Jari J Ylinen

Abstract: OBJECTIVE: To compare the efficacy of three 12-month training programmes on headache and upper extremity pain in patients with chronic neck pain. METHODS: A total of 180 female office workers, with chronic, non-specific neck pain were randomly assigned to 3 groups. The strength group performed isometric, dynamic and stretching exercises. The endurance group performed dynamic muscle and stretching exercises. The control group performed stretching exercises. Pain was assessed with a visual analogue scale. Each group was divided into 3 subgroups according to headache intensity. RESULTS: At the 12-month follow-up headache had decreased by 69% in the strength group, 58% in the endurance group and 37% in the control group compared with baseline. Neck pain diminished most in the strength group with the most severe headache (p < 0.001). In the dose analysis, one metabolic equivalent per hour of training per week accounted for a 0.6-mm decrease in headache on the visual analogue scale. Upper extremity pain decreased by 58% in the strength group, 70% in the endurance group and 21% in the control group. CONCLUSION: All of the training methods decreased headache. However, stretching, which is often recommended for patients, was less effective alone than when combined with muscle endurance and strength training. Care must be taken in recommending the type of training to be undertaken by patients with severe cervicogenic headache.

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Abstract: The active manual straight leg raise (ASLR) and passive manual straight leg raise (MSLR) tests are commonly used in clinical settings to assess hamstring tightness. However, to our knowledge, the validity and sensitivity of these tests have not been compared with the instrumental straight leg raise (ISLR). The aim of the present study was to assess the intrarater reproducibility of the ISLR and compare the sensitivity of the ASLR, MSLR, and ISLR to change. Twelve men with hamstring tightness underwent the ASLR, MSLR, and ISLR tests at baseline and after a 4-week home-based right leg stretching program with the left leg serving as a control. The ISLR measurements were repeated consecutively at baseline to assess reproducibility. The intraclass correlation coefficient for the ISLR was 0.94, and the coefficient of reproducibility was 6. Significant differences in the range of motion emerged between all testing methods (p < 0.05). In the stretched legs, the mean +/- SD increases were 17 +/- 5 degrees for ISLR, 10 +/- 8 degrees for ASLR, and 6 +/- 5 degrees for MSLR, whereas the control legs showed a significant mean change only for ASLR (5 +/- 4 degrees ). The mean standard response with the ASLR and MSLR tests did not differentiate between the treated and control legs, but it was almost 10-fold higher in the treated leg than the control leg for the ISLR, clearly differentiating between them. The ISLR had good reproducibility and sensitivity to changes, whereas ASLR and MSLR showed a poor ability to detect changes. Thus, the ISLR test is recommended for use in research evaluating the effectiveness of stretching.

Abstract: BACKGROUND: Chronic neck pain is a common condition associated not only with a decrease in neck muscle strength, but also with decrease in health-related quality of life (HRQoL). While neck strength training has been shown to be effective in improving neck muscle strength and reducing neck pain, HRQoL among patients with neck pain has been reported as an outcome in only two short-term exercise intervention studies. Thus, reports on the influence of a long-term neck strength training intervention on HRQoL among patients with chronic neck pain have been lacking. This study reports the effect of one-year neck strength training on HRQoL in females with chronic neck pain. METHODS: One hundred eighty female office workers, 25 to 53 years of age, with chronic neck pain were randomized to a strength training group (STG, n = 60), endurance training group (ETG, n = 60) or control group (CG, n = 60). The STG performed high-intensity isometric neck strengthening exercises with an elastic band while the ETG performed lighter dynamic neck muscle training. The CG received a single session of guidance on stretching exercises. HRQoL was assessed using the generic 15D questionnaire at baseline and after 12 months. Statistical comparisons among the groups were performed using bootstrap-type analysis of covariance (ANCOVA) with baseline values as covariates. Effect sizes were calculated using the Cohen method for paired samples. RESULTS: Training led to statistically significant improvement in the 15D total scores for both training groups, whereas no changes occurred for the control group (P = 0.012, between groups). The STG improved significantly in five of 15 dimensions, while the ETG improved significantly in two dimensions. Effect size (and 95% confidence intervals) for the 15D total score was 0.39 (0.13 to 0.72) for the STG, 0.37 (0.08 to 0.67) for the ETG, and -0.06 (-0.25 to 0.15) for the CG. CONCLUSIONS: One year of either strength or endurance training seemed to moderately enhance the HRQoL. Neck and upper body training can be recommended to improve HRQoL of females with neck pain if they are motivated for long-term regular exercise. TRIAL REGISTRATION: ClinicalTrials.gov NCT01057836.

Abstract: STUDY DESIGN: Translation and psychometric testing. OBJECTIVE: To cross-culturally adapt the Neck Disability Index (NDI) to the Finnish language and to assess the reliability and validity of the Finnish version of the Neck Disability Index (NDI-FI) and the modified Neck Pain and Disability Scale (mNPDS-FI) in Finnish patients with neck pain. SUMMARY OF BACKGROUND DATA: Although largely used, no previous reports exist on the translation process or the testing of the psychometric properties of the Finnish version of the NDI or the mNPDS used in Finland. METHODS: The translation of the questionnaire from English into Finnish was done in accordance with the published guidelines. A total of 101 patients with neck pain participated in the study. The reliability of the questionnaires was tested using a test-retest procedure at 2-week intervals. Further psychometric testing was done by assessing the construct validity and internal consistency of the questionnaires. RESULTS: Test-retest reliability (intraclass correlation coefficients) was excellent for the NDI-FI (0.94) and mNPDS-FI (0.91). Factor analysis identified 1 factor for the NDI-FI and 3 factors for the mNPDS-FI; pain intensity, work ability, and activities of daily living. The internal consistency value (Cronbach alpha) for the NDI-FI was 0.85, and 0.84, 0.83, and 0.82, respectively, for the 3 factors of the mNPDS-FI. The correlation between neck pain and the NDI-FI was 0.58 (P < 0.001) and 0.72 for the mNPDS-FI (P < 0.001). A statistically significant linear relationship was observed between self-estimated coping and the outcomes of the NDI-FI and the mNPDS-FI. CONCLUSION: The NDI-FI and the mNPDS-FI are reliable, valid instruments for assessing disability among Finnish patients with neck pain.

Abstract: PURPOSE: The aim was to evaluate the effect of the posterior surgical approach on hip muscle strength and range of movement (ROM). METHODS: Maximal isometric external and internal rotator strength of the hip muscles and bilateral leg extension strength were measured by dynamometers. Active (AROM) and passive (PROM) range of motion of the hip were measured by goniometers in 30 patients before and 3, 6 and 12 months after hip resurfacing. Postoperatively the patients were advised to return to their usual physical activities. RESULTS: Prior to the surgery internal rotation strength was on the same level on both sides, whereas external rotation strength of the operated hip was 26% (p < 0.001) lower compared with the unoperated side. External rotation strength remained at the lowered level, but internal rotation strength of the operated hip increased over the level of the contralateral side (both p < 0.001) at 12-month follow-up leading to the imbalance in external/internal rotation strength ratio (p < 0.001). Preoperatively, all active and passive ROMs of the operated side were statistically lower than on the unoperated side (p < 0.001). ROMs of the operated hip improved significantly with the exceptions that active external rotation decreased after the operation (p < 0.001). CONCLUSIONS: The patients reported remarkable decrease in pain postoperatively. However, the surgical procedure, particularly the division of the external hip rotator muscles led to specific external rotation strength and ROM deficits. Because typical spontaneous physical activity could not restore hip function, there is a need for specific postoperative rehabilitative programs.

Abstract: PURPOSE: The aim was to assess the effect of resurfacing hip arthroplasty on hip muscle function, when, in the posterior approach, the piriformis tendon and outer rotators of the hip joint were divided. The unoperated side was used as a control. METHODS: Thirty-three consecutive patients (mean age 55 years, 73% males) were operated using the posterior approach. Main outcome measures were isometric muscle strength of external and internal rotators and extensors of the hip and hip pain. RESULTS: Hip external rotation strength (p > 0.001) and leg extension strength (p < 0.001) were significantly lower on the operated side compared with the un-operated side prior to the surgery. On the operated side external rotation strength decreased by 29% (p < 0001) and internal rotation strength increased by 28% (p < 0.001). The changes of 12% in leg extension strength of the operated side and the changes of 3-10% in all strength measurements in the un-operated side were not significant. Three months post-operatively, the external rotation strength and leg extension strength values were 50% and 26% lower (p < 0.001) on the operated side compared with those in the un-operated side. The decreases in pain values during the rest, loading as well as during the strain of strength measurements were all significant (p < 0.001). CONCLUSION: Although hip resurfing surgery gives excellent relief of pain, significant strength deficit was found in the external rotators 3 months post-operatively.

Abstract: OBJECTIVE: To evaluate the effects of stretching on hamstring muscle compliance indirectly and directly. METHODS: Twelve healthy men were instructed to perform passive stretching of one leg daily over 4 weeks, while the other leg served as a control. An instrumental straight leg raise was used to measure stretching force and muscle compliance indirectly with surface electromyography to measure muscle activity during stretching. Muscle compliance was measured directly by computerized muscle tonometer. The thickness of the biceps femoris muscle was measured by ultrasound and knee flexion strength by a dynamometer. RESULTS: In the stretched legs the mean increase in straight leg raise was 17 degrees after 4 weeks (p<0.001) and the mean stretching force increased by 19 N (p<0.001). Improved straight leg raise correlated with biceps muscle thickness (r=0.74).The angle at which stretching was first felt increased by 15 degrees in the stretched legs (p<0.001). Controls showed no significant changes in straight leg raise. There was no difference in force between the stretched and control legs in comparison of the same angles. No significant changes were noted in muscle compliance, surface electromyography or isometric maximal knee flexion strength. CONCLUSION: Stretching improved passive straight leg raise with no change in muscle compliance. Muscle viscoelastic properties and strength were preserved despite improved straight leg raise.

Abstract: STUDY DESIGN: Cross-sectional study. OBJECTIVES: To assess age-related changes and determine reference values for passive range of motion of the cervical spine in healthy women of working age. BACKGROUND: Although cervical mobility is age dependent, the amount in which aging affects passive range of motion has not been previously reported. It is clinically important to know the effect of normal aging process on cervical motion to be able to separate and evaluate the possible effect of pathological processes. METHODS AND MEASURES: Two hundred twenty healthy women, aged 20 to 59 years, participated in the study. Passive range of motion of the cervical spine in flexion, extension, lateral flexion, and axial rotation was measured with the Cervical Measurement System. Measurements to calculate intrarater reliability were obtained on 22 subjects. RESULTS: Passive range of motion of the cervical spine diminished linearly with increasing age in all measured movement planes (P<.001 for all movements except for flexion which was P = .018). Mean body mass index adjusted reduction in passive range of motion was 0.5 degrees per 1-year increase in age. Intraclass correlation coefficients for intrarater reliability ranged from 0.79 to 0.92. CONCLUSION: A gradual age-related reduction in passive cervical range of motion was observed in women of working age.

Abstract: The aim of this study is to explore the occurrence and the risk factors of back-related loss of working time in patients undergoing surgery for lumbar disc herniation. One hundred and fifty-two gainfully employed patients underwent surgery for lumbar disc herniation. Two months postoperatively, those patients completed a self-report questionnaire including queries on back and leg pain (VAS), functional capacity (Oswestry disability index--ODI, version 1.0), and motivation to work. After 5 years, lost working time was evaluated by means of a postal questionnaire about sick leave and disability pensions. The cumulative number of back pain-related days-off work was calculated for each patient. All 152 patients, 86 men and 66 women, were prescribed sick leave for the first 2 months. Thereafter, 80 (53%) of them reported back pain-related sick leave or early retirement. A permanent work disability pension due to back problems was awarded to 15 (10%) patients, 5 men (6%) and 10 women (15%). Median number of all work disability days per year was 11 (interquartile range [IQR] 9-37); it was 9 days (IQR 9-22) in patients with minimal disability (ODI score 0-20) at 2 months postoperatively and 67 days (IQR 9-352) in those with moderate or severe disability (ODI > 20; P < 0.001). The respective means were 61, 29, and 140 days/year. Multivariate analysis showed ODI > 20, leg pain, and poor motivation to work to be the risk factors for extension of work disability. Results of the present study show that after the lumbar disc surgery, poor outcome in questionnaire measures the physical functioning (ODI) and leg pain at 2 months postoperatively, as well as poor motivation to work, are associated with the loss of working time. Patients with unfavourable prognosis should be directed to rehabilitation before the loss of employment.

Abstract: BACKGROUND: In all studies in which the strength of the neck extensor muscles has been measured, the level of thoracic support has been adjusted differently so direct comparison of the results is not possible. OBJECTIVE: To measure and compare the isometric force and isometric torque of neck extensor muscles at different levels of thoracic support. METHODS: Twenty healthy women volunteered for the study. The maximum isometric force of the neck extensor muscles was measured with the thoracic support located at five different levels. The highest level was set at the level of the spine of the scapula (level I) and the other levels were located 2.5 cm lower than the previous one, with the lowest level set 10 cm below the highest level. The maximum isometric torque for each level was calculated by multiplying the isometric force by the length of the lever arm measured from the upper tip of the thoracic support to the centre point of the cell load at the occiput. RESULTS: The maximum isometric force and maximum isometric torque of the neck extensor muscles were increased step by step from 130.5 N to 138.9 N, 141.9 N, 147.9 N and 155.4 N and from 33.7 Nm to 38.7 Nm, 42.5 Nm, 47.2 Nm and 52.7 Nm, respectively. Except for the isometric force of the cervical extensor muscles measured at levels II and III, the differences between the other levels were significant (p<0.05). There was a significant correlation between isometric force and isometric torque measurements of the neck extensor muscles at different levels (0.81<r<0.96). CONCLUSION: Maximum isometric force and maximum isometric torque measurements of the neck extensor muscles vary with the length of the lever arm. It is recommended that a specific level of thoracic support should be used in follow-up and intervention studies. Setting the level of thoracic support at a specific level will make it possible to compare the strength of the neck extensor muscles in different studies. Measurements at the level of the spine of the scapula were easier and less time consuming.

Abstract: PURPOSE: This study compared the maximal force, EMG/force ratio and co-activation characteristics of the neck-shoulder muscles between 30 adolescents with migraine-type headache, 29 with tension-type headache, and 30 headache-free controls. METHOD: Force was measured with surface electromyography (EMG) from the cervical erector spinae (CES), the sternocleidomastoid (SCM) and trapezius muscles during the maximal isometric neck flexion, neck extension and shoulder flexion. RESULTS: Girls with migraine-type headache had higher EMG/force ratios between the EMG of the left agonist SCM muscle and the corresponding maximal neck flexion (p = 0.030) and neck rotation force to the right side (p = 0.024) than the girls with tension-type headache. Migrainous girls had more co-activation of right antagonist CES muscle during maximal neck flexion force than the girls without headache (p = 0.015). Neck force production showed no significant differences between girls. Girls with tension-type headache displayed lower left shoulder flexion force than girls with migraine-type headache (p = 0.005) or with no headache (p = 0.005). In boys, no significant differences were observed. CONCLUSIONS: Girls with tension-type headache and migraine-type headache have differences in neuromuscular function in the neck-shoulder muscles. The data amplify our knowledge of the neck-shoulder muscle dysfunction in adolescent headache, and may encourage the use of specific rehabilitation methods in the management of different types of headache.

Abstract: This study investigated the natural course of neck pain (NP) in 9-12-year-olds during a 4-year follow-up. Risk factors for the occurrence and persistence of weekly NP were explored separately for boys and girls. At baseline, 1756 schoolchildren completed a questionnaire eliciting musculoskeletal pain symptoms, other physical, and psychological symptoms and frequency of physical activity, and were tested for joint hypermobility. Symptoms during the preceding three months were asked using a five-level frequency classification. Re-evaluation was performed after one and four years using identical questionnaires. During follow-up, 24% reported none, 71% fluctuating, and 5% persistent weekly NP. The frequency of NP at baseline was linearly related to weekly NP during follow-up in both genders (P<0.001). Furthermore, a significant increasing linear trend towards a more persistent course of NP was seen in children with weekly other musculoskeletal and/or other physical and psychological symptoms at baseline. Among originally neck pain-free pre-/early adolescents, weekly other musculoskeletal pain symptoms (only in girls) and other physical and psychological symptoms (in both genders) predicted the occurrence of weekly NP during follow-up. In conclusion, neck pain in schoolchildren tends to fluctuate, but there also seems to exist a subgroup (5%) with persistent NP already in pre-/early adolescents, or even earlier. Co-occurrence of frequent other musculoskeletal symptoms and/or markers of psychological stress with frequent NP are risk indicators for a more persistent course, at least within next few years. Since adult chronic NP problems might originate in childhood, further studies are needed, including preventive interventions.

Abstract: OBJECTIVE: To evaluate whether isometric exercises for the upper extremities could sufficiently activate core stabilizing muscles to increase muscle strength. DESIGN: Cross-sectional study. SETTING: Department of physical medicine and rehabilitation at a Finnish hospital. PARTICIPANTS: Healthy adult women (N=20). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Peak isometric strength of the back and abdominal muscles was measured and relative loading in 5 test exercises was evaluated by surface electromyography. RESULTS: The rectus abdominis and obliquus externus abdominis were activated to the greatest degree in a bilateral shoulder extension exercise and the average surface electromyographic activity was 114% and 101% compared with the amplitude elicited during the maximal isometric trunk flexion exercise. Horizontal shoulder extension elicited the greatest activation of the longissimus and multifidus muscles. In this exercise, the activity levels of the left side multifidus and longissimus muscles were 84% and 69%, respectively, compared with the level of activity elicited during trunk extension. CONCLUSIONS: Of all the exercises studied, bilaterally performed isometric shoulder extension and unilaterally performed horizontal shoulder extension elicited the greatest levels of activation of the trunk musculature. Thus, it can be assumed that these exercises elicit sufficient levels of contraction of the trunk muscles for the development of their endurance and strength characteristics in rehabilitation.

Abstract: OBJECTIVE: To determine changes in physical and social function during a prolonged preoperative waiting period and at 3 months after total knee arthroplasty. SUBJECTS: Forty-three patients were evaluated on the day that surgery was decided, the day before surgery, and 3 months afterwards. METHODS: Knee pain and function were assessed using a visual analogue scale and a functional assessment system. Isometric knee flexion extension strength and mobility were measured. RESULTS: Knee pain and muscle strength remained unchanged during the mean waiting time of 10 (standard deviation 8) months. On the affected side, knee extension strength was 19% weaker than on the contralateral side and did not change pre-operatively. Post-operatively, knee pain decreased by 50%. Knee extension strength decreased by 26% and flexion strength by 12% compared with the initial assessments. Knee extension strength of the operated side was 42% lower than on the non-operated side. Knee flexion mobility was decreased by 8%, while the initially detected knee extension deficit of 10 degrees (SD 7) remained unchanged. The functional assessment system did not detect any changes in function. CONCLUSION: Waiting time did not affect knee pain or isometric knee extension/flexion strength. Three months post-operatively, knee pain had decreased significantly, but the strength of the operated knee was significantly lower than the pre-operative level.

Abstract: OBJECTIVE: To study the effect of isometric neck strength exercises on upper cervical stability in patients with rheumatoid arthritis (RA). METHODS: Twenty patients with a mean (SD) age of 58 (9) years and duration of RA of 27 (10) years volunteered for the study. Lateral radiographs of the cervical spine were taken to measure the current atlantoaxial distance (AAD) in flexion and extension. Maximal isometric neck flexion and extension strength values were measured by a dynamometer. Thereafter, AADs were measured from radiographs taken at 80-90% resistance of maximal strength. RESULTS: According to the full flexion radiographs at baseline, the patients were classified into three groups: eight patients without anterior atlantoaxial subluxation (aAAS) [AAD = 2.1 (2-3) mm], seven with unstable aAAS [AAD = 6.6 (5-8) mm], and five with stable aAAS [AAD = 5.5 (5-7) mm]. During resisted flexion the AAD decreased by 5 (3-7) mm (p<0.001) in the unstable aAAS group, while in the other two groups the changes were minor. During resisted extension the AAD increased by 3 (2-6) mm (p<0.001) in the cases with unstable aAAS only. CONCLUSION: Isometric exercising towards flexion decreases the AAD in cases with unstable aAAS. Submaximal loading of the neck extensors by pushing the back of the head against the resistance even in the neutral position of the cervical spine leads to a decrease in the width of the cervical spine canal and is not recommended in unstable aAAS.

Abstract: OBJECTIVE: To compare the effectiveness of a 12-month home-based combined strength training and stretching programme against stretching alone in the treatment of chronic neck pain. DESIGN: A randomized follow-up study. PARTICIPANTS: One hundred and one patients with chronic non-specific neck pain were randomized in two groups. INTERVENTION: The strength training and stretching group was supported by 10 group training sessions and the stretching group was instructed to perform stretching exercises only as instructed in one group session. MAIN OUTCOME MEASUREMENTS: Neck pain, disability, neck muscle strength and mobility of cervical spine were measured before and after the intervention. RESULTS: No significant differences in improvement in neck pain and disability were found between the two training groups. Mean (SD) pain decreased from 64 (17) mm by 37 (95% confidence interval (CI) 44 to 30) mm in the strength training and stretching group, and from 60 (17) mm by 32 (39 to 25) mm in the stretching group. The improvements in disability were significant in both groups (P<0.001), while the changes in neck strength and mobility were minor. Training adherence decreased over time from the targeted three sessions a week, ending up at 1.1 (0.7) times a week for strength training and stretching group and 1.4 (0.8) times a week for stretching group. CONCLUSIONS: No statistically significant differences in neck pain and disability were observed between the two home-based training regimens. Combined strength training and stretching or stretching only were probably as effective in achieving a long-term improvement although the training adherence was rather low most of the time.

Abstract: BACKGROUND: The overall rate of operations after recurrent lumbar disc herniation has been shown to be 3-11%. However, little is known about the rate of residives. Thus the aim of this study was to explore the cumulative rates of re-operations and especially residive disc herniations at the same side and level as the primary disc herniation after first lumbar disc herniation surgery and the factors that influence the risk of re-operations over a five year follow-up study. METHODS: 166 virgin lumbar disc herniation patients (mean age 42 years, 57% males) were studied. Data on patients' initial disc operations and type and timing of re-operations during the follow-up were collected from patient files. Back and leg pain on visual analog scale and employment status were collected by questionnaires. RESULTS: The cumulative rate of re-operations for lumbar disc herniation was 10.2% (95% Cl 6.0 to 15.1). The rate of residives at initial site was 7.4% (95% Cl 3.7 to 11.3) and rate of lumbar disc herniations at other sites was 3.1% (95% Cl 0.6 to 6.2). The occurrence of residive lumbar disc herniations was evenly distributed across the 5 years. Neither age, gender, preoperative symptoms, physical activity nor employment had effect on the probability of re-operation. CONCLUSION: Seven percent of the lumbar disc patients had a residive lumbar disc operation within five years of their first operation. No specific factors influencing the risk for re-operation were found.

Abstract: BACKGROUND: Reliable measurements are needed to study the dysfunction of the neck muscles. The aim of this study was to determine the intra-tester repeatability of EMG and isometric force measurements of the neck muscles in adolescents with headache and headache-free controls. METHODS: A group of 30 adolescents with migraine-type headache, 29 with tension-type headache, and 30 headache-free controls were recruited. Maximal isometric neck muscle force with simultaneous recording of surface EMG from the cervical erector spinae and the sternocleidomastoideus muscles was measured twice during one day. FINDINGS: For all groups, intra-class correlation coefficients (ICC) and coefficients of variation (CV) showed acceptable repeatability of all measurements. (Force measurements: ICC 0.98-0.99, CV 0.7-3.7%; EMG measurements: ICC 0.95-0.99, CV 4.9-10.1%.) On the individual level, variation between the consecutive measurements was found to be low in all groups. INTERPRETATION: The present EMG and force measurements of neck muscles indicate acceptable intra-tester repeatability in adolescents. The repeatability was comparable in migraine- and tension-type headache and headache-free groups. The EMG and the force measurements offer the possibility to investigate neck muscle dysfunction in adolescent headache.

Abstract: Neck and shoulder pain is a common disorder which is often associated with a low-pressure pain threshold (PPT) of muscle tissues as manifested by hyperalgesia on palpation or the use of a pressure algometer. The objective of the present study was to evaluate the intratester repeatability of pressure algometer (Force-Five) on the neck and shoulder area in women with neck pain. The study was cross-sectional with single-group repeated measurements. PPT measurements in 20 women with chronic non-specific neck pain were measured on consecutive days at the levator scapulae, at two points on the trapezius muscles on each side and at the sternum as the only non-muscular site. The intratester repeatability of the PPT measurements was satisfactory or good (Intraclass correlation coefficient (ICC 0.78-0.93). The coefficient of repeatability ranged from 16.8 to 24.4N/cm2 and the coefficient of variation ranged from 10% to 22%, depending on the site tested. Considerable individual variation was observed when consecutive measures were analysed against their mean. On the group level the repeatability of the measurements allows the pressure algometer to be used for research purposes. However, on the individual level, due to the considerable variation found in the PPT results, caution is advised when interpreting the results in clinical practice.

Abstract: OBJECTIVE: To compare the effects of manual therapy and stretching exercise on neck pain and disability. DESIGN: An examiner-blinded randomized cross-over trial. Patients: A total of 125 women with non-specific neck pain. METHODS: Patients were randomized into 2 groups. Group 1 received manual therapy twice weekly and Group 2 performed stretching exercises 5 times a week. After 4 weeks the treatments were changed. The follow-up times were after 4 and 12 weeks. Neck pain (visual analogue scale) and disability indices were measured. RESULTS: Mean value (standard deviation) for neck pain was 50 mm (22) and 49 mm (19) at baseline in Group 1 and Group 2, respectively, and decreased during the first 4 weeks by 26 mm (95% Confidence Interval 20-33) and 19 mm (12-27), respectively. There was no significant difference between groups. Neck and shoulder pain and disability index decreased significantly more in Group 1 after manual therapy (p=0.01) as well as neck stiffness (p=0.01). CONCLUSION: Both stretching exercise and manual therapy considerably decreased neck pain and disability in women with non-specific neck pain. The difference in effectiveness between the 2 treatments was minor. Low-cost stretching exercises can be recommended in the first instance as an appropriate therapy intervention to relieve pain, at least in the short-term.

Abstract: To study the characteristics and changes in the total Oswestry Disability Index (ODI) and in its ten component items in female and male patients pre- and post-surgery for lumbar disc herniation. Ninety-eight patients [mean (SD) age 43 (13), 61% males] undergoing lumbar disc herniation surgery were selected for this clinical 12-month follow-up. Subjective disability and back and leg pain were assessed by ODI version 1.0 and the visual analog scale. Pre-operatively females had a significantly higher mean (SD) total ODI [59(3)] than males [51(2)] (P = 0.030). Females were more disabled in the walking, sex life, social life and travelling items of the ODI compared to males. The total Oswestry decreased by 38 (95% CI - 44 to - 31) in females and by 34 (- 39 to - 30) in males at the 1-year follow-up. Most of the improvement (88% in females and 80% in males) occurred during the first 6 weeks; thereafter the changes were minor. In males the changes were greatest in pain, social life and travelling and in females in walking, social life and travelling. Internal consistency value of ODI was 0.88 (95% CI 0.82-0.91). Item analysis of the ODI showed that all the items except pain had high corrected item correlation. As recovery following lumbar disc surgery occurred to a great extent during the first 6 weeks, the early post-operative outcome appears to be quite a reliable indicator of the overall post-operative outcome over the 1-year follow-up. The ODI proved to capture a wide range of disability in these lumbar disc surgery patients, thereby supporting the future use of the index. The "pain intensity" component, which collects data on the use of painkillers in version 1.0 of the ODI did not support the item structure of the index in this study. The use of ODI version 2.0 might remove this problem.

Abstract: AIM: The objective of the trial was to evaluate whether the positive results achieved with a one-year training regimen in patients with chronic nonspecific neck pain would have long-standing effects. METHODS: A follow-up study of two neck muscle training groups after a randomized controlled study was carried out. One-hundred and eighteen women included were those who had performed neck strength and endurance exercises in a previous randomised controlled trial. The primary outcome measures were neck pain measured by the visual analogue scale and disability indices. Isometric neck strength, range of motion (ROM) and pressure pain threshold (PPT) were measured and training frequency for the previous month elicited by a questionnaire. RESULTS: At the 3-year follow-up, neck pain and the disability indices showed no statistically discernible change compared to the situation at the 12-month follow-up. Also, gains in neck strength, ROM and PPT achieved during the training year were largely maintained. However, adherence to the specific home training program faltered considerably. CONCLUSION: The improvements achieved through long-term training were maintained at the 3-year follow-up. Since a 12-month exercise programme shows a long-term effect, exercise may not need to be performed regularly for the remainder of the subject's life.

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Abstract: Despite chronic neck pain being so common in the population, few randomized studies have evaluated exercise methods in treating the neck disorders. The aim of this review was to reassess the effectiveness of different exercise methods in relieving pain and improving disability in patients with chronic nonspecific neck pain. Ten randomized controlled or comparative high-quality trials were included in a more detailed analysis using patient-oriented primary outcome measures (e.g., patient's rated pain and disability) as well as pressure pain threshold and functional outcomes (neck strength and range of motion). Findings revealed moderate evidence supporting the effectiveness of both long-term dynamic as well as isometric resistance exercises of the neck and shoulder musculature for chronic or frequent neck disorders. Findings revealed no evidence supporting the long-term effectiveness of postural and proprioceptive exercises or other very low intensity exercises. Clinicians are encouraged to consider these findings and incorporate them into their practice when planning the treatment of patients with chronic neck disorders.

Abstract: OBJECTIVE: To study the effect of manual therapy and stretching on neck function in women with chronic neck pain. METHODS: A total of 125 women were randomized into 2 groups. Group 1 received manual therapy twice a week for 4 weeks followed by stretching exercises. Group 2 performed stretching 5 times a week for 4 weeks followed by manual therapy. Neck function was assessed by isometric neck strength and mobility measurements, and spontaneous neck pain during the past week and strain-evoked pain during the neck strength trials using a visual analogue scale. RESULTS: Both neck muscle strength (11-14%) and mobility (7-15%) improved similarly in both groups, with the exception of greater passive flexion-extension mobility (p = 0.019) in group 1 at week 4. Pain during the neck strength trials decreased from the baseline to week 4 by 26-35% and to week 12 by 39-61% similarly in both groups. Average neck pain during the past week decreased by 64% and 53% in groups 1 and 2, respectively, during the first 4 weeks, remaining rather stable thereafter. The decreases in neck pain during both the past week and strength trials showed association with the changes in neck strength results (r = 0.20-0.29). CONCLUSION: Both manual therapy and stretching were effective short-term treatments for reducing both spontaneous and strain-evoked pain in patients with chronic neck pain. It is possible that the decrease in pain reduced inhibition of the motor system and in part improved neck function. However, the changes in neck muscle strength were minor, showing that these treatments alone are not effective in improving muscle strength.

Abstract: The aim was to evaluate the tone and electric activity of the quadriceps muscle at rest and different torque levels. The second aim was to study whether thickness of soft tissues and change in the joint position would affect muscle tone. Eighteen healthy subjects participated. Computerized muscle tonometer (CMT) and surface electromyography (sEMG) measurements were performed: seated, first at rest with leg straight and then with the knee at 60 degrees . Thereafter measurements were obtained at levels of 80, 60, 40 and 20% of the maximum isometric torque at the same knee angle. Thickness of skin, subcutis and muscle was measured by ultrasound. The CMT values taken were the depth the indenter travelled and the work it did while compressing the right rectus femoris and vastus intermedius muscles. Expressed as mean (SD) depth the change in muscle tone changed from 29.2 (3.6) mm in the relaxed position to 16.9 (5.2) mm at 80% of maximal torque, and expressed as work the values were from 1589 (150) mJ to 739 (149) mJ respectively. The correlation between CMT, sEMG and torque measurements varied from r = -0.52 to -0.71 (p < 0.01). CMT was able to detect a change of 20% in torque production and 4% in tone. Tone values, at each torque level, were significantly separate from the values at the other force levels (p < 0.001-0.04). Soft tissue thickness explained most of the tone results at rest (57%). The repeatability of the CMT measures was good (ICCs 0.75-0.99). Both depth and work correlated with electric activity and muscle torque, but the correlation with work was higher. In conclusion, muscle activity, length and thickness have to be taken into account when evaluating muscle tone.

Abstract: OBJECTIVE: Previous investigations suggest little association between clinical findings and radiographic degenerative findings. However, the association between degenerative changes and neck function has not been investigated. DESIGN: A cross-sectional study. SUBJECTS: Data were collected from 179 female office workers aged 25-53 years with chronic neck pain who were referred for institutional rehabilitation. METHODS: Radiographs of the cervical spine, and neck function including isometric muscle strength and passive range of motion were evaluated. All subjects completed self-report questionnaires including questions about neck pain and disability. RESULTS: Fifty-nine percent of the women presented degenerative changes and they were older than women without the changes (p=0.001). Neck pain and disability were comparable when the patients were put into subgroups according to the radiological cervical changes. Neck mobility and muscle strength were comparable in women with or without degenerative changes, except for a lower rotational range of motion in women with degenerative changes (p=0.009). CONCLUSION: The results suggest that the degenerative changes in cervical plain films are poorly related to the severity of symptoms or neck function in women with chronic neck pain working in sedentary occupations.

Abstract: INTRODUCTION: Fighter pilots' muscular strength and endurance are subjected to very high demands. Pilots' fatigued muscles are at higher risk for injuries. The purpose of this study was to compare the effects of two different training methods in reducing muscular loading during in-flight and cervical loading testing (CLT). METHODS: There were 16 volunteer Finnish Air Force cadets who were divided into 2 groups: a strength training group (STG) and a trampoline training group (TTG). During the 6-wk training period, the STG performed dynamic flexion and extension and isometric rotation exercises, and the TTG performed trampoline bouncing exercises. During in-flight and CLT, muscle strain from the sternocleidomastoid, cervical erector spinae, trapezius, and thoracic erector spinae muscles was recorded with EMG. RESULTS: In-flight muscle strain in the STG after the training period decreased in the sternocleidomastoid 50%, cervical erector spinae 3%, trapezius 4%, and thoracic erector spinae 8%. In the TTG, the decrease was 41%, 30%, 20%, and 6%, respectively. In CLT, the results were similar. After a 3-mo follow-up period with intensive high +Gz flying, EMG during CLT was still lower than in baseline measurements. CONCLUSION: Both training methods were found to be effective in reducing muscle strain during in-flight and CLT, especially in the cervical muscles. There was no statistically significant difference between the training groups. Introduced exercises expand muscles' capacities in different ways and the authors recommend both strength and trampoline training programs to be included in fighter pilots' physical education programs.

Abstract: Exercises are commonly recommended for chronic neck pain, but evidence-based guidelines do not explain what types of exercise. The aim of this randomized study was to evaluate the rate of change in neck strength following high- and low-intensity neck muscle training and their effects on pain and disability. One hundred eighty women with chronic neck pain were randomized into a high-intensity strength training group (STG), local muscle endurance training group (ETG), or control group (CG). The neck training consisted of isometric exercises in the STG and dynamic exercises in the ETG. Both groups performed dynamic exercises for the upper extremities. Strength tests, neck pain, and disability indices were evaluated at the baseline, at the follow-ups after 2 and 6 months in the training groups, and after 12 months in all groups. In both groups the greatest gains in neck strength, as well as decrease in neck pain and disability, were achieved during the first 2 months. However, the improvements continued up to 12 months. The STG achieved the greatest strength gains at all follow-ups. The CG showed only minor changes, and significant differences were found in favor of the training groups in all measures. The change in neck pain and disability indices correlated with the isometric neck strength (r = -0.22 [-0.36 to - 0.08] to -0.36 [-0.49 to -0.23]). Neck and shoulder muscle training was shown to be an effective therapy for chronic neck pain, resulting in early improvement in both the strength tests and subjective measures. The results can be maintained and even improved with long-term training.

Abstract: OBJECTIVE: To study the extent to which muscle strength and performance, pain, and disease activity are associated with the total Health Assessment Questionnaire (HAQ) disability index and its subdimensions in male and female patients with rheumatoid arthritis. METHODS: HAQ for functional capacity was completed by 135 patients with rheumatoid arthritis referred for orthopaedic surgery (74% women; mean (SD) age 62 (10) years; disease duration 19 (13) years, 70% positive for rheumatoid factor). Knee extension, trunk extension and flexion, grip strength, walking speed, and sit-to-stand test were measured to mirror physical function. Radiographs of hands and feet, pain, and the modified 28 joint disease activity score (DAS28) were also assessed. RESULTS: Mean total HAQ was 1.08 (0.68) in women and 0.67 (0.70) in men (p = 0.0031). Women had greater disability than men in five of the eight subdimensions of the HAQ. Grip strength was 48%, knee extension strength 46%, trunk extension strength 54%, and trunk flexion strength 43% lower in women than in men. Knee extension strength was inversely correlated with walking time (r = -0.63 (95% confidence interval, -0.73 to -0.51)) and with sit-to-stand test (r = -0.47 (-0.60 to -0.31)). In an ordered logistic regression analysis in female rheumatoid patients, DAS28, pain, knee extension strength, and grip strength were associated with the total HAQ disability index. CONCLUSIONS: Women reported greater disability than men both in the total HAQ and in the majority of its eight subdimensions. In addition to disease activity and pain, muscle strength has a major impact on disability especially in female rheumatoid patients.

Abstract: Previously, in a randomized study, we showed that women with chronic neck pain were able to perform intensive training for neck and shoulder muscles and that the increase in strength was accompanied by a reduction in pain and disability. The changes were significantly greater in the training groups compared with controls. The aim of the present study was to evaluate whether the controls would achieve similar results. Thus, 59 women in the control group initiated high-intensity strength training. Maximal isometric neck strength increased by 44% in both flexion and rotation and 27% in extension at the 2-year follow-up. Statistically and also clinically significant decreases in neck pain and disability indices occurred. Stretching and aerobic exercising during the first follow-up year produced only minor changes in both subjective and functional measures. Adding progressive strength training for the second year led to a significant improvement in neck strength and also to a considerable decrease in the pain and disability scores. Thus, to achieve effective rehabilitation in cases of chronic neck pain, a combination of strength training and stretching exercises are recommended.

Abstract: PURPOSE: To examine the dose-response relationship of specific strength- and endurance-training regimes for the cervical muscles, which have been shown to be effective among women with chronic neck pain and disability. METHODS: A total of 180 female office workers, aged 25 to 53 yr, with chronic neck pain and disability were randomized into a strength-training, an endurance-training, and a control group. The training groups participated in a 12-d rehabilitation period, in which instructions for the exercises were given by an experienced physical therapist. Both training groups continued with exercises at home for 12 months. Physical activity was measured with a training diary and a 1-month all-time recall questionnaire. All activities were registered and converted into metabolic equivalents (METs). RESULTS: Specific neck, shoulder, and upper-extremity training for more than 8.75 MET.h.wk was an effective training dose for decreasing neck pain. One MET-hour of training per week accounted for an 0.8-mm decrease of neck pain on a visual analog scale (VAS) and a 0.5-mm decrease on a disability index. Both strength and endurance training decreased perceived neck pain and disability. Declines in neck pain and disability correlated positively with the amount of specific training. CONCLUSION: This study revealed that the described specific exercise protocols were associated with decreases in chronic neck pain and disability. The effective dose of training was feasible and safe to perform among female office workers.

Abstract: STUDY DESIGN: Cross-sectional descriptive study. OBJECTIVES: To determine the maximal isometric strength of the flexor, extensor, and rotator muscles of the cervical spine in healthy females of working age to document reference values for diagnostic and rehabilitation purposes. BACKGROUND: Reference values for the isometric strength of the cervical muscles have often been based on small samples. To date, reference values for rotator muscles of the cervical spine have not been published. METHODS AND MEASURES: The group consisted of 220 volunteer healthy females in 4 age groups (20-29 years, n = 57; 30-39 years, n = 51; 40-49 years, n = 51; 50-59 years, n = 61) from Jyadskyla, Finland. Isometric cervical muscle strength in flexion, extension, and rotation was evaluated with a specially designed measurement system. RESULTS: Across all age groups, mean (+/-SD) maximal isometric neck strength was 73.8 +/- 20.0 N in flexion and 190.8 +/- 31.3 N in extension. Mean (+/-SD) rotation strength was 8.1 +/- 2.3 Nm to the right and 7.9 +/- 2.3 Nm to the left. Absolute strength values did not differ among the age groups. A weak but significant correlation between body mass and neck flexion (r = 0.31, P<.01) and extension (r = 0.25, P<.01) strength was found. Intratester reliability varied from 0.87 to 0.96. CONCLUSIONS: Women aged 20 to 59 years appear to have similar absolute isometric neck muscle strength levels. Thus these values can be used as reference for the working-age female population.

Abstract: The aim of the present study was to assess the intrarater repeatability of the computerized muscle tonometer (CMT), which is a computer-driven device designed to measure and register the tone of connective tissues. The second aim was to evaluate the effect of muscle thickness on results and repeatability as well as sensitivity, which was done by comparison to a mechanical hand-held tonometer (HHT). Participants were ten healthy male volunteers. The thickness of soft tissues was measured with ultrasound and the CMT was used to evaluate the muscle tone of thigh muscles 10, 15 and 20 cm and the HHT 15 cm above the patella on both sides. Great individual variability in muscle thickness and tone was noted. Muscle thickness increased proximally on the thigh and thus the mean distance travelled by the indenter of the CMT also increased from distal to proximal from 22 to 26 mm and the work done increased from 116 to 161 mJ. Intraclass correlation (ICC) for travel and work ranged from 0.85 to 0.92 and 0.94 to 0.98, respectively. Repeatability coefficients increased somewhat at proximal measurement sites. ICC for the HHT was 0.78. The CMT also showed a considerably higher range of results, indicating greater resolution power. Despite the twofold pressure used with the HHT the distance measured was on average 60% lower compared to the CMT. In conclusion, the repeatability of the CMT was found to be good. Muscle thickness greatly affected the results and should therefore be taken into consideration when measuring muscle tone. Work was a more reliable unit of measurement than travel, which has been commonly used to describe muscle tone.

Abstract: OBJECTIVE: To assess the adherence to and effects of a 12-month combined strength and stretching home exercise regimen versus stretching alone, on patient outcome after lumbar disk surgery. DESIGN: Randomized controlled trial. SETTING: Departments of physical medicine and rehabilitation and orthopedics at a Finnish hospital. PARTICIPANTS: Patients (N=126) were randomized into either a combined strength training and stretching group (STG, n=65) or a control group (CG, n=61). INTERVENTION: The STG was instructed to perform strength training and both the STG and CG were instructed in the same stretching and stabilization exercises for 12 months. MAIN OUTCOME MEASURES: Pain on the visual analog scale (VAS), the Oswestry and the Million disability indexes, isometric and dynamic trunk muscle strength, mobility in the lumbar spine, and straight-leg raising were measured. RESULTS: The trial was completed by 71% and 77% of the patients from the STG and the CG, respectively. The mean strength training frequency decreased from 1.5 to 0.6 times a week in the STG during the intervention. The mean stretching frequency decreased from 3.7 to 1.6 times a week in both groups. Median back and leg pain varied between 17 and 23 mm (VAS), and the Million and Oswestry indices varied between 14 and 23 points 2 months postoperatively. No statistically significant changes took place in these outcome measures during the 12-month follow-up in both groups. The changes in isometric trunk extension favored the STG ( P =.016) during the first 2 months. However, during the whole 12-month training period, both dynamic and isometric back extension and flexion strength, as well as mobility of the spine and repetitive squat-test results, improved significantly in both groups, and no differences were found in any of the physical function parameters between the STG and CG. CONCLUSIONS: At the 12-month follow-up, no statistically significant changes were found in the physical function, pain, or disability measures between the groups. In the STG, training adherence with regard to training frequency and intensity remained too low to lead to specific training-induced adaptations in the neuromuscular system. Progressive loading, supervision of training, and psychosocial support is needed in long-term rehabilitation programs to maintain patient motivation.

Abstract: OBJECTIVE: To explore the associations between individual subdimensions of the health assessment questionnaire (HAQ) and clinical variables in patients with rheumatoid arthritis. METHODS: 304 patients with rheumatoid arthritis (73% female, mean (SD) age, 58 (13) years; disease duration 6 (9) years, 69% rheumatoid factor positive) completed the HAQ for functional capacity (0-3) and a 100 mm visual analogue scale for pain. Grip strength, range of motion of the large joints, Larsen score for radiographic damage of hand and foot joints, and the number of tender and swollen joints were recorded. A logit regression model was used to study associations between subdimensions of the HAQ and other variables. RESULTS: Mean (range) total HAQ score was 0.92 (0 to 2.88) and varied from 0.73 to 1.04 in the subdimensions. Disability was lowest in the "walking" and highest in the "reach" subdimension. Pain was an explanatory variable in all individual subdimensions. Decreased grip strength, limitation of shoulder and wrist motion, and a larger number of swollen and tender joints in the upper extremities were related to several subdimensions. A higher pain score and swollen joint count in the upper extremities, decreased grip strength, and limited motion of wrist, shoulder, and knee joints explained increased disability (higher total HAQ scores). CONCLUSIONS: In patients with rheumatoid arthritis, pain and range of movements of joints have the greatest impact on individual subdimensions of the HAQ. Extent of radiographic damage in peripheral joints and the number of swollen and tender joints are of lesser importance for function.

Abstract: PURPOSE: This study compared health related quality of life (HRQOL) among lumber disc surgery patients to general population, and assessed the relationships between HRQOL and other outcome measures 2 and 14 months after surgery. METHODS: The 15D instrument was use to measure HRQOL in 145 lumber disk surgery patients. Subjective outcome was also assessed by the Oswestry index, Short Depression Inventory (SDI) and pain, and objective outcome by trunk muscle strength and mobility of the spine. RESULTS: The mean (SD) 15D score among the patients 2 months after surgery was 0.880 (0.104) compared to 0.941 (0.076) among general population (p = 0.016). The 15D, Oswestry and SDI scores remained unchanged during the follow-up, while the improvements in the spine mobility and trunk muscle strength were significant. Back pain decreased by 68% and leg pain by 74% from preoperative level to 2 months check-up. Leg pain further decreased during the following 12 months, while back pain remained unchanged. HRQOL was associated with age, pain, Oswestry and SDI indices, but not with physical function. CONCLUSION: HRQOL measured by 15D was lower in lumber disc surgery patients compared to general population. 15D was associated with the subjective outcome measures of pain, Oswestry and SDI indices, but not with the objective measures of physical function. Thus, a combination of "disease specific" and "generic" measures is recommended to be used to obtain more accurate information about the overall welfare of individual.

Abstract: BACKGROUND: Free style and Greco-Roman are two types of wrestling. [figure: see text] OBJECTIVES: The aim of this study was to examine the maximal isometric strength of cervical extension (ISCE) and the maximal isometric strength of cervical flexion (ISCF) in two groups of elite wrestlers and a group of non-athletic subjects. METHODS: Fourteen elite Greco-Roman wrestlers (aged 19-25 years), 16 elite free style wrestlers (aged 18-25 years), and 16 non-athletic subjects (aged 18-25 years) participated in this study. All wrestlers competed at international level with the Iranian national team. Maximum voluntary contractions (MVC) of cervical extensor and flexor muscles were measured using a custom made device. The ratios of ISCE to weight (ISCE/weight), ISCF to weight (ISCF/weight), and ISCF to ISCE (ISCF/ISCE) were calculated for group comparisons. Pearson product moment test was used to estimate correlation between maximal isometric strength measurements and anthropometric variables. A one way analysis of variance was computed to compare ISCE/weight, ISCF/weight, and ISCF/ISCE among groups. RESULTS: There was significant correlation between maximum cervical extension and flexion strengths and weight in all groups (p<0.05, n = 46). The ratios of cervical muscle strengths to weight were significantly higher in wrestlers than in non-athletic subjects (p<0.00). Greco-Roman wrestlers appeared to be stronger than free style wrestlers following comparison of all ratios. CONCLUSIONS: Neck muscle force measurements may be a useful test for athletes in combat sports like wrestling. They can be applied to identify the weakness of a group of muscles in the neck area and to devise a proper training program.

Abstract: The purpose of the present study was to investigate neuromuscular performance characteristics in open-wheel and rally drivers using the cross-sectional study design. The subjects (N = 28) consisted of experienced international-level open-wheel drivers (n = 9), experienced international-level rally drivers (n = 9) and a physically active nondriving male control group (n = 10). In 3 separate test sessions, speed, muscle strength, and endurance tests were performed. The rally drivers had higher (p < 0.05) grip, shoulder flexion, and ankle plantar flexion strength, as compared to the control group. The open-wheel drivers showed higher strengths (p < 0.05) than the controls in neck forces, grip, shoulder flexion, and leg extension. The rally drivers were stronger (p < 0.05) than the open-wheel drivers in grip, plantar flexion, and trunk extension forces, whereas the open-wheel drivers were stronger (p < 0.01) than the rally drivers in neck lateral flexions and extension forces. Thus, competitive long-term open-wheel and rally drivers differ specifically in neuromuscular performance. For practice, these findings suggest that rally drivers should concentrate on training hand, ankle, and trunk muscles, whereas open-wheel drivers should train neck muscles, especially, and all other muscle groups rather equally.

Abstract: Muscle tenderness has been measured in several studies to evaluate effectiveness of treatment methods, but only short-term results have been reported so far. The aim of the present study was to evaluate the long-term effects of two different muscle training methods on the pressure pain threshold of neck muscles in women with neck pain. Altogether 180 woman with chronic, non-specific neck pain were randomized into three groups: neck muscle endurance training, neck muscle strength training and control groups. The main outcome measures included pressure pain threshold measurement at six muscle sites and on the sternum. Neck pain was assessed by a visual analogue scale (VAS). At the 12-month follow-up statistically significantly higher pressure pain threshold values were obtained in both training groups at all muscle sites compared to the baseline, while no significant change occurred in the controls. Significantly higher changes in pressure pain threshold were detected at all six sites in the strength training group and at four out of six sites in the endurance training group compared to the control group. This is the first study to show an increase in pressure pain thresholds as a result of long-term muscle training. A decrease in neck pain was associated with reduced pressure pain sensitivity in neck muscles, showing that the pressure pain threshold may be a useful outcome measure of the effectiveness of neck muscle rehabilitation.

Abstract: OBJECTIVE: To compare neck muscle strength and mobility of the cervical spine in rheumatoid arthritis (RA) patients with and without atlantoaxial (AA) disorders (anterior atlantoaxial subluxation [AAS], AA impaction). DESIGN: Clinical cross-sectional study. SETTING: Outpatient rheumatology and rehabilitation clinics in a Finnish hospital. PARTICIPANTS: Patients with RA (N=124; mean age +/- standard deviation, 62+/-12y [corrected]) on a waiting list for orthopedic surgery. Thirty (24%) patients presented with AA disorders (16 with anterior AAS, 8 with AA impaction, 6 with a combination of anterior AAS and AA impaction). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Neck function was measured by isometric neck strength and mobility tests, neck pain by a visual analog scale, erosion of the hands and feet by radiography, and the patients' function by the Health Assessment Questionnaire (HAQ). RESULTS: Maximal neck muscle strength against flexion, extension, and rotation was lower in patients with AA disorders compared with the other patients in both women (P=.012) and men (P=.017). Mobility was lowest in the AA impaction group in all measured directions (P<.001). Peripheral erosive disease was more frequent in the group with AA disorders. They also had longer disease duration and were more disabled (HAQ) than the other patients. CONCLUSIONS: Neck muscle strength is significantly decreased in patients with AA disorders. Mobility of the cervical spine is most limited in patients with AA impaction, but can be normal in cases with solitary anterior AAS.

Abstract: The main aim of this study was to explore the occurrence and changes of neck pain in pain-free preadolescents. The evaluation was performed at 1- and 4-year follow-ups. Of the pain-free preadolescents, 366 (71.9%) completed structured pain questionnaires at 1 and 4 years. The occurrence of neck pain at least once a month was 21.3 and 43.4% and at least once a week was 6.3 and 19.4%. Sex difference was found only at the 4-year follow-up, when subjects were 13-16-year-old. Neck pain was then more common among girls than boys (P < 0.001). The intensity of pain increased with the frequency of pain (P < 0.001). Of those with neck pain, 28% had used painkillers. The proportion increased with the frequency of neck pain (P = 0.054). Neck pain occurred more often with some other musculoskeletal pain than as a single pain. The frequency of neck pain correlated with the frequency of headache (r = 0.39 [95% confidence interval (CI), 0.30-0.47]) and with the disability (r = 0.26 [95% CI, 0.16-0.35]). This study strengthens the results of the previous cross-sectional studies that occurrence of neck pain increases with age, and that neck pain becomes more common among girls than boys in adolescence. Among preadolescents who were originally pain-free, there was only a small proportion who reported frequent neck pain at both 1 and 4 years. It also showed that the frequency of neck pain reflects the intensity of pain fairly well.

Abstract: OBJECTIVES: To evaluate neck flexion, extension, and, especially, rotation strength in women with chronic neck pain compared with healthy controls and to evaluate the repeatability of peak isometric neck strength measurements in patients with neck pain. DESIGN: Cross-sectional. SETTINGS: Rehabilitation center and physical and rehabilitation medicine department at a Finnish hospital. PARTICIPANTS: Twenty-one women with chronic neck pain and healthy controls matched for sex, age, anthropometric measures, and occupation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Peak isometric strength of the cervical muscles was tested in rotation, flexion, and extension. RESULTS: Significantly lower flexion (29%), extension (29%), and rotation forces (23%) were produced by the chronic neck pain group compared with controls. When the repeated test results were compared pairwise against their mean, considerable variation was observed in the measures on the individual level. Intratester repeatability of the neck muscle strength measurements was good in all the 4 directions tested in the chronic neck pain group (intraclass correlation coefficient range,.74-.94). The coefficient of repeatability was 15N, both in flexion and extension, and 1.8 Nm in rotation. On the group level, improvement up to 10% due to repeated testing was observed. CONCLUSIONS: The group with neck pain had lower neck muscle strength in all the directions tested than the control group. This factor should be considered when planning rehabilitation programs. Strength tests may be useful in monitoring training progress in clinical settings, but training programs should be planned so that the improvement in results is well above biologic variation, measurement error, and learning effect because of repeated testing.

Abstract:

Abstract: Several studies have reported lower neck muscle strength in patients with chronic neck pain compared to healthy controls. The aim of the present study was to evaluate the association between the severity of neck pain and disability with neck strength and range of movement in women suffering from chronic neck pain. One hundred and seventy-nine female office workers with chronic neck pain were selected to the study. The outcome was assessed by the self-rating questionnaires on neck pain (visual analogue scale, Vernon's disability index, Neck pain and disability index) and by measures of the passive range of movement (ROM) and maximal isometric neck muscle strength. No statistically significant correlation was found between perceived neck pain and the disability indices and the maximal isometric neck strength and ROM measures. However, the pain values reported during the strength tests were inversely correlated with the results of strength tests (r=-0.24 to -0.46), showing that pain was associated with decreased force production. About two-thirds of the patients felt pain during test efforts. Pain may prevent full effort during strength tests and hence the production of maximal force. Thus in patients with chronic neck pain the results do not always describe true maximal strength, but rather the patients' ability to bear strain, which may be considerably influenced by their painful condition. The results of the present study suggest that rehabilitation in cases of chronic neck pain should aim at raising tolerance to mechanical strain.

Abstract: OBJECTIVES: To compare the isometric neck muscle strength of cervical dystonia patients treated with botulinum toxin injections with that of healthy control subjects and to evaluate the association between neck strength, neck pain, and disability in these patients. DESIGN: Clinical cross-sectional study. SETTING: Outpatient rehabilitation and neurology clinics in a Finnish hospital. PARTICIPANTS: Twenty-three patients with cervical dystonia with botulinum toxin-treated neck muscles and 23 healthy control subjects. INTERVENTIONS: Not applicable.Main outcome measures Isometric neck strength was measured by a special neck strength measurement system. Disability was measured by the Neck Disability Index, and pain and symptoms of cervical dystonia by a visual analog scale. RESULTS: Isometric neck strength in all directions measured was significantly lower (25%-44%) in the cervical dystonia patients than in the healthy controls. Neck pain levels reported during the strength tests (r range, -.36 to -.70) and neck pain experienced during the preceding week (r range, -.52 to -.63) were inversely associated with isometric strength results. The difference between sides in rotation strength was 35% in the patient group (P<.001), whereas no significant difference between sides was found in the healthy controls. Fifty-one percent of the patients reported moderate or severe disability. Pain, stiffness, and incorrect position of the head were the most prominent symptoms. CONCLUSIONS: Cervical dystonia patients with botulinum toxin-treated neck muscles showed significantly lower maximal neck strength than healthy controls. The patients also had a statistically significant difference between sides in neck rotation strength. Thus, strength measures may be useful to detect disturbance in the function of the neck muscles.

Abstract: STUDY DESIGN: A cross-sectional study was conducted. OBJECTIVE: To compare maximal flexion, extension, and rotation strength as well as force-time characteristics of trunk muscles in patients who undergo lumbar disc herniation with those in healthy control subjects 2 months after surgery. SUMMARY OF BACKGROUND DATA: Insufficient attention has been paid to muscle strength characteristics after lumbar disc herniation surgery. METHODS: For this study, 30 postoperative patients with lumbar disc herniation and 30 healthy control subjects volunteered to participate. Isometric trunk flexion, extension in the standing position, and seated rotation strength were tested bilaterally in a neutral posture and at 30 degrees axial prerotation. The area under the curve was calculated to analyze explosive force capacity. Dynamic endurance strength was measured by calculating the repetition maximum. Pain during the strength measurements was assessed by a visual analog scale. RESULTS: The healthy control subjects showed 44% and 36% higher isometric trunk flexion (P < 0.001) and extension (P < 0.001) forces, respectively, than the patients. The respective values for the area under the curve were 41% and 37% higher for the trunk flexors (P < 0.001) and extensors (P < 0.001) in the healthy control subjects than in the patients. The differences in trunk rotation force between the groups were statistically significant when the lower body was rotated 30 degrees to the right (P = 0.023) or to the left (P = 0.043) and the upper body was rotated in the opposite direction. Furthermore, in the dynamic endurance strength test, the healthy control subjects performed 70% more repetitions both for trunk flexors and extensors than did the patients. Some of the patients reported mild pain during the strength measurements, but the level of pain did not correlate with the strength values. CONCLUSIONS: The recovery of maximal endurance and explosive type strength characteristics is incomplete in patients with lumbar disc herniation 2 months after surgery. Active strength training is recommended to restore muscle function in these patients.

Abstract: OBJECTIVE: To characterize isometric rotation strength in the neutral and in different prerotated positions of the neck. DESIGN: This was a descriptive study involving maximal isometric strength measurements of the cervical musculature. BACKGROUND: The literature contains only a few studies pertaining to strength levels of the neck rotator muscles in the neutral position. None of these studies have dealt in detail with maximal neck strength in selected prerotation positions. METHOD: Twenty healthy men volunteered as subjects. Maximal axial rotation strength of the neck muscles was measured in a neutral position and bilaterally at 30 degrees and 60 degrees rotation using the isometric neck strength measurement system. Isometric maximum voluntary contractions of the neck muscles in flexion and extension were also tested. RESULTS: The highest strength values were not reached in the neutral position, but at the largest joint angles, while turning the head in the opposite direction from the prerotated position. Maximal strength increased with increasing angle, and at the 60 degrees prerotation angle it was 44% higher towards the right and 27% higher towards the left compared to the values obtained in the neutral position. The smallest strength values were also produced at the largest prerotation angles, but in the same direction. CONCLUSIONS: The present results show a clear relationship between the prerotated position of the neck and maximal voluntary strength in rotation. RELEVANCE: The data suggest that neck strength is highly prerotation angle dependent. Neck strength should be measured at several prerotation positions in addition to the neutral position in order to obtain the true strength values throughout the entire range of motion. Maximal neck rotation strength between subjects is differentiated best at the greatest prerotation angles.

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Abstract: PURPOSE: To assess the prognostic value of some preoperative and early post-operative indicators in the prediction of disability 14 months after lumbar disc surgery. METHODS: Of 173 patients, who had participated in baseline measurements, 145 (84%) attended the 14-month follow-up. Before surgery the duration and intensity of pain was assessed. Follow-up questionnaires were completed during check-ups and included items on pain (VAS), Oswestry and Million disability indices, depression (BDS) and work status. RESULTS: Two months after surgery average back pain was 67% lower and leg pain 70% lower than pre-operatively. The median Oswestry and Million disability indices were 14 and 15 at 2-months and remained low also at 14-months check-up. Further, the post-operative Oswestry and Million disability indices and BDS were highly associated with 14-month back and leg pain. Although the outcome of the patients was mostly good, 5% and 8% of them, respectively, reported severe pain at 2- and 14-month check-ups. CONCLUSIONS: As recovery following lumbar disc surgery occurred to a great extent during the first 2 months, the early post-operative outcome appears to be quite a reliable indicator of the postoperative outcome in 1-year follow-up. The strong association between pain and the disability indices allows us to conclude that both the Million and Oswestry indices are clinically useful instruments in the evaluation of outcome in these cases.

Abstract: CONTEXT: Active physical training is commonly recommended for patients with chronic neck pain; however, its efficacy has not been demonstrated in randomized studies. OBJECTIVE: To evaluate the efficacy of intensive isometric neck strength training and lighter endurance training of neck muscles on pain and disability in women with chronic, nonspecific neck pain. DESIGN: Examiner-blinded randomized controlled trial conducted between February 2000 and March 2002. SETTING: Participants were recruited from occupational health care systems in southern and eastern Finland. PATIENTS: A total of 180 female office workers between the ages of 25 and 53 years with chronic, nonspecific neck pain. INTERVENTIONS: Patients were randomly assigned to either 2 training groups or to a control group, with 60 patients in each group. The endurance training group performed dynamic neck exercises, which included lifting the head up from the supine and prone positions. The strength training group performed high-intensity isometric neck strengthening and stabilization exercises with an elastic band. Both training groups performed dynamic exercises for the shoulders and upper extremities with dumbbells. All groups were advised to do aerobic and stretching exercises regularly 3 times a week. MAIN OUTCOME MEASURES: Neck pain and disability were assessed by a visual analog scale, the neck and shoulder pain and disability index, and the Vernon neck disability index. Intermediate outcome measures included mood assessed by a short depression inventory and by maximal isometric neck strength and range of motion measures. RESULTS: At the 12-month follow-up visit, both neck pain and disability had decreased in both training groups compared with the control group (P<.001). Maximal isometric neck strength had improved flexion by 110%, rotation by 76%, and extension by 69% in the strength training group. The respective improvements in the endurance training group were 28%, 29%, and 16% and in the control group were 10%, 10%, and 7%. Range of motion had also improved statistically significantly in both training groups compared with the control group in rotation, but only the strength training group had statistically significant improvements in lateral flexion and in flexion and extension. CONCLUSIONS: 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.

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Abstract: Special training methods in wrestling have been assumed to improve the stability and tolerance of the neck. The aim of this study was to measure the neck strength levels reached in an extremely physically demanding sport. A neck strength measurement system was used to measure various parameters of maximal isometric neck strength in Finnish senior wrestlers competing at the international level. The results were compared with those achieved by junior wrestlers and a control group. The means (SD) of the maximal isometric neck strength for cervical rotation were 0.4 (0.1) Nm.kg(-1) for the senior wrestlers, 0.3 (0.1) Nm.kg(-1) for the junior wrestlers, and 0.2 (0.1) Nm.kg(-1) for the nonsportsmen. The respective results for cervical flexion were 4.4 (1.4), 3.8 (0.7), and 2.3 (0.8) Nm.kg(-1); for extension, 6.0 (1.1), 5.9 (0.7), and 4.0 (0.9) Nm.kg(-1). Neck strength in flexion seems to improve more than in extension as the result of wrestling. The greatest difference was found in rotation, which in the senior wrestlers was almost 3 times that in the nonsportsmen. There was great individual variation within all groups, and the results revealed weaknesses in all directions. Maximal neck strength measurements provide information useful in planning training programs to correct possible muscle deficiency and imbalance.

Abstract: OBJECTIVE: To evaluate whether patients acquired normal physical function after cervical disk prolapse and surgery compared with healthy matched controls. DESIGN: Cross-sectional study. SETTING: Hospital in central Finland. PARTICIPANTS: Fifty-three patients with cervical diskectomy and 53 healthy matched controls. INTERVENTIONS: Not applicable.Main Outcome Measures: Postoperative physical function was studied by measuring muscle strength and range of motion (ROM) values of the neck and grip strength. Disability was assessed by the neck and shoulder pain index and by the Oswestry index, mood by the Short Depression Inventory; and pain on a visual analog scale (VAS). RESULTS: Most patients recovered well after the operation. Forty-three percent of the patients still experienced moderate or high pain (VAS score, >30mm). Subjective pain and disability were associated with decreased neck movement and strength. Both ROM and cervical muscle strength values were significantly lower (P<.001) in all the measured directions in cervical disk surgery patients compared with healthy controls. ROM was mostly confined in extension (25%). Muscle strength of the neck was mostly confined in both rotation directions (38%). No statistically significant difference in grip strength was found between the groups. CONCLUSION: The loss of muscle strength and ROM is clearly visible postoperatively and thus the effectiveness of the early identification and rehabilitation of these deficits merits further studies.

Abstract: OBJECTIVE: To study associations between pain, trunk muscle strength, flexibility and disability in patients with lumbar disc herniation 2 months after surgery. DESIGN: Clinical cross-sectional survey. PARTICIPANTS: 172 operated lumbar disc herniation patients. METHODS: Back and leg pain on Visual Analogue Scale, Oswestry Disability Index and Brief Depression Scale were applied to assess the subjectively perceived outcome. Isometric and dynamic strength of trunk muscles and mobility of the lumbar spine were measured to mirror physical impairment. RESULTS: Two months after the operation median leg pain had decreased by 87% and back pain by 81%, respectively. However, moderate or severe leg pain was still reported by 25% and back pain by 20% of the patients. Approximately 30% of the patients perceived moderate or severe disability measured by the Oswestry index. Decreased muscle strength and spine mobility caused functional disability, especially in older patients and patients with postoperative pain. Furthermore, the ratio of trunk extension/flexion strength had changed in favour of the flexion muscles, being 0.98. Greater age and depression were associated with poorer postoperative recovery. CONCLUSION: Pain, decreased trunk muscle strength and decreased mobility still remained in a considerable proportion of patients with lumbar disc herniation 2 months after surgery. Early identification of those patients with restrictions is essential in order to commence rehabilitation.

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Abstract: The anatomy of the human cervical region has a special complexity. Ultrasonography is a scanning technique, which has been successfully used to identify and measure the cervical muscle dimensions. The purpose of this study was to detect with the use of real-time ultrasonography the dimensional changes of the human semispinalis capitis muscle (SECM) during isometric cervical extension. Six junior ice hockey players took part in the study. We simultaneously measured the values of estimates, such as breadth or anteroposterior dimension (APD) and width or lateral dimension (LD), of the SECM cross-sectional area during isometric cervical extension at different maximum voluntary contraction (MVC) percent levels (0%, 20%, 40%, 60%, 80%, and 100%). The result of multiplication of the linear dimensions (APD x LD), considered as the size of the SECM, increased (p < 0.05) with increasing the level of the cervical extension force. The correlation between muscle size and extension force of 100% MVC was r = 0.79 (p = 0.05). The ultrasonography method may be useful in evaluating the function of an individual cervical muscle.

Abstract: This study examined the force production characteristics, activation/coactivation and endurance capacity of the neck extension and flexion muscles in healthy men (n=29) and women (n=28) divided into three age groups (18-26 years, 30-37 years and 45-55 years). Force and electromyography (EMG) measurements were performed during the maximal voluntary isometric extension and flexion actions. This was followed by an endurance test (ET; 60% force level of maximal voluntary contraction sustained until exhaustion), after which the force and EMG recordings were repeated. Men were both stronger and had higher values (P<0.001) for explosive force (rate of force development, RFD) than women in both actions. Younger subjects of both genders exhibited larger (P<0.05 in women) RFD values than older subjects in extension. The coactivation of the antagonist muscles during the maximal extension or flexion did not differ significantly between men and women, but the coactivation of the antagonists was larger (P<0.05) in the older age groups than in the youngest group. Women maintained the 60% force level longer than men in both actions (extension, P<0.001; flexion, not significant). The fatiguing loading led to significant decreases in maximal isometric force (P<0.001) and RFD (P<0.01-0.001), but these relative decreases did not differ between the groups. In conclusion, large gender differences in the voluntary extension and flexion force production characteristics of the neck muscles did exist, as reported earlier for other muscles of the body. No age-related differences were observed in maximal force of the extension and flexion actions within the age ranges of the subject groups studied here, but the older subjects exhibited greater coactivation and produced lower force values in the early portions of the force/time curve of the extension than the youngest group. The data indicate that explosive force production may be sensitive to aging earlier than maximal strength in the case of the neck extensor muscles.

Abstract: OBJECTIVE: To evaluate the repeatability of an advanced method of measuring the strength of functionally different groups of neck muscles using an isometric apparatus. DESIGN: A repeated measures design was used within and between sessions. BACKGROUND: Chronic neck pain has been associated with poor isometric neck strength. In rehabilitation, strength measurements may thus help to evaluate the basic condition and show whether or not treatments and exercises have been beneficial for improving strength. Previous tests have concentrated on testing strength while trying to bend forwards and backwards, but no biomechanics device, able to test rotator muscles, has been presented. METHOD: The new isometric measurement device was used to test flexion, extension and also rotation strengths of normal subjects (n = 33). RESULTS: Intratester repeatability was good with regard to all measured parameters. CONCLUSIONS: With both tests performed on the same day and test comparisons between days, intratest repeatability was good with regard to all measured parameters.

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Abstract: The purpose of this study was to evaluate for diagnostic purposes the isometric strength of the neck flexor and extensor muscles in 56 patients with neck and shoulder pain and to quantify the effect of a specific rehabilitation program. An isometric measurement protocol was performed at the beginning and at the end of a 3-week rehabilitation program that included physiotherapy, stretching, aerobic exercises, and circuit training to improve arm, shoulder, and neck muscle strength. In the beginning, mean neck flexor muscle isometric strength was 83N (+/- 48 SD) and extensor muscle strength 158N (+/- 76 SD), whereas after rehabilitation the strength measurements were 117N (+/- 43 SD) and 207N (+/- 84 SD) respectively. There was a significant increase in the ability to push forward and backward, which correlated with the lessening of neck pain and disability found at the end of the program (p < .05). Isometric strength measurement is a useful and practical method of objectively showing a functional improvement in response to rehabilitation.

Abstract: Tissue compliance measurements were used for documentation of soft tissue consistency and made possible the diagnosis of muscle spasm and the effects of treatment. We have developed a new digital electronic operated tissue compliance meter to quantify the soft tissue hardness and resistance more objectively than the conventional hand-held mechanical tissue compliance meters. The ranges of measurements were able to perform to a maximum depth of 50 millimeters from the body surface with maximal load of 4000 grams. In lateral epicondylitis was demonstrated the effect of treatment by increase of total work (area).

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Abstract: Chronic non-specific neck pain is a common condition in modern industrialized countries causing suffering, disability and considerable economical losses both for individuals and societies. Diagnosis is based mainly on symptoms and clinical examination. Treatment in chronic non-specific neck pain has been mainly passive physiotherapy, advice for stretching exercises and encouragement to maintain an active lifestyle. Active training has been also recommended, but there are no comparative studies about how best the training should be performed to ensure its effectiveness. Furthermore, several controlled studies have failed to show significant benefit from active training for neck pain and disability in the longterm. The purpose of this study was to evaluate the appropriateness of isometric neck strength tests and the effectiveness of two training methods in rehabilitation of chronic neck pain. Isometric strength tests showed moderate or good repeatability in the intervention studies, but caution should exercised while interpreting the results at the individual level. Although patients with chronic neck pain were shown to have lower neck strength compared to healthy controls on the average, isometric tests are not suitable for diagnostic purposes, as there is a considerable overlap in the values obtained between those groups. In the randomized controlled trial, the effectiveness of strength and endurance training of neck muscles were compared in women (n = 179) with chronic non-specific neck pain. Neck pain and the related disability were shown to decrease up to the 12-month follow-up and the changes were clinically significant compared to the control group. There was no statistically discernible difference in these outcomes between the two training groups. However, more patients in the strength training group were almost or completely painless. Secondary outcome measures; neck strength, range of motion and pressure pain threshold were also in favour of the strength training. The results were confirmed by the control group, which subsequently initiated strength training and obtained similar results at the 24-month follow-up as those obtained with the previous training groups. These results suggest that exercising involving specific strength or endurance training of the neck muscles with adequate support and long-term follow-up are effective rehabilitation methods for patients with chronic non-specific neck pain.