Vilijanen M et al BMJ 327: 30th August 2003. The Manipulation Association of Chartered Physiotherapists (MACP) welcomes the ongoing publication by the BMJ of research work examining the effectiveness of various treatment modalities in the management of neck pain. The authors of this particular study are to be congratulated for undertaking this work and in attempting to be reflective of clinical practice within Finland. However, as a Special Interest Group of the Chartered Society of Physiotherapists (CSP) representing musculoskeletal physiotherapy, we, the MACP, feel that there are some particularly pertinent points that need to be made with regard to what is considered usual and standard physiotherapy practise within the UK. In the UK physiotherapy treatment for neck pain is most likely to consist of manual therapy techniques and specific exercise prescription. The authors' introductory statement that 'Dynamic muscle training and relaxation training are often prescribed for neck pain' is in no way reflective of current physiotherapy management in the UK. The authors' continue their introduction with a statement that there is a lack of evidence for the use of these techniques, and it is for this very reason that they do not form a part of the management of neck pain by physiotherapists in this country. Here in the UK, physiotherapist's management strategies reflect current research evidence on the management of neck pain. This includes a recent article published in the BMJ supporting the effectiveness of manual therapy (Korthals - de Bos I et al. BMJ 326; 26th April 2003) The MACP feel it is extremely important that the distinction between, what the authors define as current practise in the management of neck pain, and what Physiotherapists in the UK consider to be usual / standard physiotherapeutic management of neck pain, is made clear. Publication of articles by the BMJ which do not reflect physiotherapeutic practise in this country may possibly have a very derogatory effect on the utilisation of physiotherapy services by the BMJ readership in the UK who do not realise that physiotherapy practises can vary widely between different countries. Perhaps future articles concerning physiotherapy, including manual therapy and manipulation, should be reviewed by a UK physiotherapist who would be able to identify whether the treatment modalities being studied are reflective of usual practise within this country. Our membership would be willing to assist in this role. Yours sincerely Jane Greening PhD MSc MCSP MMACP
Competing interests: None declared |
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Maurice Vanbellinghen, journalist 9000 Brussels
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May 2003 saw the publication in the JAMA of following study: "Neck Muscle Training in the Treatment of Chronic Neck Pain in Women - A Randomized Controlled Trial" (Jari Ylinen, MD; Esa-Pekka Takala, MD, DMedSc; Matti Nykänen, MD, DMedSc; Arja Häkkinen, PhD; Esko Mälkiä, PhD; Timo Pohjolainen, MD, DMedSc; Sirkka-Liisa Karppi, MSc; Hannu Kautiainen, BA; Olavi Airaksinen, MD, DMedSc), in JAMA. 2003;289:2509-2516. Their conclusion was: "Both strength and endurance training for 12 months were effective methods for decreasing pain and disability in women with chronic, nonspecific neck pain. Stretching and fitness training are commonly advised for patients with chronic neck pain, but stretching and aerobic exercising alone proved to be a much less effective form of training than strength training." Could the authors of the study in the BMJ please comment on this. Does this contradict their conclusions? For the general public, this seems rather confusing. Mille grazie. Competing interests: None declared |
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Eyal Lederman, Director, Centre for Professional Development in Osteopathy and Manual Therapy 15 Harberton Road, London N19 3JS
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Concerning the relaxation method used in this study, I would like to point out that several studies have suggested that the inability to relax (e.g. EMG gaps etc) is a common finding in chronic neck and shoulder conditions. In this study the subjects were taught relaxation without receiving any feedback on their results. The study assumes that the subject will be successfully able to learn to relax. There are two problems with this assumption. First is that patients with myalgia may have a greater inability to relax when compared to normal individuals. After all, this may be how they acquired their condition in the first place. From clinical experience it is often found that patients tend to stiffen their neck when instructed to fully relax. This could be seen in patients who are lying in the supine position fully relaxed and their neck supported by a pillow. How do we know how well they are relaxing? Was there any measurement of their relaxation ability as they progressed from one session to the other? The second problem with this study is that the patients themselves had no knowledge of how well they are performing this focused relaxation. We learn through making mistakes and correcting them and motor relaxation is probably no different. It is doubtful if any meaningful motor learning, in this case lowering neuromuscular activity in the target muscle, could have taken place without feedback to the subjects. The importance of knowledge of the result is supported by several studies which demonstrated that relaxation with feedback (EMG biofeedback) is generally more effective in reducing tension pain when compared to relaxation alone (no feedback). Without feedback it is unknown how well the subjects succeeded in learning the very difficult art of relaxation. Relaxation without feedback is like teaching an innumerate person maths, without ever letting them know if they are getting their sums right, never testing them and than being surprised they can’t add up. It could be argued that relaxation did not have a significant effect because of the study’s failure to successfully teach motor relaxation to this subject group. Competing interests: None declared |
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Jari Ylinen, Head of department of physical and rehabilitation medicine Jyväskylä Central Hospital, Keskussairaalantie 19, 40620 Jyväskylä, Finland
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Thank you to Viljanen et al. for their interesting study about effectiveness of dynamic muscle training in women with chronic neck pain.(1) The study is valuable, as they evaluated active neck rehabilitation, which is commonly used in the clinic, and the study appeared to be well done from the methodological point of view. On the basis of the results, they ended to the conclusion that dynamic muscle training does not have more favourable effects on chronic neck pain over advising being active. It is contradictory to findings in the study recently published by Ylinen et al.(2) It showed that both dynamic and isometric training of neck muscles effectively decreased pain and disability in women with chronic neck pain during the 1-year follow-up period, but stretching and advising aerobic exercising alone were considerably less effective. It is obvious that the difference between studies has to be related either to different training intensity or training methods or both. There was considerable difference in the average exercise frequency between studies, as Viljanen et al. reported average training to be once a week, while in Ylinen et al. found that long-term benefits could be obtained by training performed twice a week. Ylinen et al. reported significant increase in isometric neck strength and range of movement compared to the control group showing that the training load was high enough to improve physical function. Viljanen et al. found only small difference in range of movement and no improvement in dynamic muscle strength of the neck and shoulder region. Unfortunately the test was not described in the article. Both dynamic and isometric training groups performed specific neck muscle exercises in the study published by Ylinen et al. This may be the most important reason to the difference between results of two studies. The conclusion that dynamic muscle training is as ineffective treatment for chronic neck pain as general exercising is by no means justified, because it was not declared which training methods were used and furthermore it was not shown that the training was performed effectively.(1) Even though certain training program produces good results, this does not apply to all training programs and comparably poor results cannot be generalized. It is essential to declare factors causing failure in active neck rehabilitation to help avoid those in the clinic and thus it is important that training methods are published in detail even though they did not produce outstanding results. 1. Viljanen M, Malmivaara A, Uitti J, Rinne M, Palmroos P, Laippala P. Effectiveness of dynamic muscle training, relaxation training, or ordinary activity for chronic neck pain: randomised controlled trial. BMJ, Aug 2003; 327: 475 - 0. 2. Ylinen J, Takala EP, Nykänen M, Häkkinen A, Mälkiä E, Pohjolainen T, Karppi S-L, Kautiainen H, Airaksinen O. Active neck muscle training in the treatment of chronic neck pain in women: a randomized controlled trial. JAMA 2003;289:2509-16. Jari Ylinen MD.
Competing interests: None declared |
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Mark K. Frobb, General Practice Surrey, British Columbia, Canada
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Dear Editor ... On reviewing the study submitted by Viljanen et al. and the letters to the editor in subsequent issues, one cannot help be reminded of what Winston Churchill said on reviewing complex issues ... "it is always more easy to discover and proclaim general principles than to apply them." While it is true that perhaps additional exercise prescriptions may have been required to improve the core stabilization of cervical musculature, one cannot believe that the exercise regime prescribed by the authors however incomplete, was completely without merit. Dynamic strengthening of the shoulder girdle musculature with improvement of posture must be a prerequisite to fundamental restoration of normal ergonomic positioning of the thoracocervical junction and cervical lordosis. That exercise alone did not result in any significant symptomatic improvement, suggests as most therapists would agree, restoration of muscle strength and balance will not alone result in resolution of chronic neck pain without some specifically applied therapy at correcting dysfunctional movement patterns and restoring normal vertebral joint range of motion. Once began, it points to what a critical observer noted about single modalities of therapy applied to a complex multifactorial problem ... "If the only tool you have in your bag is a hammer, everything starts looking like a nail." Sincerely Mark K. Frobb MD
Competing interests: None declared |
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