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Original article
Motor Control and Learning, Institute for Human Movement Sciences and Sports, ETH Zurich, Zurich, Switzerland
Exercise Physiology Lab, Institute for Human Movement Sciences and Sports, ETH Zurich, Zurich, Switzerland
c
Department of Chiropractic, Balgrist Hospital, Zurich, Switzerland
b
a r t i c l e i n f o
a b s t r a c t
Article history:
Received 9 December 2013
Received in revised form
4 April 2014
Accepted 17 April 2014
Patients with chronic neck pain exhibit various musculoskeletal decits and respiratory dysfunction. As
there is a link between thoracic and cervical spine motion, the aim of this study was to investigate the
relationship between thoracic spine and chest mobility with respiratory function and neck disability.
Nineteen patients with chronic neck pain (7 male, 46.6 10.5 years) and 19 healthy subjects (7 male,
46.5 9.9 years) participated. Spirometry was conducted to determine maximal voluntary ventilation
(MVV), maximal inspiratory (Pimax) and maximal expiratory pressure (Pemax). Thoracic spine mobility
was measured using the Spinal Mouse. Chest expansion was assessed by subtracting chest circumference during maximal inspiration and expiration. Neck function was investigated by examining range of
motion, forward head posture, neck exor muscle synergy endurance and self-assessment (Neck
disability index (NDI)). Correlation analyses and multiple linear regression analyses were conducted
using MVV, Pimax and Pemax as independent variables. Thoracic spine mobility during exion and chest
expansion correlated signicantly to MVV (r 0.45 and 0.42), all neck motions (r between 0.39 and 0.59)
and neck muscle endurance (rS 0.36). Pemax and Pimax were related to NDI (r 0.58 and 0.46). In the
regression models, chest expansion was the only signicant predictor for MVV, and Pemax was determined by neck muscle endurance. These results suggest that chronic neck pain patients should improve
the endurance of the neck exor muscles and thoracic spine and chest mobility. Additionally, these
patients might benet from respiratory muscle endurance training, possibly by increasing chest mobility
and Pemax.
2014 Elsevier Ltd. All rights reserved.
Keywords:
Neck pain
Respiratory dysfunction
Thoracic spine
1. Introduction
Neck pain is an increasingly common disabling and costly
musculoskeletal disorder with a mean overall prevalence in the
general population of approximately 23% (Hoy et al., 2010). Its
course is characterised by periods of remission and exacerbation,
but the majority of patients do not completely recover from their
symptoms (Cote et al., 2004).
Several studies have shown that patients with chronic neck pain
present with various motor dysfunctions, such as the inhibition of
deep cervical exor muscle activation accompanied by increased
activation of the supercial neck muscles (Falla et al., 2004; Jull
et al., 2004), increased forward head posture (Yip et al., 2008)
and sensorimotor disturbances (Sjolander et al., 2008). Cervical
* Corresponding author. Institute for Human Movement Sciences and Sports,
Department of Health Sciences and Technology, ETH Zurich, Hnggerberg, Wolfgang Pauli Str. 27, 8093 Zurich, Switzerland. Tel.: 41 44 632 59 81.
E-mail address: brigitte.wirth@hest.ethz.ch (B. Wirth).
http://dx.doi.org/10.1016/j.math.2014.04.011
1356-689X/ 2014 Elsevier Ltd. All rights reserved.
441
442
Table 1
Respiratory and musculoskeletal parameters in the neck patient and in the control
group.
Parameter
MVV [l/min]
Pimax [cmH20]
Pemax [cmH20]
VC [l]
FVC [l]
FEV1/FVC [ ]
PEF [l]
Cervical exion [ ]
Cervical extension [ ]
Cervical rotation [ ]
Cervical lateral exion [ ]
Thoracic exion [ ]
Thoracic extension [ ]
Chest mobility [cm]
Forward head posture [ ]
Neck muscle endurance [s]
Neck patients
Controls
Mean (SD)
Mean (SD)
110.3
92.3
146.6
4.2
4.0
0.8
7.4
57.0
56.0
67.7
38.4
30.2
13.3
4.8
47.7
105.7
132.4
104.2
157.1
4.5
4.3
0.8
8.2
67.0
65.8
74.6
39.7
31.2
12.7
5.8
49.1
94.3
(40.0)
(28.3)
(54.1)
(0.9)
(0.8)
(0.1)
(2.0)
(13.6)
(16.1)
(7.4)
(8.5)
(15.5)
(10.5)
(2.4)
(8.0)
(77.4)
(41.2)
(27.1)
(33.6)
(1.1)
(1.0)
(0.03)
(2.0)
(10.6)
(11.1)
(10.3)
(9.8)
(13.4)
(10.6)
(2.4)
(6.4)
(51.3)
P value
Effect size
0.106
0.194
0.478
0.331
0.394
0.375
0.231
0.016
0.034
0.023
0.674
0.819
0.867
0.242
0.562
0.893
0.54
0.43
0.23
0.32
0.28
0.29
0.40
0.82
0.71
0.78
0.14
0.07
0.05
0.39
0.19
0.18
Table 2
Correlations of thoracic spine and chest mobility to respiratory and musculoskeletal parameters.
Respiratory parameters
Musculoskeletal parameters
MVV
Pimax
Pemax
Cervical exion
Cervical extension
Cervical rotation
Cervical lateral exion
Forward head posture
Neck muscle endurance (rS)
0.45
0.21
0.31
0.43
0.46
0.39
0.39
0.12
0.36
0.07
0.07
0.04
0.12
0.09
0.01
0.03
0.19
0.05
0.42
0.11
0.21
0.39
0.59
0.58
0.50
0.36
0.22
(0.005)
(0.197)
(0.058)
(0.007)
(0.004)
(0.015)
(0.015)
(0.474)
(0.029)
(0.676)
(0.676)
(0.830)
(0.480)
(0.587)
(0.939)
(0.871)
(0.248)
(0.750)
(0.008)
(0.525)
(0.210)
(0.015)
(<0.001)
(<0.001)
(0.001)
(0.027)
(0.186)
Respiratory
parameters
Musculoskeletal
parameters
Parameter
MVV
Pimax
Pemax
Thoracic exion
Thoracic extension
Chest expansion
Cervical exion
Cervical extension
Cervical rotation
Cervical lateral exion
Forward head posture
Neck muscle endurance
0.42
0.46
0.58
0.37
0.04
0.15
0.16
0.25
0.09
0.04
0.06
0.41
(0.078)
(0.048)
(0.009)
(0.116)
(0.858)
(0.542)
(0.505)
(0.303)
(0.730)
(0.863)
(0.806)
(0.091)
4. Discussion
This study revealed no changes in thoracic spine and chest
mobility in patients with chronic neck pain and showed only a fair
relation between thoracic spine and chest mobility and MVV.
Nevertheless, the correlations of chest expansion and thoracic
spine exion mobility to cervical motion, which was substantially
reduced in the neck pain patients, underline the importance of
thoracic spine and chest mobility for neck function. Interestingly,
self-reported neck disability was mainly predicted by Pemax and
Pimax, while neck mobility was of no importance.
Respiratory function was only somewhat reduced in the patient
group and this difference was not signicant, which is in contrast to
previous studies (Kapreli et al., 2009; Dimitriadis et al., 2013b).
While MVV and Pimax compare well to data in previous studies, the
subjects in this study presented with a higher Pemax. This
discrepancy might partly be explained by the only mild neck
disability of the patients in this study (average NDI 12 points)
compared with that in other studies (average NDI 30 points
(Kapreli et al., 2009)), according to the classication of NDI scores in
the original literature (Vernon and Mior, 1991). Indeed, in accordance with the study by Dimitriadis et al. (Dimitriadis et al., 2013b),
Pemax was particularly related to the NDI-G score. The difference in
443
Pemax values might also be the result of some methodological differences. Pimax and Pemax values seem to be smaller when assessed
in the standing position (Dimitriadis et al., 2013b) compared with
the sitting position (Kapreli et al., 2009). Additionally, the test
protocol was more stringent in the present study than in previous
studies (Kapreli et al., 2009; Dimitriadis et al., 2013b) (e.g. maximal
10 instead of 5 trials were conducted).
Thoracic exion mobility and chest expansion correlated with
cervical mobility, which was signicantly reduced in the patient
group in all neck motions apart from lateral exion, which is in
accordance with other studies (Chiu and Sing, 2002; Shahidi et al.,
2012). This matches the nding in healthy subjects that thoracic
spine movement contributes substantially to neck mobility,
particularly in the sagittal plane (Tsang et al., 2013). The observed
relationship of thoracic exion and chest mobility to MVV conrms
ndings in patients with ankylosing spondylitis who present with
impaired pulmonary function (Berdal et al., 2012). The nding that
Pimax and Pemax were related to the NDI-G score corroborates the
results of the study by Dimitriadis et al. (Dimitriadis et al., 2013b).
However, in contrast to the former study, neck exor muscle synergy endurance, but not forward head posture predicted Pemax in
the present study. This discrepancy might partly be explained by
the different methodology used for testing neck exor endurance.
Dimitriadis et al. (Dimitriadis et al., 2013b) conducted the craniocervical test using a biofeedback device, which was not recommended for clinical use due to its limited reliability (de Koning
et al., 2008). Nevertheless, the subjects in this study presented
with high scores for the endurance of the neck exor muscle synergy compared with that in other studies (Grimmer, 1994; Shahidi
et al., 2012). This matches with the observed high Pemax values, but
might also reect the difculties in objectively assessing endurance
of the neck exor muscle synergy. Although the chosen assessment
was recommended in a review paper (de Koning et al., 2008), a
recent study showed a limited inter-rater reliability in neck patients
(Shahidi et al., 2012). This shows the need for further research in
this clinically important eld.
The main limitation of the present study was the small sample
size with a limited age range, which makes generalization of the
results difcult. Furthermore, the measurement of spinal mobility
by the Spinal Mouse has only been validated in the standing position (Mannion et al., 2004) and still needs to be validated for the
all-fours position. As a further limitation, isometric neck muscle
strength was not assessed in this study. Such assessments should
however be included in further studies because they have emerged
as predictors for both Pimax and Pemax (Dimitriadis et al., 2013b).
Future studies on respiratory dysfunction in patients with
chronic neck pain should focus on those patients with a higher level
of neck disability to detect more pronounced effects and should
also exclude traumatic neck patients. With the intention of developing new therapeutic strategies, there is some evidence that
breathing re-education might be benecial for chronic neck pain
patients (McLaughlin et al., 2011), but further studies on this issue
Table 4
Regression models for the prediction of the respiratory parameters.
Dependent variable
MVV
Pimax
Pemax
Model
parameters
R2
Chest mobility
0.34
0.23
0.30
0.008
0.075
0.020
0.17 (0.344)
0.06 (0.761)
0.07 (0.692)
0.40 (0.038)
0.26 (0.207)
0.13 (0.488)
0.32 (0.052)
0.32 (0.074)
0.22 (0.186)
0.23 (0.138)
0.39 (0.026)
0.48 (0.005)
444
are needed (Dimitriadis et al., 2013a). Respiratory muscle endurance training reduced stiffness of the rib cage in healthy athletes
(Obayashi et al., 2012) and led to signicant increase in Pemax in
patients with chronic obstructive pulmonary disease (Scherer et al.,
2000) and spinal cord injury (Berlowitz and Tamplin, 2013), while
inconsistent ndings were reported in healthy subjects (Verges
et al., 2008; Walker et al., 2013). Thus, it should be investigated in
chronic neck pain patients whether respiratory training might increase chest mobility and Pemax, which both emerged from this
study as particularly important parameters with a view to neck
mobility and self-perceived neck disability, respectively. In a second
step, such training should be compared with conventional cervical
exor muscle endurance training, as conducted in physiotherapy
(Falla et al., 2012; Thoomes-de Graaf and Schmitt, 2012).
In conclusion, although thoracic spine and chest mobility were
related only to MVV and not to the maximal respiratory pressures,
the nding of the relationship to all cervical motions is of clinical
importance. Pemax was most closely related to NDI-G and was
mainly predicted by the endurance of the neck exor muscle synergy. These ndings suggest that respiratory muscle endurance
training might be a valuable addition to the rehabilitation of patients with chronic neck pain, possibly by increasing chest mobility
and Pemax.
Acknowledgements
We thank Dr. Rolf Nussbaumer, Dr. med. Hansjrg Holdener and
Adrian Sandmeier for their help with the patient recruitment.
Furthermore, we thank Anja Trepp from the idiag AG for providing
the Spinal Mouse.
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