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TThickness of Lower Trapezius Muscle hickness of Lower Trapezius Muscle TThickness of Lower Trapezius Muscle hickness of Lower Trapezius Muscle TThickness of Lower Trapezius Muscle hickness of Lower Trapezius Muscle
in Women with Chronic Unilateral Neck Painin Women with Chronic Unilateral Neck Pain
TThickness of Lower Trapezius Muscle hickness of Lower Trapezius Muscle
in Women with Chronic Unilateral Neck Painin Women with Chronic Unilateral Neck Painin Women with Chronic Unilateral Neck Painin Women with Chronic Unilateral Neck Painin Women with Chronic Unilateral Neck Painin Women with Chronic Unilateral Neck Pain
Ms. Kanokon Kawsoiy, MSc y,
Faculty of Associated Medical Sciences,
Department of Physical Therapy,p y py
Chiang Mai University
Definition of Neck PainDefinition of Neck Pain
“Pain located in the anatomical region of the neck with or
without radiation to head, trunk and upper limbs” , pp
Posterior region Side region(Guzman et al., 2009)
Posterior region Side region
The axioscapular musclesThe axioscapular muscles
UT
Pectoralis minor m.
UT
Levator scapulae m.
MT
Rhomboid m.LTLT
SA
Posterior side
Stability
Anterior side
(Oatis, 2004)
Stability
Mobility
The role of scapular stabilityThe role of scapular stability
• To maintain normal
orientation of the scapula
with arms by sides y
t bili / t l th• To stabilize/control the
scapula during mvt. of the
upper limb
(Oatis, 2004)
During arm elevationDuring arm elevation
Upper trapezius (UT)
UT
Upper trapezius (UT)
• Scapula upward rot. & elevation
Lower trapezius (LT)
SA• Scapular external rot., upward rot.
& post. tilt p
Serratus ant. (SA)
LT• Scapula upward rot., abduction,
post. tilt & external rot.
(Oatis, 2004; Ludewig et al., 2009)
p
Dysfunction of LT and neck pain
• EMG studies
Dysfunction of LT and neck pain
EMG studies
- Wegner et al., 2010 demonstrated MT and LT activity
in neck pain group during performed typing task in neck pain group during performed typing task
- Zakharova-Luneva et al 2012 demonstrated change LT - Zakharova-Luneva et al., 2012 demonstrated change LT
behavior in mechanical neck pain with clinical signs of
scapular dysfunctionscapular dysfunction
- Weon et al 2010 demonstrated UT LT activity - Weon et al., 2010 demonstrated UT, LT activity
SA activity during loaded isometric Sh. flexion in
f d h d tforward head posture
Dysfunction of LT and neck painDysfunction of LT and neck pain
• Dynamometer study
- Petersen et al., 2001 demonstrated significantly less LT
strength on ipsilateral side of neck pain in pts. with
unilateral neck pain
However, there has been no study investigating , y g g
LT dysfunction in unilateral neck pain y p
using ultrasound imaging (USI)using ultrasound imaging (USI)
Ultrasound imaging (USI)
Ultrasound imaging has been used to evaluate dysfunction of
Ultrasound imaging (USI)
Ultrasound imaging has been used to evaluate dysfunction of
the m. thickness either during resting & contraction
(Critchley & Coutts., 2002)(Critchley & Coutts., 2002)
• Advantages of ultrasoundg
• Non-invasive tool
• Provides images in real time g
• Free of radiation risk
• Easyy
• Rapid
• Reliable
(Whittaker et al., 2007)
Ultrasound imaging (USI)
R li bilit f LT thi k
Ultrasound imaging (USI)
• Reliability of LT m. thickness
- Inter and intra-reliability = 0.70 - 0.99
• Validity of USI in LT m. thicknessValidity of USI in LT m. thickness
- Compared with MRI
0 77 (T8)- r = 0.77 (T8)
- r = 0.62 (T5) (O’sullivan et al., 2009)
Aims of the studyAims of the study
1 T i ti t thi k f th LT b/ i il t l1. To investigate thickness of the LT b/w ipsilateral
and contralateral sides in pts. with chronic
unilateral neck painunilateral neck pain
2 T i ti t thi k f th LT i t ith 2. To investigate thickness of the LT in pts. with
chronic unilateral neck pain compared to those
ith t k iwithout neck pain
3 T d t i l ti hi b/ thi k f th LT d3. To determine relationships b/w thickness of the LT and
• Intensity of pain (VAS)
• Disability scores (NDI)
Hypotheses of the studyHypotheses of the study
1 Thi k f th LT i il t l id < 1. Thickness of the LT on ipsilateral side <
contralateral side in pts. with chronic unilateral
neck painneck pain
2 Thi k f th LT ld b d d i t ith 2. Thickness of the LT would be reduced in pts. with
chronic unilateral neck pain compared to those
ith t k iwithout neck pain
3 Th ld b ti l ti f th LT d 3. There would be negative correlations of the LT and
• Intensity of pain (VAS)
• Disability scores (NDI)
METHODSMETHODSMETHODSMETHODS
ParticipantsParticipants
Subjects Recruitments - Age: 18-59 yrsj Age 18 59 yrs
- Gender: Female
Unilateral Neck
Pain Group
Healthy
Control Group
- Arm dominance
BMIPain Group
(N = 20)
Control Group
(N = 20) - BMI
- Physical activityy y
ParticipantsParticipants
Inclusion Criteria
Neck pain group
Inclusion Criteria
• Have unilateral idiopathic neck pain (grade I-II)
• Have been persisted for chronic neck pain ≥ 3 mo.Have been persisted for chronic neck pain ≥ 3 mo.
• Have caused by neck posture, neck mvt. or
m palpationm. palpation
• Have the NDI scores ≥ 10/100
Control group
• Have no history of neck pain ≥ 12 mo • Have no history of neck pain ≥ 12 mo.
• Have no history of any headache ≥ 12 mo.
ParticipantsParticipants
Exclusion Criteria
Neck pain and control group
Exclusion Criteria
• Have back/shoulder pain
• Have history of head and neck injuryHave history of head and neck injury
• Have musculoskeletal disorders
H l i l di d• Have neurological disorders
• Have specific training of scapular m.
Ethical ClearanceEthical Clearance
Human Experimental Committee of Faculty of
Associated Medical Sciences, Chiang Mai University
MeasurementsMeasurements
1. Questionnaires
• Screening questionnaire
• General questionnaire
• Visual analog scale (VAS)Visual analog scale (VAS)
• Neck disability index-Thai version (NDI-TH)
2. Ultrasound imaging (USI)
Procedure
Subject recruitment
Procedure
Screening for inclusion and exclusion criteria
Chronic unilateral neck
( )
Healthy control group
( )pain group (n =20) (n = 20)
Questionnaires: general questionnaire, VAS, NDI-TH version
Assessment of LT thickness using USI
Measurement of the LT m. thickness using Image J program
Procedure
Subject recruitment
Procedure
Screening for inclusion and exclusion criteria
Chronic unilateral neck
( )
Healthy control group
( )pain group (n =20) (n = 20)
Questionnaires: general questionnaire, VAS, NDI-TH version
Assessment of LT thickness using USI
Measurement of the LT m. thickness using Image J program
Ultrasound imaging (USI)Ultrasound imaging (USI)
• A real time ultrasound scanner • A real-time ultrasound scanner
(Toshiba Famio 8, Tokyo, Japan)
• 12-MHz linear transducer
• Imaged at T8 SP• Imaged at T8 SP
Ultrasound MeasuresUltrasound Measures
- Placed centrally & moved laterally over T8 SP
- Moved laterally maintained lateral edge of T8 SP in view
- Randomly measured twice both sidesRandomly measured twice both sides
(O’Sullivan et al.,2009)
Thickness MeasurementThickness Measurement
(O’Sullivan et al.,2009)
VariablesVariables
• Independent variables
- Pain side (ipsilateral and contralateral side)
- Subjects group (neck pain and control)
- Lower trapezius m. thickness
• Dependent variables
- The average thickness of lower trapezius m.
- NDI and VAS Scores
Statistical AnalysisStatistical Analysis
• Descriptive statistic
- To analyze demographic data
• Independent t-test
- To compare LT thickness b/w participants groupTo compare LT thickness b/w participants group
• Dependent t-test
i / i- To compare LT thickness b/w sides
• Pearson correlation
- VAS scores and LT m. thickness
- NDI-TH scores and LT m. thickness
Data Collection LocationData Collection Location
Radiological clinic, AMS clinical service center, Faculty
f A i t d M di l S i Chi M i U i itof Associated Medical Sciences, Chiang Mai University
RESULTSRESULTSRESULTSRESULTS
ResultsResults
VariablesNeck pain
( 20)
Controls
( 20)p-value
Demographic data for participants
(n = 20) (n = 20)p
Age (yrs) 25.65 ± 3.69 25.80 ± 4.55 0.91
BMI (k / 2) 20 46 2 94 21 68 2 35 0 16BMI (kg/m2) 20.46 ± 2.94 21.68 ± 2.35 0.16
NDI (0-100) 18.70 ± 7.03 2.40 ± 2.30 < 0.01
VAS (0-100) 47.65 ± 19.06 - -
History (yrs) 1.36 ± 0.88 - -
( )Rt-hand dominance (n) 20 20 -
Rt-sides symptoms (n) 20 - -
ResultsResults
Thi k ( )
Thickness of lower trapezius muscle
Thickness (mm)
Right Left
Neck pain (n = 20) 2.76 ± 0.66 2.78 ± 0.67
C t l ( 20) bControls (n = 20) 3.28 ± 0.75a
2.93 ± 0.84b
a p < 0.05 compared between groups
b p < 0.05 compared between sides p p
ResultsResults
Correlations of LT m. and neck pain characteristics
Thickness (mm) p-value
NDI (0 100) 0 05 0 85NDI (0-100) 0.05 0.85
VAS (0-100) - 0.01 0.68 ( )
p < 0 05p < 0.05
DISCUSSIONDISCUSSIONDISCUSSIONDISCUSSION
Lower trapezius m. thicknessLower trapezius m. thickness
The control group
Participants with no neck pain showed asymmetry of
The control group
the LT m. thickness
• Dominant (Rt.) > Non-dominant (Lt.) arm side
Thi i t d b EMG ti it ’ t dThis is supported by EMG activity’s study
• % IEMG of LT m. in healthy controls
- Dominant > Non-dominant arm side (Yoshizaki et al., 2009)
Lower trapezius m. thicknessLower trapezius m. thickness
The control group The control group
Participants with no neck pain showed asymmetry of
the LT m. thickness
• Dominant (Rt.) > Non-dominant (Lt.) arm side
Do not support other study investigated in core stability mDo not support other study investigated in core stability m.
• Symmetry of TrA m. thickness in pts. with LBP
- Arm dominance not affect on core stability m.
(Springer et al., 2006)
Lower trapezius m. thicknessLower trapezius m. thickness
The neck pain group
The results showed symmetry of the LT m. thickness
The neck pain group
Painful side = Dominant side Rt handedPainful side = Dominant side Rt. handed
Thickness on Painful side
Painful = Non-painful side
Consequence
Painful Non painful side
Lower trapezius m. thicknessLower trapezius m. thickness
The neck pain group
The results showed symmetry of the LT m. thickness
The neck pain group
This is supported by USI’s study
• Similarly resting thickness of trapezius m. b/w painful and
non-painful shoulder side (O’Sullivan et al., 2012)
This is inconsistent with a previous study
• Asymmetry of neck m. in pts. with unilateral posterior neck pain
- Ipsilateral < contralateral side (Rezasoltani et al., 2010)p ( , )
Lower trapezius m. thicknessLower trapezius m. thickness
Comparison between groups
We demonstrated smaller thickness of LT m. on ipsilateral (Rt.)
Comparison between groups
in pts. with neck pain compared with control group
This supports that pain is associated with m. atrophy
• CSA of Longus colli m. of chronic bilateral neck pain
- < control group (Rezasoltani et al 2010)< control group (Rezasoltani et al., 2010)
Dysfunction of lower trapezius m.Dysfunction of lower trapezius m.
Decreased thickness of LT m. at ipsilateral side to pain in pts.
with chronic unilateral neck pain may be explained by
1. Pain adaptation theory
2 Poor control of scapular m2. Poor control of scapular m.
3. Muscle disuse /inactivity
Dysfunction of lower trapezius m.Dysfunction of lower trapezius m.
Decreased thickness of LT m. at ipsilateral side to pain in pts.
with chronic unilateral neck pain may be explained by
1. Pain adaptation theory
2 Poor control of scapular m2. Poor control of scapular m.
3. Muscle disuse /inactivity
1. Pain adaptation1. Pain adaptation
Pain adaptation (Old theory) (Lund et al., 1991)
Movement velocity and amplitude are affected by pain
• Inhibition of agonist m
p ( y) ( , )
• Inhibition of agonist m.
• Facilitation of antagonist m.
Motor adaptation to pain (New theory) (Hodges et al., 2011)
Redistribution of activity within & b/w m. and changes in
mechanical behavior
The LT m. function may be inhibited by pain in the neck
• EMG activity MT & LT (Wegner et al., 2010)
1. Pain adaptation1. Pain adaptation
Pain adaptation (Old theory) (Lund et al., 1991)
Movement velocity and amplitude are affected by pain
• Inhibition of agonist m
p ( y) ( , )
• Inhibition of agonist m.
• Facilitation of antagonist m.
Motor adaptation to pain (New theory) (Hodges et al., 2011)
Redistribution of activity within & b/w m. and changes in
mechanical behavior
The LT m. function may be inhibited by pain in the neck
• EMG activity MT & LT (Wegner et al., 2010)
Old theory (Lund et al., 1991)
Pain Neck extensor m. Neck extensor m. Agonist m.
SCMSCM Antagonist m.
Head forward
UT Upper cross syndromeUT Upper cross syndrome
Levator scapulae
LTLT LT thickness
Pain/injury
New theory (Hodges et al., 2011)
Redistribution of activity
Poor scapular control
Redistribution of activity
within & b/w m.Change at multiple
level of nervous system
Changes in mechanical
behaviorbe a o
Stiffness Modified direction/load distribution
Short time benefit Long term
Stiffness Modified direction/load distribution
Short time benefit Long term
P t ti f Load
Protection of
painful partMovement
Variability
2. Poor control of scapular m.2. Poor control of scapular m.
Imbalance of scapular m
• EMG activity UT & LT on Sh pain side
Imbalance of scapular m.
EMG activity UT & LT on Sh. pain side (Cools et al., 2012)
• EMG activity MT& LT in neck pain group (Wegner et al 2010)(Wegner et al., 2010)
Poor scapular control
load/compression forces in the Cx. Spine (Janda, 1994)
3. Muscle disuse (inactivity) 3. Muscle disuse (inactivity)
-Neck pain is often aggravated by overhead arm mvt. (Constand et al., 2013) p gg y ( , )
-Pts. with neck pain have fear of mvt. (Saavedra et al., 2012)
-Pts. with neck pain have MVC of neck m. and there were
moderate correlations b/w MVC and FABQ and NDI (Lindstroem et al 2012)moderate correlations b/w MVC and FABQ, and NDI (Lindstroem et al., 2012)
-Motor activity change associated with neck pain, resulting altered Motor activity change associated with neck pain, resulting altered
m. size (Sterling et al., 2001)
Arm activity may induce
LT m. function and thickness
CorrelationCorrelation
We found no relationships b/w thickness of LT m. and NDI
and VAS scores in pts. with chronic unilateral neck pain
This may suggest that thickness of LT m. wasn’t dependent
on severity and intensity of painon severity and intensity of pain
Do not support in a previous studyDo not support in a previous study
• Negative relationships b/w CSA of Loungus colli m. and
- NDI scores (r = - 0.45, p = 0.05)
‐ VAS scores (r = - 0.49, p = 0.03) (Javanshir et al., 2011) ( , p ) ( , )
CorrelationCorrelation
No correlation may be due to level of pain intensity and No correlation may be due to level of pain intensity and
sample size
Our study Javanshir’ study
/ /NDI scores 9/50 33/50
VAS scores 4.8/10 5.1/10
Mild Severe
Sample size of 50 is required to detect correlation coefficients
(Roscoe 1975)(Roscoe, 1975)
Limitations of The StudyLimitations of The Study
• Difficult to moved probe in abnormal scapular position
• Mild severity of VAS and NDI scores in neck pain group
• Too small sample size to detected (n = 20) p ( )
Clinical ImplicationsClinical Implications
• LT m thickness assessment using USI can be used LT m. thickness assessment using USI can be used
to detect dysfunction
• Symmetry in LT thickness is not an indicator of
h lth t lhealthy controls
• Hand dominance and side of pain should be
considered in LT thickness investigating g g
Future Direction ResearchFuture Direction Research
• To identify size of LT m. during contraction
• To determine correlations of thickness of LT. and EMG
activity, and forceactivity, and force
• T i LT thi k d f ti i l l ti• To examine LT thickness dysfunction in a larger population
• To investigate effectiveness of specific exs. program of LT
m. in pts. with neck pain
ConclusionConclusion
• Thickness of LT m. on painful side in pts. with chronic
unilateral neck pain smaller than control group
• Thickness of LT m b/w painful and non-painful sides • Thickness of LT m. b/w painful and non-painful sides
was similar in pts. with chronic unilateral neck pain
• No relationships b/w LT m. and NDI, and VAS scores
Journal publication Journal publication
• Intra-and inter-rater reliability of ultrasound imaging of the y g g
lower trapezius muscle thickness was published in
J Med Tech Phys Ther. 2014;26(2):180-8 y ( )
• Intra-rater reliability
- ICC(3 1) = 0 86-0 89 (p < 0 01)ICC(3, 1) 0.86 0.89 (p < 0.01)
• Inter-rater reliability
ICC = 0 90 0 91 (p < 0 01)- ICC(2, 1) = 0.90-0.91 (p < 0.01)
AcknowledgementsAcknowledgements
Assoc. Prof. Dr. Rungthip Puntumetakul
Faculty of Associated Medical SciencesFaculty of Associated Medical Sciences
Department of Physical Therapy
Kh K U i itKhon Kaen University
Asst. Prof. Dr. Sureeporn Uthaikhup
Asst. Prof. Dr. Patraporn Sitilertpisan
THANK YOUTHANK YOUTHANK YOUTHANK YOU
Definition of neck painDefinition of neck pain
• Anatomical location
• Severity of symptoms• Severity of symptoms
• Duration of symptoms
• Etiology of symptoms
(Misailidou et al., 2010)
Anatomical locationAnatomical location
“Pain located in the anatomical region of the neck with or
without radiation to head, trunk and upper limbs” , pp
(Guzman et al., 2009)
Severity of symptomsSeverity of symptoms
Grade Description
I N k i ith i f j th l d littl I Neck pain with no signs of major pathology and no or little
interference with activities of daily living
II N k i ith i f j th l b t i t f II Neck pain with no signs of major pathology, but interference
with activities of daily living
III N k i ith l i i t ( di l th )III Neck pain with neurologic signs or symptoms (radiculopathy)
IV Neck pain with signs of major structural pathology
(Guzman et al., 2008)
Duration of symptomsDuration of symptoms
• < 7 DaysAcute neck pain • < 7 DaysAcute neck pain
• ≥ 7 Days, < 3 Months Sub-acute neck pain
• ≥ 3 MonthsChronic neck pain
(International Association for the Study of Pain 2004)(International Association for the Study of Pain, 2004)
Etiology of symptomsEtiology of symptoms
Whi l h i t d di d (WAD)• Whiplash-associated disorders (WAD)
• Occupational neck pain
• Sports-related neck pain
• Non specific neck pain• Non-specific neck pain
(S it t l 1995; B t l 2006; (Spitzer et al.,1995; Bongers et al., 2006;
Dorshimer & Kelly, 2005; Borghouts et al., 1998)
However, it has been argued that causes of common
neck pain are unknown “idiopathic neck pain” (Bongers et al 2006)neck pain are unknown idiopathic neck pain (Bongers et al., 2006)
Prevalence of neck painPrevalence of neck pain
• Overall prevalence = 23.1% in general population
- Female = 27.2%
- Male = 17.4%
• Women experience more pain than men
• Pain increases with age g
- Peak in middle-age groups
(Hoy et al., 2010)
Factors associated with USI
• Transducer selection
Factors associated with USI
– Modes; B-mode, M-mode
– Transducers; curvilinear linear Transducers; curvilinear, linear
• Measurement error
Angle of transducer
Linear Curvilinear
– Angle of transducer
– pressure of transducer
– Placement of transducer
– Experience of assessor (≤ 16 hrs)
• Factors associated with individuals
– Body composition (fat, water)
– Body position
Risk factors of neck pain (Force task)Risk factors of neck pain (Force task)
• Non-modifiable factors
- Ageg
- Gender
Genetic- Genetic
• Modifiable factors
- Psychological healthy g
- Smoking
Exposure to tobacco- Exposure to tobacco(Hogg-Johnson et al., 2009)
Visual Analog Scale (VAS)Visual Analog Scale (VAS)
VAS is commonly used to evaluate pain perception
It consists of a 100-mm horizontal line
No pain Worse pain
i i blimaginable
Neck Disability Index (NDI)
A lf ti f k di bilit ti i
Neck Disability Index (NDI)
A self-reporting of neck disability questionnaire
It includes 10 items:
1 Pain intensity 6 Concentration1. Pain intensity
2. Personal care
6. Concentration
7. Work
3. Lifting
4 R di
8. Driving
9 Sl i4. Reading
5. Headaches
9. Sleeping
10. Recreation
(Vernon & Mior, 1991)
Neck Disability Index (NDI)
E h it i d t f 5 ith i t t l f 50
Neck Disability Index (NDI)
Each item is scored out of 5 with a maximum total score of 50
• Scoring & interpretation• Scoring & interpretation
None = 0 - 4 or 0 - 8%
Mild = 5 - 14 or 10 – 28%
Moderate = 15 – 24 or 30 - 48%
Severe = 25 - 34 or 50 – 68% %
Complete = > 34 or > 68%
(Vernon & Mior, 1991)
Upper Cross SyndromeUpper Cross Syndrome
This pattern of imbalance creates joint dysfunctionThis pattern of imbalance creates joint dysfunction
‐ Forward head posture‐ Cx. Lordosis‐ Tx. Kyphosis‐ Elevated and protracted,
Rot+Abd sh.‐ Wing scapular
(Janda 1988) (Janda 1988)
Upper Cross SyndromeUpper Cross Syndrome
(Janda 1988)
T t t & tT t t & tTreatments & managements Treatments & managements
‐ Transcutaneous
Electrical NerveElectrical Nerve
Stimulation (TENS)
Ul d‐ Ultrasound
‐ Hot/cold pack
‐ Cervical traction
‐ Cervical spine
‐ Peripheral nervep
‐ Correct posture
‐ Stretching exercise
‐ Scapular exercise
‐ CCFT & extensor muscle
‐ Bed education
‐ Correct posture
‐ Stretching exercise
‐ Hand function