Turk J Phys Med Rehab 2016;62(2):107-115
DOI: 10.5606/tftrd.2016.84565
Copyright 2016 by Turkish Society of Physical Medicine and Rehabilitation - Available online at www.ftrdergisi.com
Original Article / zgn Aratrma
Efficacy of deep neck flexor exercise for neck pain:
a randomized controlled study
Boyun arsnda derin boyun fleksr egzersizinin etkinlii: randomize kontroll alma
Amr Almaz Abdel-aziem,1 Amira Hussin Draz2
1
2
Department of Biomechanics, Faculty of Physical Therapy, Cairo University, Giza, Egypt
Department of Basic Sciences, Faculty of Physical Therapy, Cairo University, Giza, Egypt
Received / Geli tarihi: December 2014 Accepted / Kabul tarihi: May 2015
ABSTRACT
Objectives: This study aims to investigate the efficacy of deep neck flexor exercises in the management of neck pain.
Patients and methods: Sixty patients with non-specific neck pain of at least six-week duration were randomized into one of three groups:
group 1 - physical therapy agents including transcutaneous electrical nerve stimulation, continuous ultrasound and infra-red irradiation;
group 2 - physical therapy agents + isometric, stretching, and scapulothoracic exercises; and group 3 - physical therapy agents + deep neck
flexor exercise. The patients were evaluated with a visual analog scale (VAS), Neck Disability Index (NDI), and the range of motion in the
three planes at baseline and after one month of treatment, and at three-month follow-up period.
Results: Compared to baseline, all groups showed a significant decrease in VAS scores at one month. However, this improvement was
achieved only in group 3 at three months indicating a significant difference among the groups (p<0.05). During the study, the improvement
in disability was significant in group 3, as assessed by the NDI and range of motion (p<0.05).
Conclusion: This study demonstrates the superiority of the deep neck flexor exercise, which offers several advantages in pain, disability, and
range of motion outcomes, compared to isometric, stretching, and scapulothoracic exercises in combination with physical therapy agents for
the management of neck pain.
Keywords: Neck muscle; neck pain; strengthening exercise; stretching exercise.
Ama: Bu almada boyun arsnn tedavisinde derin boyun fleksr egzersizlerinin etkinlii aratrld.
Hastalar ve yntemler: En az alt hafta sreyle nonspesifik boyun arl 60 hasta gruptan birine randomize edildi: grup 1 transktanz
elektriksel sinir stimlasyonu, srekli ultrason ve kzltesi n dahil fizik tedavi ilalar; grup 2 fizik tedavi ilalar + izometrik, esneme
ve skapulotorasik egzersizler ve grup 3 fizik tedavi ilalar + derin boyun fleksr egzersizi. Hastalar balangta ve tedaviden bir ay
sonra ve takip dneminin nc aynda grsel analog lei (GA), Boyun Engellilik ndeksi (BE) ve dzlemde hareket akl ile
deerlendirildi.
Bulgular: Balangca kyasla, tm gruplarda birinci ayda GA skorlarnda anlaml bir d izlendi. Ancak, bu iyileme, nc ayda
yalnzca grup 3te elde edildi; bu da gruplar arasnda anlaml bir farkllk olduunu gsteriyordu (p<0.05). alma srasnda engellilikte
grlen iyileme, BE ve hareket akl ile deerlendirildii zere, grup 3te anlaml dzeyde idi (p<0.05).
Sonu: Bu alma boyun ars tedavisinde fizik tedavi ile birlikte izometrik, esneme ve skapulotorasik egzersizlere kyasla, ar, engellilik
ve hareket akl sonular asndan birtakm avantajlar ile derin boyun fleksr egzersizinin stnln gstermektedir.
Anahtar szckler: Boyun kas; boyun ars; kuvvetlendirme egzersizi; esneme egzersizi.
Corresponding author / letiim adresi: Amr Almaz Abdel-aziem, MD. 7 Ahmed Elzaiat Street, Ben Elsaryat, EI-Dokki, Faculty of Physical Therapy, Cairo University,
12612 Giza, Egypt. e-mail / e-posta: [email protected]
Cite this article as:
Abdel-aziem AA, Draz AH. Efficacy of deep neck flexor exercise for neck pain: a randomized controlled study. Turk J Phys Med Rehab 2016;62:107-15.
108
The prevalence of neck pain was reported to range
from 22% to 30% of the population. It is considered
one of the most common pain problems.[1,2] It is
usually accompanied by a substantial negative effect
on daily life that results in extensive use of healthcare
resources.[2,3] It is important to understand which
structures are capable of producing pain and disability,
to improve patients functional status and quality of
life. Numerous studies have shown an association
between reduction in the strength and endurance
capacity of the cervical muscles and neck pain.[4,5]
There are specific muscles in the cervical spine when
weakened tend to cause neck pain; the most common
of these being the deep and anterior cervical flexors[4-6]
Patients with chronic, nonspecific neck pain have
decreased maximal isometric strength and isometric
endurance of the cervical muscles.[7,8]
The cervical segment is supported by the longus
colli muscle anteriorly and the semispinalis cervicis
and cervical multifidus muscles posteriorly.[9,10]
In particular, the longus colli muscle has a major
postural function in supporting the cervical lordosis.[10]
In addition, the craniocervical region is supported by
the longus capitis muscle anteriorly and the suboccipital
extensor, semispinalis, and splenius capitis muscles
posteriorly.[11]
Studies have identified impaired activation of the
deep cervical flexor muscles, the longus colli and
longus capitis, in people with neck pain.[12,13] Given
the role of the deep cervical flexor muscles in postural
support and the knowledge of impaired activation of
these muscles in people with neck pain, it is likely
that this patient population also would display deficits
in the postural endurance of these muscles. Indeed,
people with neck pain drift into a more forward head
position when distracted.[14]
Thus, exercise is one of the most frequently used
modalities in the rehabilitation of subjects with
neck pain to gain muscle strength, endurance, and
flexibility in order to restore injured tissues, and to
sustain normal life activities.[2] Exercise programs for
managing neck pain differ with regard to duration,
training frequency, intensity, and mode of exercise.
Previous studies have shown that isometric exercises
and strength training can have positive effects on
neck pain.[15,16] On the other hand, retraining the
deep cervical flexor muscles, which has been shown
to decrease neck pain symptoms and increase the
activation of the deep cervical flexor muscles during
performance of the clinical test of craniocervical
flexion,[17] may improve the ability to maintain an
Turk J Phys Med Rehab
upright posture of the cervical spine. In this study,
we aim to investigate whether deep neck flexor (DNF)
exercise is effective in the management of neck pain
when this intervention is added as a supplement to
physical therapy agents (PTA) or when it is compared
with isometric, stretching, and scapulothoracic
exercises.
PATIENTS AND METHODS
Sixty patients with neck pain with a duration
of at least six weeks were recruited into the study.
Neck pain was defined as non-specific neck pain
without specific, identifiable etiology (i.e. infection,
inflammatory disease), but which could be reproduced
by neck movement or provocation tests in the location
of the dorsal part of the neck in an area limited by
a horizontal line through the most inferior portion
of the occipital region and a horizontal line through
the spinous process of the first thoracic vertebra.[1]
Patients were excluded if they had a history of cervical
spine injury or surgery, if their neck pain was
secondary to other conditions (including neoplasm,
neurological diseases or vascular diseases), if they
had a radiculopathy presenting neurological deficit
or if they had infection or inflammatory arthritis in
the cervical spine, if they had received physiotherapy
within the six-months of the study or a poor general
health status that would interfere with the exercises
during the study. The patients were also excluded
if they had pain with any cause in or around the
scapula, shoulder, upper extremities and lumbar spine
that prevents stabilization of these structures. These
exclusion criteria were verified by examining medical
history, physical examination and by X-ray.[18] All
procedures were approved by the Research Ethical
Committee of the Faculty of Physical Therapy, Cairo
University, and conducted in accordance with the
Declaration of Helsinki. Written informed consent was
obtained from patients who participated in this study.
The study was a randomized, single-blind,
prospective study with a three-month follow-up period.
After baseline characteristics (weight, height, and age)
were recorded, the patients were assigned to one of
the three following treatment groups on the basis
of a computer-generated minimization method,[19]
taking into account subjects age, and degree of neck
pain as assessed by visual analog scale (VAS): group
1: PTA; group 2: PTA + isometric, stretching of
the cervical, shoulder, chest, and scapular muscles
and scapulothoracic exercises; and group 3: PTA +
DNF exercise. The demographic characteristics of the
subjects are shown in Table 1.
Efficacy of deep neck flexor exercise
109
Table 1. Demographic characteristics of subjects
Age (years)
Height (cm)
Weight (kg)
Group 1 (n=20)
Group 2 (n=20)
Group 3 (n=20)
MeanSD MeanSD MeanSD p
48.507.82
172.405.10
75.905.33
47.906.79
175.255.65
77.105.11
50.104.71
173.805.88
74.153.51
0.553
0.276
0.148
SD: Standard deviation.
Interventions
Physical therapy agents included a combination
of conventional transcutaneous electrical nerve
stimulation (TENS), continuous ultrasound and
infrared irradiation with the assistance of the same
physiotherapist for all groups during the study.
Following infrared irradiation for 20 min at a 40
cm distance for the neck region (R 125, 250 watt,
Philips; 126597: Australia). Transcutaneous electrical
nerve stimulation was administered at a frequency
of 80 Hz with 10-30 mA intensity for 30 minutes.
Four surface electrodes, 5x5 cm each, were placed
over the painful area in the neck region,[20] TENS
was delivered using Intelect Advanced (REF2773MS;
Chattanooga: Mexico). The intensity of TENS was
adjusted to produce a tingling sensation that was
approximately 2-3 times the patients sensory threshold.
The continuous ultrasound was used with 1.5 W/cm 2
intensity and at a frequency of 1 MHz over the neck
area for 10 minutes, using Metron Accusonic Plus
(Metron Medical, Australia Pty Ltd. Carrum Downs
Victoria Australia 3201).
Deep neck flexors exercise: The patients performed
deep neck flexor strengthening exercises as described
by Petersen,[21] without the use of a biofeedback unit.
The patient was supine, with the cervical spine in a
neutral position, and instructed to flatten the curve of
the neck by nodding the head. This position was held
for 10 seconds and repeated 10 times. The therapist
or patient monitors the sternocleidomastoid muscles
to ensure minimal to no activation of these muscles
during the deep neck flexor contraction (Figure 1).
exercises, the patients should stand against the wall
with the arms approximately shoulder width apart
(step 1), the patient performs a push-up with a plus
exercise by pushing away from the wall until the elbows
are fully extended and the scapulae are protracted as
far as possible (step 2) (Figure 2). For lower and middle
trapezius strengthening exercises, from prone position,
the patient should horizontally abduct the shoulder with
scapular depression, adduction and upward rotation.
This should be performed at approximately 120-135
abduction for lower trapezius muscle re-education
(Figure 3), and at approximately 90 abduction for
middle trapezius muscle re-education. The shoulder
should be externally rotated so the thumb points up
toward the ceiling and the scapula should not elevate
towards the head. The patient may place his head and
neck in any comfortable posture. If the patient is unable
to rotate the neck, he must put a pillow under the upper
chest and keep the neck in neutral position, with the
forehead resting on the patients opposite forearm or a
small towel roll. All exercises were conducted under the
guidance of the same physiotherapist.
At each visit during the study, the patients were
instructed to perform their exercises regularly. All
patients were instructed to perform the exercises at
home, twice daily. The duration of physical therapy
Isometric and stretching exercise: The session
included 5-6 minutes jogging and 10 minutes stretching
(the cervical, shoulder, chest, and scapular muscles) in
the standing position, and 15 minutes of isometric
exercises (cervical flexion, extension, rotation and
side-bending by resisting the forehead in the seated
position) for a total of 30 minutes.
Scapulothoracic exercises which include serratus
anterior and both middle and lower trapezius muscle
strengthening.[22] For serratus anterior strengthening
Figure 1. Deep neck flexors strengthening exercises.
Turk J Phys Med Rehab
110
Step 1
Step 2
Figure 2. Serratus anterior strengthening exercises.
intervention was four weeks (five days each week).
At the initial treatment visit, each patient was educated
on the importance of correct postural alignment of
the spine during sitting and standing activities. If the
patient changes his position often, this will keep stress
and strain from his neck and upper back.
discontinued seven days prior to the start of the study.
If the patient required additional analgesic medication
because of neck pain during the study, treatment with
simple analgesic (paracetamol, maximum of 500 to
1000 mg daily) was permitted.
Clinical assessments were made at baseline and at
months one and three. Pain was assessed using the
following parameters; a 10 cm VAS (the patients used
the VAS to make an assessment of their own pain, with
0 representing no pain, and 10 cm representing severe
pain).[23] The use of non-steroidal anti-inflammatory
drugs (NSAIDs) was not permitted during the study
period; any pre-treatment with NSAIDs had to be
Disability was assessed using the Neck Disability
Index (NDI).[24] At the same time, active range of
motion (ROM) of the cervical spine in three planes
was measured with universal goniometry (UG)
with a double-armed full-circle protractor made of
transparent plastic (Benchmark Medical, Inc. Malvern,
PA, USA) as a reliable method when the same therapist
takes the measurements[25] for all patients. The length
of the arms was 30 cm (12 inches) and the scale of the
protractor was marked in 1 increments.
Figure 3. Trapezius strengthening exercises.
The participants position and placement of
the UG were standardized. All subjects sat in a
standard metal-frame chair so that their thoracic
spine maintained contact with the chair's backrest
and their lumbosacral spine filled the gap between
the seat and the backrest. Their feet were positioned
flat on the floor and their arms rested freely at their
sides. As instructed by the examiner, each subject
performed three repetitions of neck active ROM
(warm-ups) in each direction within a designated
cardinal plane to increase compliance of the neck's
soft tissues.[25] All assessments were recorded by the
same blinded examiner.[18]
Assessment
Efficacy of deep neck flexor exercise
111
For measuring cervical flexion and extension,
the starting position for both cervical flexion and
extension was assumed after the examiner manually
adjusted the subject's neck so that the external
acoustic meatus-to-base of nares reference line was
parallel to the floor. The UG's axis was centered over
the external acoustic meatus; the fixed arm was held
vertical, while the movable arm was aligned with the
meatus-to-base of nares reference line as the subject
actively flexed and extended the neck.
For measuring cervical lateral f lexion, each
subject bent his or her head and cervical spine first
left and then right without elevating his or her
shoulder. The examiner aligned the fixed arm of the
UG parallel with a horizontal reference line between
the patient's sternal notch and acromion process; the
movable arm was aligned with the midline of the
patient's nose. The starting or neutral position was
with the arms of the UG perpendicular.
For measuring cervical rotation, each subject
rotated his or her head first left and then right. The
UG axis was centered on the top of the subject's head;
the fixed arm was aligned parallel to an imaginary
line between the subject's acromion processes, and the
movable arm was aligned with the subject's nose. The
examiner wrote down both start and end points of the
cervical active ROM for the three planes of motion.
The placement procedure for the UG for measuring
the ROM of the cervical spine in three planes has been
described by Youdas et al.[25]
Statistical analysis
Data was analyzed using a SPSS version 16.0
software (SPSS Inc., Chicago, IL, USA). Treatment
groups were compared by one-way analysis of variance
(ANOVA). Repeated ANOVA measurements were used
to evaluate the clinical assessment parameters over
the time of observation. Bonferroni test as a post hoc
test was used to determine the change between groups
when indicated. The level of significance for all tests
was set at 0.05.
RESULTS
Sixty patients were divided into three equal groups.
There was no significant difference between the groups
in terms of age, height, and weight (p=0.553, p=0.276,
p=0.148), respectively.
For VAS there was no difference between prevalues of the three groups (p=0.396). Compared with
baseline, a significant decrease of VAS score in all
groups after one-month of treatment, this decline was
maintained only in group 3 at three-months follow-up
(p=0.001). After one-month of treatment, the decrease
in VAS score of group 2 and 3 were significantly
lower than group 1 (p=0.001), without significant
differences between group 2 and 3 (p=0.191). However,
at three-months follow-up, the VAS score of group 2
and 3 were significantly lower than group 1 (p=0.001),
with the VAS score of group 3 was significantly lower
than group 2 (p=0.002).
For NDI there was no difference between prevalues of the three groups (p=0.957). Compared with
baseline, a significant decrease of NDI score in all
groups after one-month of treatment, this decline was
maintained only in group 3 at three-month follow-up
(p=0.001). After one-month of treatment the NDI score
of group 3 was significantly lower than group 1 and 2
(p=0.001, p=0.030), respectively, without significant
difference between group 1 and 2 (p=0.259). Moreover,
at three-month follow-up the NDI score of group 3
was significantly lower than group 1 and 2 (p=0.001),
without significant differences between group 1 and 2
(p=0.629), as shown in Table 2.
Table 3 shows the ROM measurements. For
sagittal and transverse ROM there was no significant
Table 2. The values of visual analog scale and neck disability index at baseline, one-month,
and three-month follow-up
Visual analog scale
At baseline
1 month
3 month
Neck disability index
At baseline
1 month
3 month
SD: Standard deviation.
Group 1 (n=20)
Group 2 (n=20)
Group 3 (n=20)
MeanSD MeanSD MeanSD p
6.851.09
5.301.22
5.651.57
6.401.10
3.851.09
4.101.21
6.700.98
3.351.27
2.751.02
0.396
0.001
0.001
19.205.20
15.905.62
18.105.23
19.456.19
13.857.17
18.906.04
19.704.43
9.853.75
9.454.16
0.957
0.005
0.001
Turk J Phys Med Rehab
112
Table 3. The patients range of motion in three planes at baseline, one-month, and threemonth follow-up
Group 1 (n=20)
Sagittal plane
At baseline
1 month
3 month
Frontal plane
At baseline
1 month
3 month
Transverse plane
At baseline
1 month
3 month
Group 2 (n=20)
Group 3 (n=20)
MeanSD MeanSD MeanSD p
94.7512.88
102.1513.93
100.8510.68
98.510.75
114.909.30
113.358.98
93.812.05
112.3511.36
114.4011.28
0.425
0.001
0.001
59.2010.42
64.408.64
62.459.43
57.658.69
72.6010.19
69.658.58
62.1010.45
70.758.78
75.608.83
0.359
0.018
0.001
102.6511.16
115.1515.63
117.214.94
103.9513.17
132.8011.27
127.4511.27
104.509.44
131.611.04
134.5511.22
0.870
0.001
0.001
SD: Standard deviation.
difference between pre-values of the three groups
(p=0.425, p=0.870), respectively. There was significant
increase in ROM after one-month of treatment and at
three-month follow-up for all groups (p=0.001). After
one-month of treatment, and at three-month follow-up
the improvement of group 2 and 3 were significantly
higher than group 1 (p=0.001), without significant
difference between group 2 and 3 (p=0.616, p=0.577,
p=0.768, and p=0.080), respectively.
For the ROM in the frontal plane, there was no
significant difference between pre values of the three
groups (p=0.359). There were significant improvement
after one-month of treatment in all groups, this
improvement was maintained only in group 3 at
three-month follow-up (p=0.001). After one-month
of treatment, the improvement of group 2 and 3 were
significantly higher than group 1 (p=0.018), without
significant differences between group 2 and 3 (p=0.529).
However, at three-month follow-up, the improvement
of group 2 and 3 were significantly higher than
group 1 (p=0.001), with the improvement of group 3
was significantly higher than group 2 (p=0.040).
with other groups, the improvement in disability
assessment parameter in the DCF exercise group was
also indicative of the effectiveness of DCF exercise in
the management of neck pain.
Lluch et al.[26] showed the effectiveness of DCF
exercise in improving neck pain and disability in
patients with chronic neck pain. Moreover, this
patient with chronic neck pain due to prolonged
immobilization responded positively to DCF training,
resulting in an increase in cervical spine range
of motion and a reduction of dizziness, pain, and
limitations in activities.[27]
DISCUSSION
Recently, Falla et al.[28] explained the reasons why
DCF exercise is effective in improving neck pain and
function, they found that specific training of the deep
cervical flexor muscles in women with chronic neck
pain reduces pain and improves the activation of these
muscles, especially in those with the least activation
of their deep cervical flexors before training. This
finding suggests that the selection of exercise based
on a precise assessment of the patients' neuromuscular
control and targeted exercise interventions based on
this assessment are likely to be the most beneficial to
patients with neck pain.
This study demonstrated the efficacy of DCF
exercise in the management of neck pain when
this intervention is used as a supplement to PTA
or is compared with isometric, stretching, and
scapulothoracic exercises. The results showed that,
while pain significantly decreased in all treatment
groups after one-month of treatment, this improvement
was maintained throughout the follow-up after threemonths only in those patients treated with DCF
exercise in addition to PTA. Moreover, compared
Sihawong et al.[29] evaluated the effects of an
exercise program focusing on muscle stretching and
endurance training on the 12-month incidence rate
of neck pain in office workers. They found that
there was no significant difference in pain intensity,
disability and quality of life and health status between
the intervention and control groups. This was against
the findings of the current study. However, exercise
programs that aim to enhance motor control of the
cervical spine improve the specificity of neck muscle
Efficacy of deep neck flexor exercise
activity and reduce pain and disability in patients with
neck pain.[30]
Moreover, Dusunceli et al.[18] found that PTA
combined with isometric and stretching exercises
is more effective than PTA alone in reducing pain,
improving neck mobility and increasing neck range
of motion. However, their study demonstrates the
superiority of the neck stabilization exercises, with
some advantages in the pain and disability outcomes,
compared with isometric and stretching exercises
in combination with physical therapy agents for the
management of neck pain.
The DCF exercises directly activate the deep
cervical flexor musculature,[31,32] which have a relatively
high density of muscle spindles.[9] Improved cervical
kinesthetic sense following DCF training[33] also may
explain the higher improvement of neck stability in the
third group. Moreover, the forward head position of
subjects with chronic neck pain[14] has been associated
with compressive loading of the cervical tissues[34,35]
The improved cervical posture created through DCF
exercise, may have an additional long-term benefit of
reducing recurrent episodes of neck pain.[36]
Jull et al.[37] studied the coordination between the
deep and superficial cervical flexor muscles in a low
load cranio-cervical flexion (C-CF) task. The results
revealed increased electromyographic amplitude
of the large superficial sternocleidomastoid, and
anterior scalene muscles in patients with neck pain.
This was associated with reduced activation of the
DCF muscles, and reduced range of C-CF motion
to perform the task.[13] So, Jull et al.[38] compared the
physiological effects of low load C-CF exercise and
neck flexor strengthening to evaluate effects on deep
and superficial cervical muscle activity during the
C-CF test. Their study showed that activation of the
DCF was increased at each of the five levels of the
C-CF test and activity of the sternocleidomastoid
and anterior scalene muscles were reduced following
C-CF training. This supports the results of the
current study.
The DCF exercises combined with PTA had
advantages over the isometric, stretching, and
scapulothoracic exercises combined with PTA or PTA
alone, for the results of the NDI in the three-month
follow-up period, suggesting that DCF exercises may
be more effective in improving neck disability. Since
disability is usually accompanied by a substantial
effect on daily life, resulting in an extensive use
of healthcare resources,[2,3] to improve the patients
disability or enable them to return to normal activity
113
is the main aim of any treatment approach. With
regard to the results of the present study, DCF exercises
combined with PTA may be a better approach for
meeting this aim.
The results of the active ROM of the cervical
spine showed that only the DCF exercises combined
with PTA group achieved a significant increase in
the three plane measurements during the follow-up
especially the frontal plane ROM. On the other hand,
the exercises combined with PTA group showed a
significant increase in the sagittal plane and transverse
plane ROMs at three-month follow-up, while no
significant improvement was observed in PTA alone
group at three-month follow-up. Even though some
studies have found no correlation between ROM and
symptomatic improvement in any of the treatment
groups.[6,39]
Moreover, Howell[40] deducted the need for further
research to explore the association between the NDI,
neck pain and cervical ranges of motion. The current
study proved that the reduction of neck pain, and
improvement of neck stability was associated with
improvement in ROM in the three planes of movement
especially for the DCF exercises combined with PTA
group.
There are some limitations of this study. First,
the small number of cases recruited. Second, because
there was no group consisting of DCF exercise alone,
we cannot conclude whether DCF exercise without
PTA has similar effects on improvement in neck
pain. Although there were significant differences
between the groups treated with DCF exercise +
PTA, exercise + PTA or PTA alone in our study,
further controlled studies of DCF exercise without
PTA on large populations are required in order to
establish its definitive effectiveness. Moreover, future
work will be needed to include electromyography
studies to record the effect of additional DCF exercise
training on muscular activities in those patients
with neck pain. Third, the gender in this study was
limited to males only. Thus, the appropriateness of
generalizing the results is confined to this specific
population. Fourth, the lack of a strictly recorded,
dose-specific home-exercise program maintained
during the course of treatment. Lastly, the effect
of the rehabilitation program on the participants
psychological parameters such as quality of life was
not examined.
In conclusion, this study shows that a combination
treatment of DCF exercise + PTA is the most effective
Turk J Phys Med Rehab
114
intervention for the management of neck pain,
with some advantages in pain, disability, and ROM
over the combination of isometric, stretching, and
scapulothoracic exercises + PTA, or PTA alone.
Acknowledgement
The authors gratefully acknowledge Faris Al Thobaiti,
student of physical therapy, for drawing the exercises figures.
Declaration of conflicting interests
The authors declared no conflicts of interest with respect
to the authorship and/or publication of this article.
Funding
The authors received no financial support for the research
and/or authorship of this article.
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