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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