Influence of Extracorporeal Shockwave Therapy in Patients of Mechanical Neck Pain
Phase: NA
Conditions: Neck Pain Musculoskeletal, Neck Pain, Extracorporeal Shock Wave Therapy, Mechanical Neck Pain, Cervical Pain, Posterior, Pain Threshold
Sponsor: Benha University

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INFLUENCE OF EXTRACORPOREAL SHOCKWAVE 
THERAPY IN PATIENTS OF MECHANICAL NECK 
PAIN 
 
 
NCT number: NCT……………….       
 
 
 
Document date   2023/7                 
 
 
 
 
 
 
 

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INFLUENCE OF EXTRACORPOREAL SHOCKWAVE 
THERAPY IN PATIENTS OF MECHANICAL NECK 
PAIN 
 
 
By 
Mohamed Faramawy Shible El. deeb 
B.Sc. in physical therapy, October 6 university (2018) 
 
 
 
A Protocol Submitted in A Partial Fulfillment of The Requirements for The 
Master Degree in Physical Therapy for Musculoskeletal Disorders and its 
Surgeries 
 
 
 
Faculty of Physical Therapy 
Cairo University 
2023 
 
 

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SUPERVISORS 
 
Prof. Dr. Enas Fawzy Youssef 
Professor and Chairperson of the Department of Physical Therapy for 
Musculoskeletal Disorders and its Surgery, 
Faculty of Physical Therapy, 
Cairo University 
 
Ass. Prof. Dr. Reda kotb Abdelrazik Gadelhak 
Ass. Professor in the Department of Physical Therapy for Musculoskeletal 
Disorders and its Surgery, 
Faculty of Physical Therapy, 
Benha University 
 
Dr Mona Mohamed Ibrahim Ahmed 
Lecturer in the Department of Physical Therapy for Musculoskeletal 
Disorders and its Surgery, 
Faculty of Physical Therapy, 
Cairo University 
 
 
 
 
 

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CHAPTER I 
INTRODUCTION 
About 75% of people have mechanical neck pain (MNP) Which was 
considered the most common musculoskeletal disorder after low back pain. 
(Genebra et al., 2017; Osama & Rehman, 2020). 
Patients with MNP suffer from pain (decreased pressure pain threshold), 
active trigger points (often in the upper trapezius), muscle spasm, limited range 
of motion, proprioceptive deficits causing disability and impaired life quality 
(Heintz & Hegedus., 2008; Kindler et al., 2010; Ziaeifar et al., 2014; 
Stanton et al., 2016; Blanpied et al., 2017; Ye et al., 2017; Osama & 
Rehman, 2020; Erdem et al., 2021).  
Mechanical neck pain is a multifactorial condition that arises insidiously 
with many predisposing factors as overhead manual activities, repetitive 
movements, huge physical effort, poor posture (e.g., with heavy smartphone 
and computer use) and psychosocial status with associated increased muscle 
tension (Heintz & Hegedus, 2008; Genebra et al., 2017; Cho et al., 2019; 
Osama & Rehman., 2020). 
Conservative management of MNP includes medications and 
physiotherapy. Physiotherapy includes exercise (stretching, strengthening, 
stabilization, endurance training), manual therapy (muscle energy technique as 
post isometric relaxation, myofascial release, trigger point release), dry 
needling, ultrasound, laser, electrotherapy, heat or infrared and ice with weak 
evidence  for their efficacy except for exercises (Leaver et al., 2010; Desai et 

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al., 2013; Gross et al., 2015; Cerezo-Tellez et al., 2016; Cohen and Hooten, 
2017; Thomas et al., 2019: Sbardella et al., 2021; Samiullah et al., 2022). 
Myofascial release therapy, deep friction massage, stretching, and/or 
isometric exercises can improve pain, function, cervical ROM, and/or Quality 
of life in patients with neck pain (Hou et al., 2002; Pesco et al., 2006; Salo et 
al., 2010; Blanpied et al., 2017; Khan et al., 2022). 
Extracorporeal shockwave therapy has been shown to reduce neck pain, 
pressure pain threshold, and disability in patients with neck pain with trigger 
points. However, because the studies of neck pain are of low quality due to 
lack of blinding and small sample size so its efficacy remains unknown (Yoo 
et al., 2020; Jun et al., 2021). 
Statement of the problem 
This study will try to answer the following question what is/are the 
effect(s) of adding extracorporeal shockwave therapy to the Routine 
physiotherapy on pain, function, range of motion (ROM), and position sense 
in patients with chronic mechanical neck pain? 
Purposes of the study  
The purpose of this study to explore the effect the effect of adding 
extracorporeal shockwave therapy to the Routine physiotherapy on neck pain, 
function, ROM, joint position sense in patients with chronic mechanical neck 
pain. 
Significance of the study 
Mechanical neck pain is a frequent condition that has a detrimental 
impact on patient's biopsychosocial characteristics as a results of increased 

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muscle tension (Heintz & Hegedus, 2008; Genebra et al., 2017; Osama & 
Rehman, 2020; Erdem et al., 2021). 
Physiotherapy interventions for MNP is effective in short-term, however 
they lack high quality evidence (Desai et al., 2013; Cohen and Hooten, 2017; 
Sbardella et al., 2021; Samiullah et al., 2022). 
Extracorporeal shockwave therapy for treatment of MNP is promising 
in increasing pressure pain threshold and decreasing disability. Although 
further high-quality studies were needed to confirm its efficacy (Carroll et al., 
2009; Cohen and Hooten, 2017; Manafnezhad et al., 2019). 
Myofascial syndrome, which is characterized by taut bands that cause 
pain and limit range of motion in individuals with non-specific neck pain, is a 
substantial source of pain, hence breaking the cycle of pain by relaxing tense 
bands is primary goal of its treatment (Rahbar., 2021). 
The efficacy of Extracorporeal shock wave therapy on myofascial 
condition is now the subject of more research to determine its effectiveness, 
especially in the upper trapezius which need further research to confirm its 
pain-relieving characteristics and their capability to promote tissue 
proliferation and repair (Rahbar., 2021). 
Consequently, extracorporeal shockwave therapy combined with 
Routine physiotherapy needs to be investigated whether it will be helpful in 
improving clinical outcomes of mechanical neck pain or not. 
Several therapies were used to treat MNP patients; nonetheless, MNP is 
quite common, with most patients experiencing chronic and recurring 
symptoms after one year. Newer interventions as extracorporeal shockwave 

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therapy may help to treat this condition well (Carroll et al., 2009; Cohen and 
Hooten, 2017; Manafnezhad et al., 2019). 
Hypotheses 
It is hypothesized that: 
1- There will be no significant effect of adding ESWT to routine 
physiotherapy on pressure pain threshold in patients with MNP. 
2- There will be no significant effect of adding ESWT to routine 
physiotherapy program on neck function in patients with MNP. 
3- There will be no significant effect of adding ESWT to routine 
physiotherapy on cervical flexion active range of motion (AROM) in 
patients with MNP.  
4- There will be no significant effect of adding ESWT to routine 
physiotherapy on cervical extension AROM in patients with MNP. 
5- There will be no significant effect of adding ESWT to routine 
physiotherapy on cervical side bending to the right AROM in patients 
with MNP. 
6- There will be no significant effect of adding ESWT to routine 
physiotherapy on cervical side bending to the left AROM in patients with 
MNP. 
7- There will be no significant effect of adding ESWT to routine 
physiotherapy on cervical rotation to the right AROM in patients with 
MNP. 

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8- There will be no significant effect of adding ESWT to routine 
physiotherapy on cervical rotation to the left AROM in patients with 
MNP. 
9- There will be no significant effect of adding ESWT to routine 
physiotherapy on cervical flexion joint position sense (JPS) in patients 
with MNP. 
10- There will be no significant effect of adding ESWT to routine 
physiotherapy on cervical extension JPS in patients with MNP. 
11- There will be no significant effect of adding ESWT to routine 
physiotherapy on cervical side bending to the right JPS in patients with 
MNP. 
12- There will be no significant effect of adding ESWT to routine 
physiotherapy on cervical side bending to the left JPS in patients with 
MNP. 
13- There will be no significant effect of adding ESWT to routine 
physiotherapy on cervical rotation to the right JPS in patients with MNP. 
14- There will be no significant effect of adding ESWT to routine 
physiotherapy on cervical rotation to the left JPS in patients with MNP. 
Delimitations 
     This study will be delimited to the following: 
1. Fifty-two patients (males and females) with non-specific neck pain. 
2. The age of the patients will range between 18-29 years (Jahre et al., 2020). 

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3. The instrumentations will be limited to: Pressure algometer to assess 
pressure pain threshold, The Arabic version of Neck disability index 
(NDI) to assess neck function, and goniometer to assess cervical range of 
motion (CROM) and joint position sense, at base line and after 4 weeks 
of treatment. 
4. The intervention will be limited to; extracorporeal shockwave therapy and 
routine physiotherapy (Deep friction massage, stretching, isometric 
training, and home program of postural correction). 
Basic Assumption 
It will be assumed that: 
1. All subjects will be committed to the therapist instructions and to 
assessment and treatment steps during the study. 
2. All subjects will not take any medications or modality that interfere with 
the treatment in this study. 
Definition of terms: 
Joint position sense: is the ability of a person to perceive a presented 
joint angle and then, after the limb has been moved, to actively or passively 
reproduces the same joint angle. (Riemann & Lephart, 2002). 
Mechanical neck pain (MNP): pain in cervical region (From the inion 
to the last cervical vertebra including up to spine of scapula, upper clavicle, 
and suprasternal notch), and has no definitive underlying cause (other than 
poor posture, repetitive activities, strain, and psychology) often associated with 
neural pain in the neck or cervical region, and liability of limiting movement 

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resulting in disability and decreased life quality (Heintz & Hegedus, 2008; 
Guzman et al., 2009; Blanpied et al., 2017). 
Myofascial trigger points (MTrPs): hypersensitive bands or spots within 
skeletal muscle that are taut (Travell & Simons.,1999). 
 
CHAPTER II 
REVIEW OF LITERATURE 
     This chapter provides a review of the available literatures related to 
mechanical neck pain and provides a clear understanding of the current 
concepts under the following headings: 
• Functional anatomy and biomechanics of cervical region. 
• Mechanical neck pain. 
a. Epidemiology of MNP 
b. Impact 
c. Causes and risk factors 
d. Assessment of MNP 
e. Treatment of MNP 
Functional Anatomy and Biomechanics of Cervical Region 
Cervical region of the spine is made of seven vertebrae aligned in a 
lordotic curve. The smallest functional unit is the mobile segment; that is, any 
two adjacent vertebrae, the intervening intervertebral disk (absent at C0-2, i.e 
between occiput, atlas and axis or atlanto-occipital and atlanto-axial joints), 
and all the soft tissues that secure them together (capsule, muscles, ligaments).  

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Muscles acting on the neck are levator scapulae, Obliquus superior, 
rectus capitis posterior minor, rectus anterior and rectus lateralis, and longus 
cervicis among others. The ligaments are anterior and posterior longitudinal 
ligaments, posterior atlanto-occipital and atlantoaxial membranes, Transverse 
Ligament, ligamentum flavum, Alar Ligaments and the interspinous, 
supraspinous, and intertransverse ligaments.  
There is cartilaginous joint type between the vertebral bodies and 
synovial joint between the zygapophyseal facets located between the upper and 
lower articular facets. The movements of the head were produced by muscles 
and affected by shape of the vertebrae and mobility between them.  
The cervical spine is divided into two distinct regions: the upper cervical 
spine, or craniovertebral region (occipital condyles and the first two cervical 
vertebrae, C1 and C2), and the lower cervical spine (C3 to C7). Cervical spine 
allows flexion and extension, side bending, and rotation. side bending is 
coupled with rotation at individual segment (Levangie and Norkin., 2011). 
Mechanical Neck Pain 
Epidemiology 
In terms of prevalence, neck pain ranks among the top five chronic pain 
conditions (Cohen and Hooten, 2017). It affects women more than men 
(Erdem et al., 2021). Psychosocial and genetic variables were risk factors for 
its prevalence (Cohen and Hooten, 2017). It affects about half of the general 
population (Haldeman et al, 2010). 
Impact 
Neck pain reduces the quality of life for those who suffer from it. It 
places a significant financial and social load on the individual as it causes 

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significant disability. Up to 85% of affected people still complaining or having 
recurrences more than one year later (Carroll et al., 2009; Cohen and 
Hooten, 2017). 
More than 50% of patients of neck pain complain of symptoms that are 
not improved even after 6 months and less than 50% improved after 6 months 
(Borghouts et al., 1998; Blanpied et al., 2017). 
The deep and anterior neck flexors, were the the most frequent muscles 
in the cervical spine that are prone to weakness in cases of neck pain (Oh and 
Song, 2016). 
Active trigger points in the upper trapezius, sternocleidomastoid, levator 
scapulae, and suboccipital muscles are present in patients with mechanical 
neck pain, which causes pain, hypomobility, and impairment (Fernandez-de-
Las et al., 2007; Ziaeifar et al., 2014). 
Because of their impaired proprioception, patients with chronic neck 
pain performed worse on head to neutral repositioning tests compared to 
asymptomatic controls. (Treleaven, 2008; Stanton et al., 2016). 
Based on symptoms including hypomobility, headache, trauma, and 
referred or radiating pain, neck pain can be classified as neck pain with deficits 
in mobility, neck pain with movement coordination disorders, neck pain with 
headaches, and neck pain with radiation (Blanpied et al., 2017). 
Causes and risk factors 
Female gender, advanced age, strenuous physical demands at work, 
smoking, sedentary lifestyle, lack of social or professional support, and a 
history of neck or low back disorders are risk factors for neck pain (Carroll et 

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al., 2009; McLean et al., 2010). Neck pain is frequently observed as a result 
of employment factors such as the workplace, such as work overload, computer 
use, and study time (Kazeminasab et al., 2022). 
Along with intra-muscular shear forces, low intensity task contributes to 
Ca+2 accumulations in Type1 fibers and increases motor unit activation due to 
slow blood supply leading to mechanical Neck Pain (Visser and van Dieën, 
2006). 
Assessment of MNP 
In individuals without a clear underlying pathology, routine imaging 
tests including computed tomography, magnetic resonance imaging, and 
ultrasound might not be necessary (Blanpied et al., 2017). 
The neck pain and disability can be assessed using neck disability index 
(NDI) and numeric pain-rating scale (NPRS) that have acceptable 
psychometric properties (Vernon, 2008; Hjermstad et al., 2011; 
Schellingerhout et al., 2012; Lauche et al., 2013; Abbott and Schmitt, 
2014). 
The pressure pain threshold can be precisely measured with a pressure 
algometer. Locally reduced readings (on the neck) point to a mechanical 
overreaction at the local level. Widespread lower readings (for example, on the 
neck and lower extremity) suggest a malfunction of the central processing of 
noxious receptors as in fibromyalgia and chronic fatigue syndromes (Walton 
et al., 2014; Blanpied et al., 2017). 

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Cervical ROM can be assessed using cervical range of motion (CROM) 
goniometer, both standard goniometers, and the inclinometers with acceptable 
reliability and validity (Snodgrass et al., 2014). 
The Short Form-36 Health Survey (SF-36) commonly used for 
investigating health related life quality in patients with non-specific neck pain 
(Saarni et al., 2006). 
Joint position error (JPE) in degrees will be used to measure the accuracy 
of cervical proprioception. (Reddy et al., 2022). 
Treatment of MNP: 
Conservative management of patients with neck pain includes 
medications (Muscle relaxants and non-steroidal anti-inflammatory drugs) and 
physiotherapy. Physiotherapy includes exercise that has strongest evidence, 
massage, acupuncture, yoga, and spinal manipulation with weaker evidence. 
Surgery is indicated only for patients with significant neurological deficits with 
failed conservative measures (Cohen and Hooten, 2017; Samiullah et al., 
2022). 
In order to effectively treat patients with neck pain and mobility 
problems, clinicians should employ a multimodal strategy. The efficacy of 
manual therapy seems to lessen as the condition progresses from subacute to 
chronic. Although it may cause brief discomfort, manipulation might not be 
any more effective compared to mobilization. Patients with subacute and 
chronic neck pain who have mobility deficits should be managed with exercise 
(neuromuscular exercise as coordination, proprioception, and postural training, 
stretching, strengthening, endurance training, aerobic conditioning, and 

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cognitive training), dry needling, LASER, or intermittent traction (Miller et al 
2010; Schroeder et al., 2013; Blanpied et al., 2017). 
Exercises as strength or endurance training of the neck and upper body 
seemed to moderately enhance the health-related quality of life in patients with 
neck pain (Salo et al., 2010). In addition to endurance and stretching exercises, 
strengthening exercise has a strong record of effectiveness for treatment of 
neck pain (Louw et al., 2017). Sensorimotor exercises as cervical JPS, cervical 
movement sense, oculomotor control exercises and balance exercises were 
indicated for patients with neck pain due to sensorimotor disturbances 
(Treleaven., 2008). 
Postural endurance exercises of deep neck flexors are more effective 
compared to isometric resistive exercises of neck muscles in decreasing pain 
and disability (Gogoi, 2015). Postural exercises at home or work decreased 
pain and disability, and improved endurance and posture (Abadiyan et al., 
2021). 
Muscle energy Technique (MET), is a soft tissue technique that that 
combine isotonic and isometric contractions, and were found effective to 
improve pain, ROM and function (Visser and van Dieën 2006; Chaitow and 
Crenshaw, 2006; Samiullah et al., 2022). 
Myofascial release therapy is a soft tissue method that involves 
application of a low intensity, long-lasting stretch with the elbows or knuckles 
to apply pressure over compromised fascia after identifying the taut bands in 
the fascia (Ajimsha et al., 2014). slow movement in the spasmed muscles 
stimulate the parasympathetic nervous system, resulting in relaxation, which 

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lower discomfort, enhances blood flow, and relieve muscle tension (Schleip, 
2003). 
 
Extracorporeal Shock wave therapy 
ESWT is a modern, non-invasive therapeutic tool which is effective, 
safe and advantageous. ESWT may replace surgery in several orthopedic 
pathologies with at least the same results, but without its drawbacks. The 
potential for translational research and development of ESWT technology is 
remarkable and probably still undisclosed (Romeo et al.,2013). The 
extracorporeal shock wave therapy is as effective as dry needling for relieving 
pain, improving function for patients with myofascial trigger points after a 
series of three treatments. (Luan et al.,2019). Shock waves can be classified 
as extracorporeal or focused and radial (pneumatic) shock waves. There is lack 
of evidence that focused ESWT is effective for short-term relief of neck pain 
(Yoo et al., 2020). Extracorporeal shock wave therapy is an effective 
intervention for the treatment of pain, disability, and depression in chronic low 
back pain patients. (Han et al.,2015). Extracorporeal shock wave therapy 
(focused and radical) is superior to conventional therapies in reducing neck 
pain patients' pain and pain pressure threshold (Jun et al., 2021). In individuals 
with neck pain, phonophoresis and ESWT both successfully reduced pain and 
neck impairment, but ECSWT was preferable because it had more effect in a 
short term (Taheri et al., 2021). Patients with generalized neck pain can 
benefit from ESWT and dry needling to treat upper trapezius myofascial 
trigger points (Manafnezhad et al., 2019). The neck pain therapy program 
used infrared irradiation to treat patients (Chiu et al., 2005). The efficacy of 

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Extracorporeal shock wave therapy on myofascial condition is now the subject 
of more research to determine its effectiveness, especially in the upper 
trapezius which need further research to confirm its pain-relieving 
characteristics and their capability to promote tissue proliferation and repair 
(Rahbar., 2021). ESWT combined with Wuqinxi exercise can relieve pain, 
increase joint range of motion and muscle strength better than conventional 
ultrasound therapy (Lin S et al.,2023). extracorporeal shock wave therapy is 
superior to other treatments in terms of alleviating the pain intensity and 
pressure pain threshold of patients with myofascial pain syndrome in the neck 
and shoulder (Jun, J.H et al.,2021). ESWT can avoid the adverse effects of 
invasive procedures on patient; compared with TPI, dry needling and US, 
ESWT can more effectively relieve the pain of MPS patients (Tao wu et al., 
2022). Both dry needle and ESWT applications may improve pain level (based 
on VAS) and ROMs in patients with active trigger points in upper trapezius 
muscle (Toghtamesh et al.,2020). 
CHAPTER III 
PATIENTS, MATERIALS, AND METHODS 
The aim of this study is to examine the effect of adding ESWT to 
conventional physiotherapy program in treatment of chronic mechanical neck 
pain. It will be conducted at the outpatient clinic of physiotherapy, faculty of 
physical therapy, Benha University from July 2023 to Jun 2024.  
Study design 
This study will be Double-blinded (participant, statistician and 
evaluator), pretest- posttest controlled trial. 

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Patients 
Fifty-two patients with mechanical neck pain screened by the principal 
researcher will be included for study after being informed about study aim and 
signing the consent form (APPENDIX I). 
The study subjects will be randomly assigned into two groups A and 
group B (ratio 1:1) using a computer-generated random data sheet using www. 
random. Org. 
Group A will receive only routine physiotherapy in the form of 
stretching, isometric training, and home program of postural correction. Group 
B will receive ESWT combined with routine physiotherapy. The treatment will 
last 4 weeks, 2 sessions weekly one session with ESWT and another without.  
Sample size calculation 
Sample size calculation was done using G-POWER 3.1 software and 
considering two-sided α = 0.05, power = 80% and Effect size = 0.8 (large) 
based on the study of Cho et al. (2012), the total sample size was calculated to 
be 52 (26 in each group). 
Inclusion criteria 
Patients will be included in the study if they fulfil the following criteria: 
1. Patients (both males and females) with neck pain for more than three 
months. 
2. Patients will be aged between 18 and 29 years old (Jahre et al., 2020). 
3. Patient has at least one taut band at upper fibers of trapezius as 
described in assessment procedures. 
4. Patient visual analogue scale (VAS) 3 to 8 out of 10 
Exclusion criteria: 

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Patients will be excluded if they: 
1. Were treated for neck or shoulder pain during the last three months. 
2. Had neck or shoulder operation during the last two years.  
3. Had any structural pathology of the cervical spine, such as disk 
prolapse, spinal stenosis, or cervical spondylosis. 
4. Had traumatic history, instability, spasmodic torticollis. 
5. Had cardiovascular, respiratory, or allergic disease, neck 
osteoarthritis. 
6. Had homeostatic disorders. 
7. Fibromyalgia, shoulder diseases (tendonitis, bursitis, capsulitis). 
8. inflammatory rheumatic diseases. 
9. Severe psychiatric illness and other diseases that restrict physical 
loading, and pregnancy (Salo et al., 2010). 
Instrumentations: 
A. Assessment tools: 
1. Pressure algometer (with a circular flat tip of 1 cm2 will be used to assess 
pressure pain threshold (Asiri et al., 2020). The reliability is 
excellent (Walton et al., 2014). 
2. The Arabic version of Neck disability index (NDI) will be used to assess 
neck function. It includes questions regarding daily living activities such 
personal care, lifting, reading, working, driving, sleeping, and recreation 
activities as well as pain severity, focus, and headache (Elbeltagy et al., 
2020). 
3. Goniometer will be used to assess cervical range of motion (CROM) and 
joint position sense as shown in figure1. 
 

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Fig. 1: Standard goniometer 
B. Treatment tools: 
Extracorporeal shockwave therapy (GymnaUniphy NV Pasweg 6A |/B-
3740 Bilzen, Belgium Radial extracorporeal shockwave therapy) (rESWT) 
pneumatic type machine (figure2). 
 
Fig. 2: Extracorporeal shock wave therapy. 
A. Assessment procedures: 
Assessment will be done at base line and after 4 weeks of treatment. 
Pressure Pain Threshold 
For the purpose of measuring the local pressure pain threshold in the 
upper trapezius, a pressure algometer (Baseline algometer 10kg) will be used. 
The person will lie down in a prone lying position. After identifying a taut 
band, a digital pressure algometer will be used to apply pressure 
perpendicular to the muscle fibers at a rate of 4 to 5 N/s (40–50 kPa/s). 
Patients will be instructed to provide the examiner with the specific instant at 
which pressure changed into pain. After that, the test will be repeated three 
times, with a minimum 30-second gap between each test, and the average 
will be calculated and the whole procedures will be repeated on the opposite 
side (Blanpied et al., 2017; Jun et al., 2021). Searching for taut bands in 
trapezius based on anatomically predicted sites of taut bands: MTrP1 

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intermediate part of the anterior border of the upper part of the muscle near 
the vertical fibers of the muscle attached to clavicle. MTrP2 distal and 
slightly lateral to MTrP1. MTrP3 medial to the scapula and on the border of 
the medial fibers near the inferior border of the muscle. MTrP3.1 medial 
fibers near the inferior margin of the muscle, medial to MTrP3; nervous 
branch. MTrP5 medial to scapula in the intermediate part of muscle belly. 
MTrP5.1 medial to the scapula in the intermediate part of the muscle belly 
inferior to MTrP5.1. MTrP5.2 medial to the scapula in the intermediate part 
of the muscle belly. inferior to MTrP5.1 (Akamatsu et al.,2015). The 
previous muscle's taut bands will be evaluated: upper fibers of the trapezius. 
A mean difference of 0.94 kg/cm2 in pain pressure threshold was considered 
as minimal clinically important difference (Asiri et al., 2020). 
Neck disability assessment 
 A 10-item neck disability index (NDI) will be used to assess neck 
disability. Each item will be evaluated and scored on a 5-point scale, with 0 
denoting "no handicap" and 5 denoting "full disability." According to the final 
score, mild, moderate, and severe disabilities were respectively, 5, 14, 15, 24, 
and 25 (Vernon and Mior, 1991). The Arabic version of NDI is reliable 
(Elbeltagy et al., 2018). In the current investigation, a 10% reduction in the 
neck disability score was considered to be the lowest clinically significant 
difference (Lauche et al., 2013). 
Cervical range of motion assessment 
     Cervical range of motion (in all directions) will be measured using 
standard goniometer (Baseline Plastic Goniometer - 360 Degree Head - 12 
inches). Participants will be seated upright and asked to actively move their 
neck in each direction three times. This method is valid and reliable for 

22 
 
assessment of cervical range of motion (Audette et al., 2010; de Koning et 
al., 2008). 
The external auditory meatus will be covered by the axis as it measures 
cervical flexion and extension. The moveable arm will be parallel to the fixed 
arm and positioned vertically along the imaginary axis that runs from the 
external auditory meatus to the base of the nares. The patient will be asked to 
flex and extend his head, and the range of flexion and extension will be 
assessed in degrees. The axis will be positioned at the middle of the sternal line 
that runs between the acromion processes for lateral flexion, and the movable 
arm will be oriented at the most prominent part of the nose. The patient will be 
requested to complete side-by-side cervical lateral flexion and measures. The 
axis will be positioned over the center of the patient’s head, moving arm 
positioned at the tip of the nose, fixed arm parallel to an imaginary line going 
between the acromion process. The patient will be asked to rotate their neck 
and take measurements. There is a 0.80 to 0.98 intra-rater reliability range. 
(Youdas et al., 1991; Khan et al., 2022). 
Cervical joint position sense assessment 
Joint position error (JPE) in degrees will be used to measure the accuracy 
of cervical proprioception. The cervical range of motion in all directions will 
be assessed, and the target position will be chosen at 50% of the total range. 
The patient will sit upright on a stool, with their feet flat on the floor. The 
individual will be asked to choose their own neutral head posture, and the 
examiner will then fasten the device to their head. Prior to testing, all 
participants will close their eyes. The participant's head will then be moved 
into the specified position, which the physical therapist will hold for 5 seconds 
before instructing them to memorize it after that the participant's head will be 

23 
 
led back to the starting position by the examiner or patient himself. The patient 
will next be asked to move their heads to the previously learned target position. 
The accuracy of the subjects' repositioning will be measured in degrees once 
their heads have been moved to the target position (JPE). The cervical flexion, 
extension, and rotation to right and left Will be assessed for joint position 
sense. The test will be repeated three times in each direction, and the final 
measure will be based on the mean of these trials (Reddy et al., 2022). 
B. Treatment procedures 
Treatment frequency will be 2 sessions per week for 4 weeks (Lee et al., 
2013; Blanpied et al., 2017). 
Extracorporeal shockwave therapy 
Patients in the experimental group (B) will receive ESWT with radial prob 
once a week for four weeks (Mostafa et al.,2016; Mohamed et al.,2021; 
Kamel et al 2020; Luan et al 2019; Savas.,2013). The ESWT will be 
applied using the following treatment parameters: 2,000 pulses, intensity of 
0.2 Mj/mm2, and 10 Hz frequency (Manafnezhad et al., 2019). The ESWT 
will be applied for 3 minutes on trigger points of trapezius muscles. 
Participants will be asked to lie down in a prone position with their arms next 
to the body. ESWT will be applied (for 4 sessions) at second session of each 
week. 
Routine physiotherapy 
Stretching exercises 
Exercises were performed in the following order: stretching towards 
lateral flexion for the upper part of the trapezius as shown in figure 3, and 
flexion for the extensor muscles. holding each movement for 30 seconds. Each 

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exercise will be repeated 3 times. Finally, a neck straightening exercise will be 
performed by chin tuck 5 times for 3–5 seconds. Patients will be advised to 
perform the stretching program 5 times a week, a stretching take about 10 
minutes to perform (Ylinen et al., 2007). 
 
Fig. 3: Stretching exercises for the upper fiber of trapezius (Park, K. N et al 
2013). 
Isometric muscle training 
The patient will be asked to press against the therapist's hand in each of 
the six directions; flexion, extension, right rotation, left rotation, right side 
bending, and left side bending while seated upright (Jaiya , 2022; Deen et al, 
2020). The therapist or patient himself will exert resistance on the forehead, 
occiput, right chin, left chin, right head, and left head, in that order as shown 
in figure 4. The exercise frequency will be two sets of five repetitions with a 
ten-second hold between each set. 

25 
 
 
Fig. 4: Isometric muscle training (Jaya et al., 2022) 
Postural correction home program 
Patients will receive instruction on  
• Sitting: (Switch sitting positions often, take brief walks around 
your office or home. 
•  gently stretch your muscles every hour so often to help relieve 
muscle tension, relax your shoulders; they should not be rounded 
or pulled backwards. 
•  Keep your elbows in close to your body. They should be bent 
between 90 and 120 degrees. 

26 
 
•  make sure that your back is fully supported, use a back pillow or 
other back support if your chair does not have a backrest that can 
support your lower back's curve. 
•  Standing: in proper posture (Stand up straight and tall, keep your 
shoulders back, pull your stomach in, put your weight mostly on 
the balls of your feet, keep your head level, let your arms hang 
down naturally at your sides. 
• Sleeping: The pillow for your head should support the natural 
curve of your neck and be comfortable. A pillow that's too high 
can put your neck into a position that causes muscle strain on your 
back, neck, and shoulders. Choose a pillow that will keep the neck 
aligned with the chest and lower back. Your pillow should be 
adjustable to allow you to sleep in different positions. 
• Additionally, they will receive instructions on how to engage their 
deep neck muscles (e.g., chin in or nodding exercises). They will 
then be required to carry out this at home and repeat session 
exercises at home. 
Statistical analysis: 
Statistical analysis was conducted using SPSS for Windows, version 
26 (SPSS, Inc., Chicago, IL). Before final analysis, data were screened for 
normality assumption, homogeneity of variance, and presence of extreme 
scores, and the p-value was set at < 0.05. This analysis was done as a pre-
requisite for parametric testing of the analysis of differences. 

27 
 
Comparison between mean values of the different parameters in the two 
groups was performed using repeated measure MANOVA test to determine 
the significant differences between both groups at the two times testing 
intervals (pre and post). 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

28 
 
Appendix I 
   Consent form 
I am …………………………………………..freely and voluntarily consent to 
participate in this research study under direction of the researcher: Mohamed 
Faramawy Shible El. deeb. I may withdraw my consent and discontinue 
participation in this research at any time without prejudice to me. 
Date:/……. /20……. 
Participant…………….………… 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

29 
 
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42 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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