# Exercise as it relates to Disease/Resistance training versus fitness training for chronic neck muscle pain relief in women

This is a critique of the research article, Effect of Two Contrasting Types of Physical Exercise on Chronic Neck Muscle Pain (Andersen L, KjÆr M, SØgaard K, Hansen L, Kryger A, SjØgaard G 2007)

## What is the background to this research?

Chronic neck muscle pain (CNP), is a prevalent and steadily increasing health issue, negatively influencing the day-to-day lives specifically of individuals in the workforce. Common neck stress injuries are caused by misuse, underuse or overuse of all the neck muscles but the descending aspect of the trapezius muscle is most commonly aligned with muscle pain. Resistance training and fitness training are methods with proven benefits in limiting CNP. Physical fitness when applied from week-to-week shows an increase in blood circulation in the affected area indicating significant evidence in reduction of neck pain, however this study focuses on non-direct fitness work (no intense upper body fitness). Supervised resistance training is commonly associated with reductions in muscle pain (more commonly than endurance or high intensity fitness exercise) however it is understood that training of injured muscles may result in further injury or increased severity when one study investigated lower back pain and physiological distress.
Researchers have developed this article to assess resistance training and indirect fitness training (leg cycling) and its influence on the neck pain in women clinically diagnosed with trapezius myalgia(a symptom of severe neck pain). An ageing and computer orientated population has caused for an increase in studies regarding chronic neck pain and many different methods including massage therapy, customised desk and chair arrangements, altercations of life at home, cryotherapy and heat therapy amongst many others but one of the most researched areas is different or collative exercise formats such as strength training and endurance training, and its overall benefit short-term and long term.

## Where is the research from?

The study took place in Copenhagen, Denmark, and was published by the American College of Rheumatology (2008) in July 2007. Supported by the Danish Medical Research Council and the Danish Rheumatism Association.
The lead author Lars L. Andersen, is a reputable Professor of Musculoskeletal Disorders with a PhD (Faculty of Health Sciences) from University of Copenhagen: Copenhagen, DK. with many credible publications. With over 450 publications, from work with COVID-19 survivors and chest muscle thickness, to pain sensitivity post-amputation. Andersen was the source of all data and study design within this paper.

## What kind of research was this?

This article was a Randomised controlled trial; comparing the two controlled groups (SST & GFT), to the reference group (REF), as well as comparing both controlled groups to each other in determining the effectiveness of both. The researchers would use the data to identify the significance from similar experiments and studies.
Inclusion criterion of women:
* 30-60 years old
* More than 30 days of neck pain in the year
* Frequent neck pain or discomfort
* Higher than 2/9 on a pain scale (0- no pain, 9-worst pain imaginable)
Exclusion criterion of women:
* Previous neck trauma or injuries
* Other health implications (cardiovascular diseases, arthritis, life threatening diseases)
* Patient described own neck pain as in high levels of current neck pain (self-directed on a scale of 1-5, >3 resulted in exclusion)

## What did the research involve?

Participants from 7 workplaces were sent a questionnaire on the recruitment for the experiment of individuals with CNP whom worked repetitive and monotonous jobs (banks, post offices and industrial production units). 48 women (aged 45±9) were eligible by criterion to be placed into one of 3 intervention groups (SST, GFT & REF) in 2005-2006. The participants of the strength training and fitness groups participating in the study were allocated 20 minutes of high-intensity training, 3 times weekly for a period spanning 10 weeks. The strength training intervention group was locally to the neck and shoulder with a direct emphasis on dumbbell exercises (abduction, elevation, row and flies) using progressive overload (Exercises-5, Sets-3, 12RM-8RM) in line with American College of Sports Medicine guidelines in 2005. The fitness intervention group used a Monark bicycle ergometer at 50-70% (steady increase throughout 10 weeks) of their VO2max. Participants were asked to complete the VAS scale for pain as a measuring system in the two control groups. The REF group received health education but no physical training was offered.

### Study Limitations

* The variability of participants is limited as only women with similar workloads and working style were the focus point of this randomised controlled trial, this potentially affecting the external validity of the research affecting how generalisable resistance training and fitness training are in reductions of CNP.
* The title of the experiment doesn't properly identify the population, mention of women in high-to-moderate sedentary, computer-based jobs may provide further insight into the aim of the research.
* The results table listed results pre-intervention, post-intervention and 10-weeks post-intervention. The study however often underlines the benefits of certain reported pain altercations from the first 5 weeks and the second 5 weeks (in-training) from pre-intervention to post-intervention, a larger results table with more VAS reports may have assisted in supporting these statements.

### Study Strengths

* The study used previously significant articles, to shape the methodology in both fitness and strength training. For example, the experiment used training frequencies of 3 times per week with 10 weeks duration where supportive studies in resistance training likewise indicated that 3–5times per week with durations of 8–15 weeks were adequate in providing resistance development and pain minimising in areas of the trapezius.
* Randomised control trial removed performance bias and other self-directed bias in the trial which assisted in producing a higher significance of results.
* Compliance of participants in supervised workouts had documentation to account for compliance level resulting in an overall high appliance level across both training intervention groups.
The experiment intervention groups:
SST- specific strength training
GFT- general fitness training performed as leg bicycling
REF- Reference group

## What were the basic results?

General Fitness (leg bicycling):
* GFT saw an acute decrease in pain but the effect was of minor clinical relevance and only lasted 2 hours post activity. (p<0.001)
* VO2max was increased 21% in the GFT group (p< 0.0001)
Specific Strength Exercise:
* Isometric muscle strength increased significantly in the SST (p<0.001)
* 10 weeks following intervention saw no change with SST at a level much lower than the other groups
* 17/18 participants in the SST group saw a significant reduction in pain over time
Other:
* Scaling of the REF group stayed the same
Table 1: 100-mm visual analog scale (VAS) :
| | Pre Intervention | | Post Intervention | | % Change | P-Value |
| | Mean | SD | Mean | SD | | |
| Specific Strength Exercise | 44 | 25 | 10 | 10 | 77.27 | <0.001 |
| General Fitness (leg bicycling) | 50 | 16 | 45 | 13 | 10 | <0.001 |
| No Intervention (REF) | 43 | 27 | 35 | 29 | 18.60 | - |
SD = Standard Deviation
The authors showed a decrease on the VAS scale in both interventions (GFT and SST) but a much higher % change from pre-to-post intervention. The REF group remained unchanged. A 10-week intervention in strength exercise was found to be of high clinical importance and general fitness had acute benefits in reduction of pain of the descending trapezius muscle. The authors suggested that the increased VO2max and the decrease in rating of pain for the GFT group are both due to increase in core temperature, and increase in trapezius muscle oxygenation.

## What conclusions can we take from this research?

A very interesting study that found clear benefits in resistance training and indirect fitness in decreasing Trapezius myalgia, however studies that investigate the benefits of both training type collectively from week to week have found results that could improve and assist further research. In this study, it is clear that in the battle of the two exercise interventions, neck specific resistance training is clearly the dominant and suggested training type in limiting pain in women whom work under repetitive and monotonous jobs and this is supported further in other studies, especially when considering over a long time span.
The amount, specificity and intensity of exercise is progressively better understood on ways to benefit the individual whom suffers from CNP and the usage of repetitions, sets and duration of the program align with a lot of current studies. The best alternative guidelines have been outlined by the American College of Sports Medicine guidelines which also align adequately in regards to this study.
It would be suggested that further studies look at a wider audience of potentially men and woman in a wider range of occupations to more accurately support educated claims created by many other articles including this one. Despite limitations to this study, overall a well informed piece that provides significant information and evidence that can be implemented by health professionals for individuals suffering from CNP of any form.

## Practical advice

If you are currently suffering from chronic neck muscle pain and you work a monotonous and repetitive job, there are many professional support systems and online educational resources that you can implement into your daily life to reduce this pain. some strategies include 1-3 resistance sessions per week for 10-20 weeks with a focus of 8-12 reps, which is proven to be an effective pain relief in women with chronic neck muscle pain. Both dynamic resistance training and fitness training in your schedule collectively will see long term and short term benefits, with assistance from the ACSM guidelines.
Some examples of resistance exercises that assist in alleviation of pain over time include:
* Dumbbell 1-arm row
* Dumbbell shoulder abduction and shoulder elevation
* Reverse flies
* Barbell upright row
Consult with a specialist or medical practitioner if symptoms of neck trauma escalate, or get in contact with the following accredited professionals:
* Orthopedist
* Sports Scientist (Personal trainer)
* Physiotherapist

## Further information/resources

* https://www.health.gov.au/
* https://www.healthdirect.gov.au/neck-pain
* https://painspecialistsaustralia.com.au/neck-pain
* https://www.webmd.com/pain-management/managing-neck-pain-home
* https://health.clevelandclinic.org/do-you-have-a-stiff-neck-try-these-simple-remedies/

## References

* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Andersen L, KjÆr M, SØgaard K, Hansen L, Kryger A, SjØgaard G. Effect of two contrasting types of physical exercise on chronic neck muscle pain. Arthritis &amp; Rheumatism. 2007;59(1):84-91.
* 1 2 3 4 5 Ireland, J., Window, P. and O’Leary, S.P., 2022. The impact of exercise intended for fitness or sport on the prevalence of non‐specific neck pain in adults: A systematic review. Musculoskeletal Care, 20(2), pp.229-244.
* 1 2 3 Louw, S., Makwela, S., Manas, L., Meyer, L., Terblanche, D. and Brink, Y., 2017. Effectiveness of exercise in office workers with neck pain: A systematic review and meta-analysis. The South African journal of physiotherapy, 73(1).
* 1 2 3 4 5 6 7 8 Hagberg M, Harms-Ringdahl K, Nisell R, Hjelm E. Rehabilitation of neck-shoulder pain in women industrial workers: A randomized trial comparing isometric shoulder endurance training with isometric shoulder strength training. Archives of Physical Medicine and Rehabilitation. 2000;81(8):1051-1058.
* ↑ Hurwitz EL, Morgenstern H, Chiao C. Effects of recreationalphysical activity and back exercises on low back pain andpsychological distress: findings from the UCLA Low BackPain Study. Am J Public Health 2005;95:1817–24.
* ↑ Vincent, K., Maigne, J.Y., Fischhoff, C., Lanlo, O. and Dagenais, S., 2013. Systematic review of manual therapies for nonspecific neck pain. Joint Bone Spine, 80(5), pp.508-515.
* 1 2 Andersen L. Research.Gate [Internet]. 2013 [cited 9 September 2022]. Available from: https://www.researchgate.net/profile/Lars-Andersen-19
* 1 2 3 Anon, ACSM Physical activity guidelines resources. ACSM_CMS. Available at: https://www.acsm.org/education-resources/trending-topics-resources/physical-activity-guidelines [Accessed September 11, 2022].
* ↑ Myles P, Troedel S, Boquest M, Reeves M. The Pain Visual Analog Scale: Is It Linear or Nonlinear?. Anesthesia &amp; Analgesia. 1999;89(6):1517.
* ↑ Rattray B. Sport research/Critiquing the literature - Wikiversity [Internet]. En.wikiversity.org. 2018 [cited 9 September 2022]. Available from: https://en.wikiversity.org/wiki/Sport_research/Critiquing_the_literature
* 1 2 3 Gross, A.R., Paquin, J.P., Dupont, G., Blanchette, S., Lalonde, P., Cristie, T., Graham, N., Kay, T.M., Burnie, S.J., Gelley, G. and Goldsmith, C.H., 2016. Exercises for mechanical neck disorders: A Cochrane review update. Manual therapy, 24, pp.25-45.
* ↑ Andersen, C.H., Andersen, L.L., Pedersen, M.T., Mortensen, P., Karstad, K., Mortensen, O.S., Zebis, M.K. and Sjøgaard, G., 2013. Dose-response of strengthening exercise for treatment of severe neck pain in women. The Journal of Strength & Conditioning Research, 27(12), pp.3322-3328