Clinical Scenario
Neck pain affects both civilian and military personnel, with a 1-year prevalence estimated at 26% to 37% and up to 62%, respectively.1 The significantly higher incidence rate in military personnel has brought to light a need for effective treatment and mitigating protocols. This is especially true for military trades like pilots and aircrew, who are at a significantly higher risk of experiencing chronic neck pain.1,2 The financial burden of training an individual pilot is approximately $15.2 million, and the inability to deploy poses an even greater cost to operational effectiveness.2 Determining treatment and mitigation protocols to reduce neck pain is critical for the retention of these personnel. By identifying exercise programs that yield significant improvements to neck pain severity in other populations, strategies to support military personnel can be developed and trialed.
While traditional treatments include deep neck flexor stabilizing exercises, manual therapy, electrical therapy, and other nonsurgical interventions, scapular orientation and motion is getting an increasing amount of attention to reduce the symptoms and disability associated with neck pain.3–5 This shift in treatment is likely due to increasing evidence connecting strategies targeting scapular dyskinesis and alignment impairments with decreases in neck and shoulder pain symptoms.3,4,6
The most commonly administered measurement of neck pain disability is the Neck Disability Index (NDI).7 The NDI consists of 10 questions assessing functional activities, symptoms, and concentration, and it contains good content validity in patients with chronic, nontraumatic neck pain.7 The Visual Analogue Scale (VAS) is a 10-cm line with “No Pain” beside the 0 and “Most intense pain imaginable” beside the 10, where the individual points to where their pain level is.8,9 The Numerical Pain Rating Scale (NRS) is similar to the VAS, but the individual uses a NRS to measure their pain.10 With virtual interventions and situations that do not allow for in-person access to qualified therapists and applied manual therapy, methods that can be coached at a distance could be of value. The purpose of this critically appraised topic (CAT) is to explore the effectiveness of exercise interventions targeting the scapular kinematic NDI, VAS, and NRS scores for neck pain.
Focused Clinical Question
What is the effectiveness of including exercise programs targeting scapular kinematics and stability to decrease neck pain?
Summary of Search, “Best” Evidence Appraised, and Key Findings
- •The literature was searched to identify peer-reviewed articles that investigated the effectiveness of exercise programs targeting scapular kinematics and control in individuals with chronic neck pain.
- •Of the 74 identified articles, 58 were excluded based on the title and abstract, 9 were excluded as article was not available in English, 2 were excluded based on evidence quality, and 2 were excluded as manual therapy including soft tissue mobilization was included in the intervention. Of the included articles, 2 were randomized control trials and 1 was a pre–post test control design.
- •Exercise programs targeting the scapular motion and stabilization of 3 training sessions for 4 to 6 weeks decreased neck pain severity.
- •Exercise programs include a “learning” phase where participants are coached in some capacity, and progressions were individualized rather than based on a predetermined timeline.
Evidence Quality Assessment
The studies included were assessed with the Oxford Centre for Evidence-Based Medicine levels of evidence (2009) and evaluated using PEDro (1999).
Clinical Bottom Line
Based on the available literature, there are good to excellent levels of evidence to support the inclusion of exercise programs targeting scapular kinematics and stability to decrease pain in individuals with chronic neck pain.11–13 The current evidence included individuals with chronic neck pain for a minimum of 6 weeks with and without scapular dyskinesis pain.11–13 All protocols in the studies reviewed for this article included 3 sessions per week, with a duration of 411 and 612,13 weeks. All exercise programs included a “learning” or coaching phase to ensure that the participants were performing exercises and movements as intended by the therapist and researchers and that progressions were individualized rather than based on timeline-determined pain.11–13 Further research is needed to identify specific guidelines, limitations, and applications for the inclusion of scapular-focused exercise interventions included for neck pain reduction.
Strength of Recommendation
Based on the Oxford Centre for Evidence-Based Medicine Scale, level 1b and 2b evidence exists.14
Search Strategy
A database search was conducted in July 2020 to include peer-reviewed publications dating to January 2016. The search terms used were
- •P – Individuals with neck pain
- •I – Exercise program targeting scapular kinematics and/or stability
- •C – N/A
- •O – Neck pain (NDI, VAS, and NRS)
The Sources Searched
- •EBSCOhost
- •PubMed
- •Human Kinetics Journals
- •Omni
- •Google Scholar
Inclusion Criteria
- •Studies classified as level 2 evidence or higher on the Oxford Centre for Evidence-Based Medicine Scale14
- •PEDro scale rating “fair” (4–5) or above; PEDro is applied for randomized control trials only15
- •Studies that identify exercise programs that target scapular motion or kinematics focus as treatment
- •Studies that include VAS, NRS, and/or NDI as an outcome measure
Exclusion Criteria
- •Studies that involved children or older adults (aged 60 y and older)
- •Studies using exercise in combination with other therapeutic treatments (massage therapy, palpation, acupuncture, etc)
- •Studies involving surgical intervention
- •Articles published prior to January 2016
- •The Oxford 2011 Levels of Evidence, level 3 or lower14
- •PEDro score of “poor” (0–4); PEDro is applied for randomized control trials only15
Results of Search
The search of the literature returned 74 possible studies for inclusion. Three studies met the inclusion criteria (Table 1). The studies included were identified as best evidence and selected for inclusion in this CAT.
Summary of Study Designs of Articles Retrieved
| Level of evidence (Oxford Centre for Evidence-Based Medicine)14 | Study design/methodology of articles retrieved | Number located | Author |
|---|---|---|---|
| Level 1b | Single-blind randomized control study | 2 | Derakhshani et al12 Derakhshani et al13 |
| Level 2b | Pre–post test control design | 1 | Ashwini et al11 |
Best Evidence
As described in Table 2, the following studies were identified as the “best” evidence and selected for inclusion in the CAT. These studies were selected as they adhered to inclusion/exclusion requirements.
Characteristics of Included Studies
| Author(s) | Ashwini et al11 | Derakhshani et al12 | Derakhshani et al13 |
|---|---|---|---|
| Study design | Pre–post test control design | RCT | RCT |
| N, males:females | 27, 11:16 | 42, 27:15 | 140, 140:0 |
| Age range, average age | 18–50 y, 31.26 (5.77) | 20–26 y, 22.64 (1.69) | 21–27 y, 23.41 (1.88) |
| Intervention frequency, duration | 3 sessions/wk, 4 wk | 3 sessions/wk, 6 wk | 3 sessions/wk, 6 wk |
| Intervention group exercises | Week 1: (1) Scapula position training with tactile and verbal cues Weeks 1 and 2: (1) Prone extension (2) External rotation in the side-lying position (3) Forward flexion in the side-lying position (4) Horizontal abduction with external rotation in the prone position Weeks 3 and 4 (1) Individualized stretching | Group 1: SUREE with visual feedback Group 2: SUREE without visual feedback | Group 1: (1) SUREE (2) Shrug exercise Group 2: (1) SUREE (2) Shrug exercise (3) PCSPT (4) MSDW |
| Control group exercises | N/A | (1) At-home exercises based on postural correction during daily activities (2) Lectures informing on activities promoting general health | (1) Chin-talk (2) Push-up (3) Shoulder shrug |
| Main findings within group | NRS: Significant improvement of 4.81 (1.07) (P < .001) NDI: Significant improvement of 24.47% (8.46) (P < .001) | VAS: Group 1: Significant improvements by 2.35 (0.84) (P < .001) Group 2: Significant improvements by 2.35 (0.74) (P < .001) Control group: No significant change (0.035 [0.74], P = .10) | VAS: Group 1: Significant improvements (1.75 [0.86], P = .000) Group 2: Significant improvements (2.50 [1.16], P = .000) Control group: No significant changes (0.16 [0.57], P = .339) |
| Main findings between group | N/A | No significance between group 1 and group 2 (P > .99) Significant differences between control and both intervention groups (P < .001) | No significance between intervention group 1 and group 2 (0.903, P = .019) Significant differences favoring intervention group 1 (1.277, P = .002) and group 2 (2.180, P = .001) against the control group |
| Level of evidence14 | 2b | 1b | 1b |
| Validity score | Fair16 | PEDro 6/1015 | PEDro 5/1015 |
| Conclusion | 4 wk of scapular stabilizing exercise shows significant improvement to NDI and NRS scores | 6 wk of SUREE with and without visual feedback significantly decrease neck pain. No significant differences if exercises performed with or without visual feedback | 6 wk of SUREE and shrug exercise program, with and without passive interventions, can significantly decrease neck pain intensity, EMG, and scapular kinematics Inclusion of passive scapular correction interventions superior compared with SUREE and shrug exercises alone |
Abbreviations: EMG, electromyography; MSDW, mobilization of scapula during wall slide exercise, standing in front of a wall with shoulders and elbows flexed at 90°, participants were instructed to slide upward while pushing forearms into wall. Investigator brought scapula to more abduction, upward rotation, and elevation, position was held for 10 s before returning to starting position; NDI, Neck Disability Index; NRS, Numeric Pain Rating Scale; PCSPT, participant sat with hands supported to allow the elevation and abduction of the scapula taken to elevation and abduction with hands supported; RCT, randomized control trials; SUREE, Scapular Upward Rotation and Elevation Exercise program, including the abduction with lateral rotation wall slide, medial/lateral rotation in adduction, active, and passive elevation, and active assisted elevation; VAS, Visual Analogue Scale.
Summary of Best Evidence
The characteristics of the included studies are described in Table 2.
Implications for Practice, Education, and Future Research
The results of the 3 studies included in the CAT indicate that exercise programs targeting scapular kinematics and stability are effective at decreasing neck pain. While specific exercise and movement prescription varied between studies, each intervention protocol included a “coaching” phase where participants learned scapular placement and movement control.
All included studies-based movement and exercise progressions on individual progress, not predetermined timelines, and occurred at a frequency of 3 sessions per week for 411 and 6 weeks.12,13 Coaching and feedback included performing exercises in front of a mirror for visual feedback,12 tactile cues from a physical therapist,11–13 and verbal cues from a physical therapist.11–13 Seemingly, however, not all feedback and cues are equal. The Scapular Upward Rotation and Elevation Exercise program implemented by Derakhshani et al12 demonstrated significant improvements to VAS scores (P < .001), with no significant difference if exercises were performed with and without visual feedback (P > .99). Derakhshani et al13 indicated a potential benefit for the inclusion of sensorimotor training with and without passive intervention aimed at addressing scapular position and mobilization. However, sensorimotor training with passive intervention yielded statistically superior VAS score improvements (1.75 [0.86], P = .000), when compared with the significant improvements of sensorimotor training alone (2.50 [1.16], P = .000). Sensorimotor training with and without passive intervention were also favoured over conventional exercise training (chin-talk, push-up, and shoulder shrug exercises, 3 sessions per wk), which did not yield significant changes (0.16 [0.57], P = .339).
The commonalities of a coaching phase, 3 sessions per week, and individualized exercise and movement progression indicate a potential benefit in including exercise programs targeting scapular kinematics and stability to treat neck pain. For at-risk populations with unpredictable life demands like the military, the protocols outlined in all 3 studies would be accessible, as they require minimal time and resources. These findings could also be of value in situations where appointments must occur virtually or when qualified practitioners are not present to provide palpation and other manual therapies. Ashwini et al11 demonstrated a scapular-focused exercise program’s ability to yield NDI improvements of 24.47% at 95% CI, after only 4 weeks of intervention. While the other 2 studies were slightly longer in duration, a 4- to 6-week timeline could be helpful in planning a return to work/duty/play and could aid progression from corrective exercise to strength and conditioning programs. Further research is needed to define the limitations of this potential strategy and the significance of scapular-focused exercise interventions on neck pain in specific populations like the military and athletes. As the intention of this CAT was to examine interventions including only exercises and cueing, a review examining the combination of manual therapy and other modalities is recommended.
This CAT should be reviewed in 2 years to determine whether additional best research evidence has been published that could aid in answering the focused clinical question.
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