Cervical Stabilization Exercises Improved Pain, Disability, and Physical Impairments in University Violinists With Nonspecific Neck Pain
Phase: NA
Conditions: Neck Pain
Sponsor: National Cheng Kung University



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Effects of Cervical Stabilization Exercise in Violinists with Chronic Neck Pain  
 
I. 
Background 
Many people start to learn a musical instrument at an early age because substantial time is required to 
become skilled. Playing the violin requires constant elevation of the left shoulder and lateral flexion and 
rotation of the cervical spine to firmly support the instrument against the chin. Prolonged exposure to an 
asymmetric posture and increased muscle activity in the neck–shoulder region may lead to neck pain. 
Playing-related musculoskeletal symptoms is very common. Seventy-four percent of adolescent string 
instrumentalists in Australia experienced musculoskeletal symptoms, and approximately sixty-eight percent 
of Dutch university students reported chronic musculoskeletal pain and symptoms that interfered with their 
ability to play the instrument at the usual level during the past year. Neck pain is associated with reduced 
strength and endurance of cervical muscles, in particular the deep cervical flexors. The deep cervical flexors 
(longus capitis and colli) play a vital role in adjusting cervical curve and maintaining segmental stability. 
The aim of this study is to investigate the effects of cervical stabilization exercise on neck pain, neck 
disability, and physical impairments in university violin players with chronic nonspecific neck pain. 
 
II. Methods 
Participants 
Violin players aged 18-25 years will be recruited from university symphony orchestras. The inclusion 
criteria are: duration of playing the instrument longer than 5 years; practicing the violin more than 5 hours 
per week; constant or frequently occurring neck pain for more than 3 months. The participants will be 
excluded if they had previous surgery in the neck and shoulder regions, currently participate in a structured 
exercises program, currently receive treatment for neck and shoulder pain, have neurological symptoms of 
the upper extremities, and other diseases that might prevent full participation in the study, such as cancer and 
rheumatic arthritis. 
Study design and procedure 
This study has a single-group pretest-posttest design with 3 measurements. The period between the 2 
pretests at week 0 and 4 served as the baseline period. During the baseline period, the participants will not 
receive any intervention and be instructed to maintain their usual activity. Participants start a 6-week 
exercise program at week 5. The period between the second pretest at week 4 and the posttest at week 10 
served as the intervention period. 
Measurement 
All the participants will complete the following measurements: 
(1) 
Basic information 
Includes age, gender, height, mass, duration of playing violin, average weekly hour of 
playing, health status and history of neck pain. 
(2) 
Neck Disability Index (NDI) 
NDI is a reliable, valid and responsive questionnaire used to assess the self-rated disability of 
patients with neck pain. The index is composed of 10 items including pain, personal care, 
lifting, reading, headaches, concentration, work, driving, sleeping and recreation. A higher 
percentage score of NDI indicates greater disability associated with neck pain. 
(3) 
Cervical joint position sense 
Cervical joint position sense will be assessed by the cervcal joint reposition error. The 
participants will be instructed to memorize the neutral head position, perform maximal 
cervical movement, and then relocate the head to the starting position blindfolded. The greater 
the distance between the starting and returning positions, the poor the cervical joint position 
sense.  
(4) 
Cervical range of motion (ROM) 
Cervical range of motion will be measured using a validated cervical range-of-motion device 
(Performance Attainment Associates, Lindstrom, MN, USA). Participants will be instructed to 
move their heads from their own natural neutral position into maximal flexion, extension, left 
lateral flexion, right lateral flexion, left rotation, and right rotation positions. 
(5) 
Spinal Posture and Scapular Position Test) 

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Upper body posture will be measured using the photographic method. Postural angles (frontal 
head tilt, frontal shoulder, scapular rotation and upper thoracic) will be analyzed and 
measured from the images using the ImageJ software. 
(6) 
Cervical muscle endurance 
Cervical muscle endurance will be measured using a stopwatch for the successful time 
holding the tested position. The longer the holding time, the better the muscle endurance. 
(7) 
Craniocervical Flexion Test (CCFT) 
The craniocervical flexion test is a clinical test for assessing the neuromuscular control of 
deep cervical flexors. A pressure biofeedback unit (Stabilizer, Chattanooga Group, USA) will 
be used to measure the pressure change during head nodding in a hook-lying position.  
Intervention 
The participants will follow instructional videos and perform the exercise program at home, 20 minutes 
a day, 3 days a week for 6 weeks. The exercise program will be progressed by increasing the repetition of 
exercise first and then by increasing the intensity. The exercise program will include axial elongation 
exercise, craniocervical flexion exercise, cervical extension exercise, and cervico-scapulothoracic 
strengthening exercises 
Statistical analysis 
Descriptive statistics were summarized as means and standard deviations for normally distributed data 
and medians and interquartile ranges for skew data. A one-way repeated-measures analysis of variance 
(ANOVA) was used to identify any statistically significant differences among three time points for each 
dependent variable. 
 
III. Expected outcome 
The results of this study will help clinicians in management of nonspecific neck pain for 
violinists. The cervical stabilization exercise program used in this study can empower the violinists 
for self-care, and improve their quality of life.