Effects of extracorporeal shock wave therapy combined with Wuqinxi exercise on cervical motor function in patients with subacute mechanical neck pain

Effects of extracorporeal shock wave therapy combined with Wuqinxi exercise on cervical motor function in patients with subacute mechanical neck pain | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effects of extracorporeal shock wave therapy combined with Wuqinxi exercise on cervical motor function in patients with subacute mechanical neck pain Shaoping Lin, Tingting Lun, Shixiong Wang, Jin Yu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2582526/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: This study aims to observe the effects of extracorporeal shock wave therapy combined with Wuqinxi exercise on cervical motor function in patients with subacute mechanical neck pain. Methods : 70 participants with subacute mechanical neck pain were randomly assigned into an intervention or control groups.The intervention group was treated with extracorporeal shock wave therapy and Wuqinxi exercise,while the control group was received ultrasound therapy,for 4 weeks.The Visual Analogue Scale(VAS),Neck Disability Index(NDI) and Maximal Isometric Strength(MIS) were used for assessment at baseline,after one session,1 st week,and 4 th week after intervention.The flexion/extension ratio(F/E R)was calculated through MIS.The range of motion was measured at baseline and 4th week after intervention. Results: 63 participants (intervention group n=32, control group n=31) completed the study.Intervention group showed more significant improvement in the Neck Disability Index after intervention[5.69, 95% confidence interval (CI): 3.05 to 8.31, p <0.001].The improvement was more significant in intervention group on the Visual Analogue Scale[1.99，95% confidence interval (CI):1.03 to 2.93, p <0.05].Neck muscle strength recovered better in intervention group.Flexion/Extention Strength Ratio decreased more significant in intervention group [0.24，95% confidence interval (CI): 0.13 to 0.35, p <0.05].At the same time, intervention group showed greater increase in range of motion( p <0.05),except healthy side rotation ( p =0.096). Conclusions: Extracorporeal shock wave therapy combined with Wuqinxi exercise can relieve pain, increase joint range of motion and muscle strength better than ultrasound therapy.It can significantly improve the motor function of cervical spine. Trial registration: Registration Number:ChiCTR2200064781(17/10/2022) Extracorporeal shock wave therapy Wuqinxi exercise neck pain cervical motor function Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 What Is Known There are many treatment options for subacute mechanical neck pain, but there is a long way to go from treatment to home training that can prevent exacerbation and recurrence. What is New Extracorporeal shock wave therapy for musculoskeletal pain is a recent trend in pain clinic, but Wuqinxi exercise is rarely used for cervical spine disease training,although Chinese people use it to improve the immune system.As a bionic exercise,Wuqinxi exercise can train the cervical muscles and improve the motor function of the cervical spine, which is worthy of being recommended in the community. Objective Subacute Mechanical Neck Pain (SMNP) is defined as pain in the neck region with or without upper limb pain for more than 6 weeks and less than 3 months . 1、2 Studies have shown that 30% of patients with acute or subacute mechanical neck pain will be prolonged to chronic neck pain,and even the neck pain lasts for more than 6 months. 3 Therefore, treatment for subacute mechanical neck pain is particularly important,which includes physiotherapy,acupuncture,massage,drugs and block injection,etc. 4、5 However,50% to 85% of patients develop continuous or recurrent neck pain due to lack of regular treatment and follow-up home exercise. 6 Extracorporeal Shock Wave Therapy(ESWT) uses high-energy external mechanical waves to act on the surface of the human body and produce instantaneous cavitation. 7 It is a non-invasive treatment with insignificant adverse events, 8 ESWT was first used for extracorporeal lithotomy and is often used to treat various tendinopathy injuries,fracture nonunion and calcification diseases in rehabilitation clinic.Studies have shown that ESWT has a significant effect on musculoskeletal pain,which can effectively improve pain threshold and reduce muscle tension. 7、9、10 Fatma Alzahra H 11 found that ESWT had more significant improvements in treating neck pain than taking non-steroidal drugs. Wuqinxi exercise,created by Hua Tuo,is an important Qigong of traditional Chinese health keeping. 12 Based on the theory of traditional Chinese medicine,it integrates a set of health training skills by imitating the daily movements of tiger,bear,deer,monkey and bird. Wuqinxi exercise emphasizes the combination of physical and mental exercise with breathing to stretch muscles and bones and restore physical strength.It is a popular traditional Chinese Qigong technique used to prevent diseases and strengthen the body.Studies have confirmed that Wuqinxi exercise can significantly improve the physical function of patients with chronic diseases such as knee arthritis,hip arthritis and low back pain,effectively improve muscle strength and joint flexibility. 13、14、15 However,there are few studies focus on the therapeutic effect in neck pain. At present,the research on subacute mechanical neck pain focuses on symptomatic treatment in hospitals,and rarely extends to muscle training at home.Most of patients lack of muscle exercise and do not know what kind of exercise to choose,which is an important reason for recurrent neck pain. The aim of this study is to investigate the therapeutic effect of ESWT combined with Wuqinxi exercise in subacute mechanical neck pain,and provide a feasible cervical spine exercise for patients with mechanical neck pain at home.It is predicted that combined treatment could significantly relieve the symptoms of neck pain and improve the cervical motor function. Design Trial Design and Participants This study was a single-center,randomized,double-blind,parallel-group trial.The study subjects were 70 participants with subacute mechanical neck pain in the Outpatient of Rehabilitation Medicine ,Guangzhou First People's Hospital from January 2022 to January 2023. Based on our previous small sample trial,Wuqinxi exercise had a positive effect on preventing short-term recurrence in patients with subacute mechanical neck pain, so we predicted that it would also have a positive effect in this study. Inclusion criteria ①Meeting the working group on the classification of mechanical neck pain and related diseases of bone and joint decade 2000-2010,non-specific mechanical neck pain grade I or II criteria; 16 ②20-60 years old; ③ Neck pain attack in the past 6 weeks to 3 months;④Except neck pain,no more than three aches in other parts of body. Exclusion criteria ① Cervical spine trauma or surgery;② Bone and joint tumors or bone tuberculosis;③Severe osteoporosis or endocrine system diseases; ④Infectious diseases. All participants provided informed written consent and the study was approved by the Ethics Committee in Guangzhou First people’s hospital (Reference number:K-2022-133-01).This study was registered in the Chinese Clinical Trial Registry (Registration number：ChiCTR2200064781) Randomization and Intervention The rehabilitation physicians screened the subacute mechanical neck pain patients who meeting the inclusion criteria and fully explained the procedures and precautions for the participants to participate in the intervention before signing the informed consent. A statistician used a computer to generate random numbers and put them in envelopes that were opened by the participants.The therapist grouped the participants based on random numbers in the envelopes.70 participants were randomly assigned into intervention or control groups.The intervention group received ESWT combined with Wuqinxi exercise,while the control group received ultrasound therapy,for 4 weeks, They were evaluated by another therapist.The therapist participating in the assessment and the participants was not aware of the grouping.All participants signed informed consent and volunteered to join the study. Interventi on Group The participants were seated,and the therapist positioned the pain site.EMS SwissClast extracorporeal shock wave pain treatment system was used. 17 2,000 shocks in one session with the energy of 1.5-2.5 bar and frequency of 8-10 Hz,twice a week,for 4 weeks. We selected monkey exercise in Wuqinxi exercise,which has the highest involvement in cervical movement. 18 Firstly,we analyzed the essentials of monkey exercise for the enrolled participants,and played monkey exercise video simultaneously in the therapy room.The monkey exercise is a bionic movement that simulates the monkey standing on their toes in the wild, which includes lifting the body,pulling back the neck,lifting the shoulders, pulling back the bilateral shoulder blades,and then rotating the cervical spine left and right. Figure 1 shows the essentials of monkey exercise: Both wrists bend in front of body, breathe in slowly, two hands lift to chest,lift bilateral shoulder, shrink the neck,and the neck rotate to the left,lasts for 5 seconds,then the neck return to neutral position,bilateral shoulder sink and breathe out at the same time,rest for 5 seconds,again repeat above movement but the neck rotate to the right. 19 The above exercise was repeated 10 times on each side,a total of 15-20 minutes,twice a week. Control Group ꎮ Participants in the control group were treated with ultrasound therapy.ITO US-750 ultrasonic therapy instrument was used.The frequency of ultrasound was 1 MHz, and the intensity was 0.5-1.5 W/cm 2 ,last for 10 minutes.5 times a week for 4 weeks. Outcome measures Neck Disability Index(NDI) The Neck Disability Index is widely used to assess the neck pain on daily living, 20 and is a excellent guide to assess cervical motor function. 21 It was assessed at baseline,after one session,1 st week and 4 th week after intervention.10 categories included pain intensity,personal care,lifting, reading,headaches,concentration,work,driving,sleep and recreation. Each category has a minimum score of 0 and a maximum score of 5.The total score ranges from 0 to 50,higher scores indicating greater dysfunction. Visual Analogue Scale( VAS) The VAS was widely used to assess musculoskeletal pain when impaired cervical motor function occurred.It was exhibited by the participants through a 0–10 scale.Participants were informed to mark the line according to the pain intensity at baseline,after one session,1 st week, and 4 th week after intervention.0 means no pain and 10 means worst pain. Range of motion (ROM) Decreased range of motion occurs in most patients with mechanical neck pain,and it is related to cervical motor function impaired. 22、23 The universal goniometer will be used to assess joint motion in all directions of the cervical spine at baseline and 4 th week after intervention. Maximal Isometric Strength(MIS) Maximal isometric neck extension and flexion strength values were significantly lower in the patients with mechanical neck pain versus healthy controls. 24 Maximal isometric strength is commonly used to assess the neck strength.Maximal isometric neck extension and flexion strength was measured using MicroFet 3 dynamometer (Hoggan Health Industries, Sandy,UT, USA) at baseline,after one session,1 st week and 4 th week after intervention.Repeat once after 30 seconds rest between each set of movements,and take the average of the two measurements. The flexion/extension strength ratio(F/E R) The flexion/extension strength ratio reflects the motor function of cervical spine.According to the study of Prushansky T, 25 F/E R of patients with mechanical neck pain is between 0.6 and 0.8,which is higher than that of normal patients without neck pain.Through the formula F/E R=maximal isometric neck flexion strength/maximal isometric neck extension strength,F/E R was calculated at baseline,after one session,1 st week and 4 th week after intervention. Statistical Methods This study is a randomized controlled trial, Neck Disability Index is the main outcome measure.Referring to the study of Gezginaslan M 26 ,combined with the results of our previous small sample study, we predict that the average difference of Neck Disability Index between the two groups is 5.6.The standard deviation is 4.8, the sample assumption is α=0.05, β is 0.1,and according to the formula N=[(Z α +Z β ) 2 *2σ 2 ]/δ 2 ,the minimum sample size of each group is 16.Considering the drop rate of 20% at most in this study,the final sample size of each group is 20.In order to improve the statistical efficiency of the study, on the basis of meeting the minimum sample size content,70 subjects were included in this study,35 cases in each group. Differences in baseline characteristics between the two groups were compared using independent t-tests or chisquare tests.Two-way repeated measure analysis of variance was used to analyze the changes of VAS, ROM,NDI, MIS and F/E R in different sessions within each group.Analysis of variance（ANOVA）was used for outcome measures on the 4 th week after intervention between two groups.All tests were 2-sided and a p value<0.05 was considered as statistically significant.SPSS statistical software version 28.0 was used to perform statistical analyses. Results Baseline Characteristics of Participants Figure 2 shows the flow of study.70 participants with subacute mechanical neck pain who met the inclusion criteria and signed informed consent were randomly assigned into intervention or control groups. After 4 weeks of intervention,63 participants (intervention group n=32, control group n=31) completed the study.In intervention group,one participant refused to continue intervention, one participant drop out due to travel, and one participant had dizziness attack and stopped intervention. In control group,2 participants refused to continue intervention and 2 participants requested intervention modification.The mean age of the participants was 38.5 (standard deviation 8.4) years, 30 (47.6%)were women,the mean disease duration was 8.0 (standard deviation 1.9) weeks,the baseline value of VAS was 6.4 (standard deviation 1.3).The baseline value of NDI was 28.8 (standard deviation 5.3), the baseline value of the Neck flexion range of motion was 41.1 (standard deviation 3.9)degrees, and the baseline value of the extension was 41.8 (standard deviation 3.9)degrees.Pain side lateral flexion was 33.8 (standard deviation 7.7)degrees,healthy side lateral flexion was 41.1 (standard deviation 5.5)degrees,pain side rotation was 41.5 (standard deviation 5.0)degrees,the healthy side rotation was 36.9 (standard deviation 7.3)degrees.The baseline value of maximal isometric strength of cervical flexion was 11.6 (standard deviation 3.1)lbs,the baseline value of maximal isometric strength of cervical extention was 14.5 (standard deviation 3.4)lbs and the baseline value of F/E R was 0.93 (standard deviation 0.24). Table 1 describes the characteristics of the participants in two groups at baseline. Both groups had similar demographic and sociodemographic characteristics, pain levels,neck strength,and cervical motor function.There is also no significant difference in VAS, NDI,ROM,MIS except for F/E R( p <0.05). Table 1 Baseline Characteristics of Participants in the intervention and control groups Characteristic Intervention Group （N=32） Control Group （N=31） Age，y，mean（SD） 38.4（7.3） 38.8（9.5） Female 15（46.9） 15（48.4） Hight，cm，mean（SD） 166.3（6.7） 165.5（6.8） Weight，kg，mean（SD） 64.2（9.6） 65.2（7.9） Pain on the left side 15（46.9） 17（54.8） Disease duration，wk，mean（SD） 8.0（1.9） 7.8（1.9） Body Mass Index, mean (SD) 23.1（2.3） 23.8（2.3） Visual Analogue Scale，mean（SD） 6.7（1.4） 6.1（1.2） Neck Disability Index，mean（SD） 29.0（5.5） 28.5（5.3） Range of motion，degree，mean（SD） Flexion 41.6（3.8） 40.5（4.0） Extention 41.7（4.5） 41.9（3.2） Pain side lateral flexion 34.7（7.3） 32.9（8.2） Healthy side Lateral flexion 42.7（3.1） 39.4（6.6） Pain side rotation 42.5（1.8） 39.5（6.3） Healthy side rotation 37.5（6.4） 36.2（8.2） Maximal Isometric Strength，lb，mean（SD） Flexion 12.2（3.5） 11.0（2.5） Extension 14.7（3.9） 14.4（2.9） The flexion/extension strength ratio，mean（SD） 1.05（0.21） 0.81（0.22） Whole sample After 4 weeks,NDI decreased from 29.0（5.5）to 4.1(1.2) in intervention group and decreased from 28.5（5.3）to 9.3(2.9)in control group. Table 2 and Figure 3 show the changes in NDI before and after intervention between intervention group and control group.Compared with the control group,the intervention group showed more significant improvement in the NDI after 4 weeks of intervention[5.69, 95% confidence interval (CI): 3.05 to 8.31, p <0.001]. As an important indicator of clinical symptom improvement,pain symptoms are also evaluated by the NDI. Figure 4 describes participants' pain symptoms improved significantly after 4 weeks of intervention.The scores of VAS decreased from 6.7（1.4）to 2.1（0.9）in intervention group and decreased from 6.1（1.2）to 3.5（1.1）in control group，Intergroup comparison showed that the improvement was more significant in the intervention group after 4 weeks of intervention[1.99，95% confidence interval (CI):1.03 to 2.93, p <0.05]. Table 2 Comparison of Neck Disability Index before and after intervention between intervention group and control group Intervention Group（n=32） Control Group（n=31） Baseline，Mean（SD） 29.0（5.5） 28.5（5.3） After 4 th week，Mean（SD） 4.1(1.2) 9.3(2.9) Change，Mean（95% CI） 24.88(19.67,30.09) 19.19(13.95,24.43) Between group difference change， Mean（95% CI） 5.69（3.05，8.31） p value <.001 Mobility Deficits is another reason to seek medical attention. Figure 5 shows that after 4 weeks of intervention, the range of cervical motion in both groups were increased.The comparison between two groups showed that the progress of intervention group was significantly better than that of control group, which was closer to the normal range of cervical motion.The difference between two groups was statistically significant ( p <0.05),except healthy side rotation ( p =0.096). Maximal isometric neck extension and flexion strength of the participants in both groups were improved after intervention, and the maximal isometric neck extension and flexion strength of the participants in intervention group were ahead of the control group in both speed and amplitude of recovery after intervention. Figure 6 shows that after 4 weeks of intervention, maximal isometric neck flexion strength in intervention group increased from 12.2 (3.5)lbs to 16.6 (1.6)lbs,maximal isometric neck extension strength increased from 14.7 (3.9)lbs to 22.6 (2.0)lbs.Maximal isometric neck flexion strength in control group increased from 11.0 (2.5)lbs to 14.5 (2.2)lbs, maximal isometric neck extension strength increased from 14.4 (2.8)lbs to 19.9 (2.7)lbs.Intergroup comparison showed that the improvement was more significant in intervention group after 4 weeks of intervention，maximal isometric neck flexion strength[0.91，95% confidence interval (CI): 0.38 to 2.20, p <0.05 ]and maximal isometric neck extension strength[2.42，95% confidence interval (CI): 0.72 to 4.13, p <0.05 ]. At the same time, Figure 7 shows F/E R Decreased after intervention, another indicator of improved cervical stability, from 1.05(0.21) to 0.74(0.81) in intervention group and from 0.81(0.22) to 0.74(0.14) in control group.The improvement was more significant in intervention group compared with control group after 4 weeks of intervention [difference=0.24，95% confidence interval (CI): 0.13 to 0.35, p <0.05]. Discussion Possible mechanisms of subacute mechanical neck pain Subacute mechanical neck pain often results in cervical spine dysfunction,including moderate pain,mobility deficits,neck muscles weakness, 27 and neuromuscular control of neck and back muscles decreased,which lead to changes in proprioception and postural stability of the cervical spine. 28 It is mainly caused by the musculoskeletal injuries,coupled with factors such as cold, excessive desk work,abnormal posture and ergonomics,etc. 29、30、31 It was found that muscles and fascia imbalance in the neck,shoulder and back,and neuromuscular control efficiency decreased. 32 Most people who lack of regular and timely treatment develop myofascial pain syndrome(MPS). 33 Meanwhile,the deep cervical flexors are inhibited,resulting in spasticity and excessive activation of cervical trapezius and erectus spinae, and lower trapezius and serratus anterior are weakened. 34 The pain symptoms were more effective relieved Based on our results,the neck pain symptoms of the participants in the control group with ultrasound therapy was improved,but the assessment of the intervention group were superior to the control group.the immediate effect in the intervention group were significant,which may be due to the immediate effect of ESWT.Studies have shown that ESWT can increase the pain threshold of healthy people after one session, and last for 3 hours. 35 Luan S et al.reported that the VAS of patients with neck pain decreased significantly after one session of ESWT,showing the same analgesic effect as Dry Needling. 36 Gezginaslan M conducted randomized controlled trials with 7 sessions of ESWT with an intensity of 0.26 mJ/mm 2 ,and found that the VAS and Pittsburgh Sleep Quality Index (PSQI) in the intervention group were better than traditional physical therapy. 26 ESWT works on the human body through high frequency mechanical waves,the analgesia mechanism is not well established,is probably the ESWT improve the local blood supply, 37 eliminates the pain induced the release of the material, to prevent muscle pain receptors activation and selectivity of the myelin sheath fiber damage. 38 Wuqinxi exercise can effectively improve cervical mobility deficits The monkey exercise in Wuqinxi exercise improved joint range of motion,body flexibility and stability by imitating monkeys looking around,including neck extension,retraction,lateral flexion and rotation,as well as coordinated shoulder the contraction of shoulder and back muscles. 39 We can see the improvement of ROM in the intervention group was significantly better than the control group after 4 weeks of intervention.The ROM of the cervical spine in all directions was improved more effectively,while the healthy side rotation was not significantly different between the two groups.This maybe result from the insufficient sample size. In order to perform Wuqinxi exercise better,participants in the intervention group were required to complete ESWT first.ESWT can release fascia tension obviously, 30 and reverses the vicious cycle of pain-spasticity-ischaemia-pain.Combined with the analgesic effect and myofascial release effect of ESWT, participants felt more relaxed and easy when performing Wuqinxi exercise, and the neck, shoulder and back muscles were more fully involved in the training.Xiao Z et al.reported that Wuqinxi exercise can effectively enhance muscle strength and endurance,and improve joint stability and flexibility. 15 This study backs up our findings. The strength of the cervical spine was effectively restored Monkey exercise is a good Craniocervical Flexion Exercise (CFE).CFE need to contract the deep cervical flexors of the upper cervical part of the spine. 40 Jull et al.suggested that the low-load CFE effectively trains the deep cervical flexors in the early stages of rehabilitation. 41 Rotation in neck with retraction can effectively trains the deep cervical flexors without recruitment of the superficial flexors,and the contraction of cervical trapezius muscle can be coordinated with shoulder lifting while breathing,so as to effectively improve the nerve control ability of muscles around cervical spine and scapula,and enhance the muscle strength. 28 The American Physical Therapy Association guidelines for neck pain suggest that neck and shoulder muscles endurance training should be provided for patients with subacute mechanical neck pain. 2 Studies reported that Wuqinxi exercise can effectively reduce low back pain by activating the vitality of multifidus muscle and enhancing the stability of spine. 42、43 After intervention with Wuqinxi,Maximal isometric neck extension and flexion strength increased significantly in the intervention group compared with the control group,Moreover,the F/E R decreased more than that in the control group, indicating that the motor function of the cervical spine recovered better. NDI reflects the motor function of the cervical spine as well as the ability to perform daily activities. The NDI measured pain, daily care, work, recreation and sleep, reflecting the ability include pain, ROM and muscle strength in real life. 21 Therefore,cervical pain,mobility deficits, or muscle weakness can affect the score of NDI.At the same time,the decrease of the NDI score indicates that the cervical motor function have been restored and the treatment is effective.The analgesic effect of ESWT and the effect of Wuqinxi exercise on increasing ROM and muscle strength combined to influence the NDI.Repeated measure analysis of variance showed that the improvement of NDI was more significant in the intervention group.This indicated that ESWT combined with Wuqinxi exercise was more effective than ultrasonic therapy. Outlook on Wuqinxi exercise The Wuqinxi exercise is popular in China,where people practice it to improve their immune system and prevent disease.Studies reported that Wuqinxi exercise has an effect on improving state of mind,increasing the activity of NK cells and effectively adjusting the balance of immune. 44 But people were not aware of Wuqinxi exercise could heal musculoskeletal injuries in neck.At present our research is the first study using Wuqinxi exercise in the treatment of subacute mechanical neck pain. As a relatively interesting bionic exercise, the monkey exercise of Wuqinxi exercise is simple and easy to learn.It is a safe and effective treatment,which can be used as a rehabilitation training exercise for patients with subacute mechanical neck pain at home,it is helpful to improve the symptoms of neck pain.We followed up the participants one month after finishing intervention and found that many of them would continue to practice Wuqinxi exercise for the prevention of neck pain recurrence and symptomatic management of mild neck pain. Limitations of our study:①Since it is difficult for patients with subacute mechanical neck pain to qualify for inpatient care, the majority of participants are outpatients. This poses a challenge to quality control of participants during intervention and may introduce some bias.②We failed to add inclusion criteria that participants need to have good imitation ability.Some participants need repeated instructions on the movement essentials of monkey exercise. Conclusion ESWT combined with Wuqinxi exercise can relieve pain,increase joint range of motion and muscle strength better than conventional ultrasound therapy.It can significantly improve the motor function of cervical spine. Declarations Acknowledgements We would like to thank the participants of this study and the colleagues and interns in the outpatient of rehabilitation medicine. Authors’ contributions Shaoping Lin completed the assessment of participants and the writing of the study.Tingting Lun was responsible for teaching and supervising participants to perform Wuqinxi exercise.Shixiong Wang administered extracorporeal shock wave therapy.Jin Yu completed the study design and intervention content setting. Funding The authors received the following financial support for the research, author status, and/or publication of this article: (1) Guangdong University Scientific Research Platform and Project of Education Department of Guangdong Province (no.2019KZDZX1041); (2) Guangzhou Health Science and Technology Project(no.20221A010004). Availability of data and materials All data generated or analyzed during this study are included in this published article [and its supplementary information files]. Ethics approval and consent to participate All participants signed an informed consent. The study was approved by the Ethics Committee in Guangzhou First people’s hospital (reference number:K-2022-133-01)and conducted in accordance with the declaration of Helsinki. Consent for publication Nie HY (participant for Figure 1) declares his consent to the publication of identifying information/images in BMC (open access online publication). Competing interests The authors declare that they have no competing interests. Authors' information 1 Clinical school of Acupuncture,Moxibustion and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou,China. 2 Department of Rehabilitation Medicine, Guangzhou First People's Hospital, Guangzhou, China. References Mahajan R,Kataria C,Bansal K.Comparative Effectiveness of Muscle Energy Technique and Static Stretching for Treatment of Subacute Mechanical Neck Pain. Int J Health Rehab Sci(IJHRS) ,2012;1(1):16-24.doi:10.5455/ijhrs.00000004. Blanpied PR,Gross AR,Elliott JM,et al.Neck Pain: Revision 2017. 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Ochiai N,Ohtori S,Sasho T,et al.Extracorporeal shock wave therapy improves motor dysfunction and pain originating from knee osteoarthritis in rats. Osteoarthr Cartilage .2007;15(9):1093-1096. doi:10.1016/j.joca.2007.03.011. Xiao CM,Li JJ,Kang Y,Zhuang YC.Follow-up of a Wuqinxi exercise at home programme to reduce pain and improve function for knee osteoarthritis in older people:a randomised controlled trial. Age Ageing . 2021;50(2):570-575.doi:10.1093/ageing/afaa179. Kim BB,Lee JH,Jeong HJ,Cynn HS.Effects of suboccipital release with craniocervical flexion exercise on craniocervical alignment and extrinsic cervical muscle activity in subjects with forward head posture. J Electromyogr Kines .2016;30:31-7.doi:10.1016/j.jelekin.2016.05.007. Jull G,Falla D,Vicenzino B,Hodges P.The effect of therapeutic exercise on activation of the deep cervical flexor muscles in people with chronic neck pain. Man Ther .2009;14(6):696-701.doi: 10.1016/j.math.2009.05.004. Bai YH,Dong LW,Wang JR,Zeng JY,Zhang J.Effect of Wuqinxi on Improving the Function of Lumbosacral Multi Clef Muscle. Chin J Rehabil Med .2012;27(4):368–370. Zhang F,Bai YH,Zhang J.The Influence of“wuqinxi”exercises on the Lumbosacral Multifidus. J Phys Ther Sci .2014;26(6):881-884.doi:10.1589/jpts.26.881. Yu DH,Wu JM.Efects of Exercising Building-Up QigongWuqinxi on Middle-Aged and Old People’s NK Cell Activity. J Shang hai Univ Sport .2008;32(1):56-58. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2582526","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":186695163,"identity":"bedc8c94-64d9-455a-9797-213d1473524a","order_by":0,"name":"Shaoping Lin","email":"","orcid":"","institution":"Guangzhou University of Chinese Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shaoping","middleName":"","lastName":"Lin","suffix":""},{"id":186695165,"identity":"360c0311-858f-4fe2-b594-0b03cc9b5f21","order_by":1,"name":"Tingting Lun","email":"","orcid":"","institution":"Guangzhou University of Chinese Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tingting","middleName":"","lastName":"Lun","suffix":""},{"id":186695166,"identity":"753afc64-ddeb-4de5-9132-baa3a1d4b45f","order_by":2,"name":"Shixiong Wang","email":"","orcid":"","institution":"Guangzhou First People's Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shixiong","middleName":"","lastName":"Wang","suffix":""},{"id":186695167,"identity":"4e4e6225-6031-4593-b361-79224dcd7279","order_by":3,"name":"Jin Yu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyUlEQVRIiWNgGAWjYFCCA0BcAeOwEaXlMBCfIU0LMwMDYxspWgwOnj/46ea8WnuD46cTGD6UHWbgn91AQMuBw8zSuduOMxucyd3AOOPcYQaJOwcIamFjzt12jM3gBu8GZt62wwwGEgnEaJlzjAes5S/xWhpqJMBaGInRInngsLF0zrEDBpJAvxzsOZfOI3GDgBa+Gwcffs6pqbPnO35244MfZdZy/DMIaFG4cQBEHQZzQEwe/OqBQL6/AUTVEVQ4CkbBKBgFIxgAAICYSOmG1KH7AAAAAElFTkSuQmCC","orcid":"","institution":"Guangzhou University of Chinese Medicine","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Jin","middleName":"","lastName":"Yu","suffix":""}],"badges":[],"createdAt":"2023-02-13 14:14:37","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2582526/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2582526/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":35284846,"identity":"e8915b61-1678-4a96-b402-9098cca2905e","added_by":"auto","created_at":"2023-04-04 17:59:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1000290,"visible":true,"origin":"","legend":"\u003cp\u003eThe essentials of the monkey exercise.(A)Hands with wrists bend lift to the chest , lift shoulders. (B)shrink the neck and rotate to the left.(C)return to neutral position.(D)Hands with wrists bend lift to the chest , lift shoulders.(E)shrink the neck and rotate to the right.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-2582526/v1/f71ec5974056e9389f1b48b7.png"},{"id":35284845,"identity":"a51ed921-a846-4153-9bcf-196c36e49a5b","added_by":"auto","created_at":"2023-04-04 17:59:15","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":88520,"visible":true,"origin":"","legend":"\u003cp\u003eFlow of the study\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-2582526/v1/bef2ef4bc1913d781f1982ca.png"},{"id":35284732,"identity":"7f932636-2311-4a4a-8ef6-493df0432abb","added_by":"auto","created_at":"2023-04-04 17:51:15","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":48462,"visible":true,"origin":"","legend":"\u003cp\u003eChanges of Neck Disability Index before and after intervention in intervention and control groups.One-way repeated measure analysis of variance showed statistically significant differences in NDI each session between groups (all \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001).The improvement was more significant in the intervention group compared with the control group after 4 weeks of intervention(\u003cem\u003ep\u003c/em\u003e\u0026lt;0.001).\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-2582526/v1/641795d3c7fe8f76b4f59a2a.png"},{"id":35284731,"identity":"1a27e868-6412-4906-9758-598b5eeb3d3c","added_by":"auto","created_at":"2023-04-04 17:51:15","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":53433,"visible":true,"origin":"","legend":"\u003cp\u003eChanges of Visual Analogue Scale before and after intervention in intervention and control groups.one-way repeated measure analysis of variance showed statistically significant differences in VAS each session between groups (all \u003cem\u003ep\u003c/em\u003e\u0026lt;0.05).The improvement was more significant in the intervention group compared with the control group after 4 weeks of intervention(\u003cem\u003ep\u003c/em\u003e\u0026lt;0.05).\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-2582526/v1/bedf23ce4afd656525093a55.png"},{"id":35284733,"identity":"212d251b-4f31-474e-a494-ee32db7c2f65","added_by":"auto","created_at":"2023-04-04 17:51:15","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":132626,"visible":true,"origin":"","legend":"\u003cp\u003eChanges of cervical active range of motion before and after intervention in intervention and control groups.A One-way analysis of variance showed that ROM differences between the groups were statistically significant(all \u003cem\u003ep\u003c/em\u003e\u0026lt;0.05) on the 4\u003csup\u003eth\u003c/sup\u003e week after intervention, except for the healthy side roration(\u003cem\u003ep\u003c/em\u003e=0.096).\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-2582526/v1/b43eb556b64f6eeefa031e8b.png"},{"id":35284734,"identity":"477d665a-66f8-43aa-823f-f7de75acded8","added_by":"auto","created_at":"2023-04-04 17:51:15","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":61549,"visible":true,"origin":"","legend":"\u003cp\u003eChanges of Maximal Isometric Strength before and after intervention in intervention and control groups.one-way repeated measure analysis of variance showed statistically significant differences in Maximal Isometric Strength each session between groups (all \u003cem\u003ep\u003c/em\u003e\u0026lt;0.05).The improvement was more significant in the intervention group compared with the control group after 4 weeks of intervention(\u003cem\u003ep\u003c/em\u003e\u0026lt;0.05).\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-2582526/v1/6b80da4b55b11d3c7fafca39.png"},{"id":35284736,"identity":"52019d98-655e-46e7-9d6d-96ff9fe93c05","added_by":"auto","created_at":"2023-04-04 17:51:15","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":38513,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of F/E R before and after intervention between intervention group and control group.\u003cem\u003ep\u003c/em\u003e value at baseline F/E R was \u0026lt;0.05 between two groups.The improvement was more significant in the intervention group compared with the control group on the 4\u003csup\u003eth\u003c/sup\u003e week after intervention[difference=0.24，95% confidence interval (CI): 0.13 to 0.35,\u003cem\u003ep\u003c/em\u003e\u0026lt;0.05].\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-2582526/v1/940e3c1cfef4b61289f2dee3.png"},{"id":36764085,"identity":"79c88970-629a-411a-aa4a-864631200861","added_by":"auto","created_at":"2023-05-10 04:59:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1605242,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2582526/v1/640e9e39-5365-4610-bb66-80bc14b9c9ee.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effects of extracorporeal shock wave therapy combined with Wuqinxi exercise on cervical motor function in patients with subacute mechanical neck pain","fulltext":[{"header":"What Is Known","content":"\u003cp\u003eThere are many treatment options for subacute mechanical neck pain, but there is a long way to go from treatment to home training that can prevent exacerbation and recurrence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWhat is New\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eExtracorporeal shock wave therapy for musculoskeletal pain is a recent trend in pain clinic, but Wuqinxi exercise is rarely used for cervical spine disease training,although Chinese people use it to improve the \u0026nbsp;immune system.As a bionic exercise,Wuqinxi exercise can train the cervical muscles and improve the motor function of the cervical spine, which is worthy of being recommended in the community.\u003c/p\u003e"},{"header":"Objective","content":"\u003cp\u003eSubacute Mechanical Neck Pain (SMNP) is defined as pain in the neck region with or without upper limb pain for more than 6 weeks and less than 3 months .\u003csup\u003e1、2\u003c/sup\u003e Studies have shown that 30% of patients with acute or subacute mechanical neck pain will be prolonged to chronic neck pain,and even the neck pain lasts for more than 6 months.\u003csup\u003e3\u003c/sup\u003e Therefore, treatment for subacute mechanical neck pain is particularly important,which includes\u0026nbsp;physiotherapy,acupuncture,massage,drugs and block injection,etc.\u003csup\u003e4、5\u003c/sup\u003e However,50% to 85% of patients develop continuous or recurrent neck pain due to lack of regular treatment and follow-up home exercise.\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eExtracorporeal Shock Wave Therapy(ESWT) uses high-energy external mechanical waves to act on the surface of the human body and produce instantaneous cavitation.\u003csup\u003e7\u003c/sup\u003eIt\u0026nbsp;is a non-invasive treatment\u0026nbsp;with\u0026nbsp;insignificant adverse events,\u003csup\u003e8\u003c/sup\u003e ESWT was first used for extracorporeal lithotomy and is often used to treat various tendinopathy injuries,fracture nonunion and calcification diseases in rehabilitation clinic.Studies have shown that ESWT has a significant effect on\u0026nbsp;musculoskeletal pain,which can effectively improve pain threshold and reduce muscle tension.\u003csup\u003e7、9、10\u003c/sup\u003eFatma Alzahra H\u003csup\u003e11\u003c/sup\u003e found that ESWT had more significant improvements in treating neck pain than taking non-steroidal drugs.\u003c/p\u003e\n\u003cp\u003eWuqinxi exercise,created by Hua Tuo,is an important Qigong of traditional Chinese health keeping.\u003csup\u003e12\u003c/sup\u003e Based on the theory of traditional Chinese medicine,it integrates a set of health training skills by imitating the daily movements of tiger,bear,deer,monkey and bird. Wuqinxi exercise emphasizes the combination of physical and mental exercise with breathing to stretch muscles and bones and restore physical strength.It is a popular traditional Chinese Qigong technique used to prevent diseases and strengthen the body.Studies have confirmed that Wuqinxi exercise can significantly improve the physical function of patients with chronic diseases such as knee arthritis,hip arthritis and low back pain,effectively improve muscle strength and joint flexibility.\u003csup\u003e13、14、15\u003c/sup\u003eHowever,there are few studies focus on the therapeutic effect in neck pain.\u003c/p\u003e\n\u003cp\u003eAt present,the research on subacute mechanical neck pain focuses on symptomatic treatment in hospitals,and rarely extends to muscle training at home.Most of patients lack of muscle exercise and do not know what kind of exercise to choose,which is an important reason for recurrent neck pain. The aim of this study is to investigate the therapeutic effect of ESWT combined with Wuqinxi exercise in subacute mechanical neck pain,and provide a feasible cervical spine exercise for patients with mechanical neck pain at home.It is predicted that combined treatment could significantly relieve the symptoms of neck pain and improve the cervical motor function.\u003c/p\u003e"},{"header":"Design","content":"\u003cp\u003e\u003cstrong\u003eTrial Design and Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was a single-center,randomized,double-blind,parallel-group trial.The study subjects were 70 participants with subacute mechanical neck pain in the Outpatient of Rehabilitation Medicine ,Guangzhou First People\u0026apos;s Hospital from January 2022 to January 2023. Based on our previous small sample trial,Wuqinxi exercise had a positive effect on preventing short-term recurrence in patients with subacute mechanical neck pain, so we predicted that it would also have a positive effect in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e①Meeting the working group on the classification of mechanical neck pain and related diseases of bone and joint decade 2000-2010,non-specific mechanical neck pain grade I or II criteria;\u003csup\u003e16\u0026nbsp;\u003c/sup\u003e②20-60 years old; ③ Neck pain attack in the past 6 weeks to 3 months;④Except neck pain,no more than three aches in other parts of body.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e① Cervical spine trauma or surgery;② Bone and joint tumors or bone tuberculosis;③Severe osteoporosis or endocrine system diseases; ④Infectious diseases.\u003c/p\u003e\n\u003cp\u003eAll participants provided informed written consent and the study was approved by the Ethics Committee in\u0026nbsp;Guangzhou First people\u0026rsquo;s hospital\u0026nbsp;(Reference number:K-2022-133-01).This study was registered in the Chinese Clinical Trial Registry (Registration number：ChiCTR2200064781)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRandomization and Intervention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe rehabilitation physicians screened the subacute mechanical neck pain patients who meeting the inclusion criteria and fully explained the procedures and precautions for the participants to participate in the intervention before signing the informed consent. A statistician used a computer to generate random numbers and put them in envelopes that were opened by the participants.The therapist grouped the participants based on random numbers in the envelopes.70 participants were randomly assigned into intervention or control groups.The intervention group received ESWT combined with Wuqinxi exercise,while the control group received ultrasound therapy,for 4 weeks, They were evaluated by another therapist.The therapist participating in the assessment and the participants was not aware of the grouping.All participants signed informed consent and volunteered to join the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInterventi\u003c/strong\u003e\u003cstrong\u003eon Group\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe participants were seated,and the therapist positioned the pain site.EMS SwissClast extracorporeal shock wave pain treatment system was used.\u003csup\u003e17\u0026nbsp;\u003c/sup\u003e2,000\u0026nbsp;shocks in one session with the energy of 1.5-2.5 bar and frequency of\u0026nbsp;8-10 Hz,twice a week,for 4 weeks. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe selected\u0026nbsp;monkey exercise\u0026nbsp;in Wuqinxi exercise,which has the highest involvement in cervical movement.\u003csup\u003e18\u0026nbsp;\u003c/sup\u003eFirstly,we analyzed the essentials of\u0026nbsp;monkey exercise\u0026nbsp;for the enrolled participants,and played\u0026nbsp;monkey exercise\u0026nbsp;video simultaneously in the therapy room.The\u0026nbsp;monkey exercise\u0026nbsp;is a\u0026nbsp;bionic movement\u0026nbsp;that simulates the monkey standing on their toes in the wild, which includes lifting the body,pulling back the neck,lifting the shoulders, pulling back the bilateral shoulder blades,and then rotating the cervical spine left and right.\u003cstrong\u003eFigure 1\u003c/strong\u003e shows the essentials of monkey exercise: Both wrists bend in front of body, breathe in slowly, two hands lift to chest,lift bilateral shoulder, shrink the neck,and the neck rotate to the left,lasts for 5 seconds,then the neck return to neutral position,bilateral shoulder sink and breathe out at the same time,rest for 5 seconds,again repeat above movement but the neck rotate to the right.\u003csup\u003e19\u003c/sup\u003eThe above exercise was repeated 10 times on each side,a total of 15-20 minutes,twice a week.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eControl Group\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eꎮ Participants in the control group were treated with ultrasound therapy.ITO US-750 ultrasonic therapy instrument was used.The frequency of ultrasound was 1 MHz, and the intensity was 0.5-1.5 W/cm\u003csup\u003e2\u003c/sup\u003e,last for 10 minutes.5 times a week for 4 weeks.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcome measures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNeck Disability Index(NDI)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Neck Disability Index\u0026nbsp;is\u0026nbsp;widely used to assess the\u0026nbsp;neck pain\u0026nbsp;on daily living,\u003csup\u003e20\u003c/sup\u003eand is a excellent\u0026nbsp;guide\u0026nbsp;to\u0026nbsp;assess\u0026nbsp;cervical motor\u0026nbsp;function.\u003csup\u003e21\u003c/sup\u003eIt was assessed at baseline,after one\u0026nbsp;session,1\u003csup\u003est\u003c/sup\u003e week and 4\u003csup\u003eth\u003c/sup\u003e week after intervention.10 categories included pain\u0026nbsp;intensity,personal\u0026nbsp;care,lifting, reading,headaches,concentration,work,driving,sleep and\u0026nbsp;recreation. Each category has a minimum score of 0 and a maximum score of 5.The total score ranges from 0 to 50,higher scores indicating greater dysfunction.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVisual Analogue Scale(\u003c/strong\u003e\u003cstrong\u003eVAS)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe VAS was\u0026nbsp;widely used to assess musculoskeletal pain when\u0026nbsp;impaired\u0026nbsp;cervical motor\u0026nbsp;function\u0026nbsp;occurred.It was\u0026nbsp;exhibited by the participants through a 0\u0026ndash;10 scale.Participants were informed to mark the line according to the pain intensity at\u0026nbsp;baseline,after one session,1\u003csup\u003est\u003c/sup\u003e week, and 4\u003csup\u003eth\u003c/sup\u003e week after intervention.0 means no pain and 10 means worst pain.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRange of motion\u003c/strong\u003e\u003cstrong\u003e(ROM)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDecreased range of motion occurs in most patients with mechanical neck pain,and it is related to cervical motor function impaired.\u003csup\u003e22、23\u003c/sup\u003eThe universal goniometer will be used to assess joint motion in all directions of the cervical spine at baseline and 4\u003csup\u003eth\u003c/sup\u003e week after intervention.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaximal Isometric Strength(MIS)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMaximal isometric neck extension and flexion strength values were significantly lower in the patients\u0026nbsp;with mechanical neck pain\u0026nbsp;versus healthy controls.\u003csup\u003e24\u0026nbsp;\u003c/sup\u003eMaximal isometric strength is commonly used to assess the neck strength.Maximal isometric neck extension and flexion strength\u0026nbsp;was measured using MicroFet 3 dynamometer (Hoggan Health Industries, Sandy,UT, USA) at baseline,after one session,1\u003csup\u003est\u003c/sup\u003e week and 4\u003csup\u003eth\u003c/sup\u003e week after intervention.Repeat once after 30 seconds rest between each set of movements,and take the average of the two measurements.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe flexion/extension strength ratio(F/E R)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe flexion/extension strength ratio reflects the motor function of cervical spine.According to the study of Prushansky T,\u003csup\u003e25\u003c/sup\u003eF/E R of patients with mechanical neck pain is between 0.6 and 0.8,which is higher than that of normal patients without neck pain.Through the formula F/E R=maximal isometric neck flexion strength/maximal isometric neck extension strength,F/E R was calculated at baseline,after one session,1\u003csup\u003est\u003c/sup\u003e week and 4\u003csup\u003eth\u003c/sup\u003e week after intervention.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is a randomized controlled trial, Neck Disability Index is the main outcome measure.Referring to the study of Gezginaslan M \u003csup\u003e26\u003c/sup\u003e,combined with the results of our previous small sample study,\u003csup\u003e\u0026nbsp;\u003c/sup\u003ewe predict that the average difference of Neck Disability Index between the two groups is 5.6.The standard deviation is 4.8, the sample assumption is \u0026alpha;=0.05, \u0026beta; is 0.1,and according to the formula N=[(Z\u003csub\u003e\u0026alpha;\u003c/sub\u003e+Z\u003csub\u003e\u0026beta;\u003c/sub\u003e) \u003csup\u003e2\u003c/sup\u003e*2\u0026sigma;\u003csup\u003e2\u003c/sup\u003e]/\u0026delta;\u003csup\u003e2\u003c/sup\u003e,the minimum sample size of each group is 16.Considering the drop rate of 20% at most in this study,the final sample size of each group is 20.In order to improve the statistical efficiency of the study, on the basis of meeting the minimum sample size content,70 subjects were included in this study,35 cases in each group.\u003c/p\u003e\n\u003cp\u003eDifferences in baseline characteristics between the two groups were compared using independent t-tests\u0026nbsp;or chisquare tests.Two-way repeated measure analysis of variance was used to analyze the changes of VAS, ROM,NDI, MIS and F/E R in different sessions within each group.Analysis of variance（ANOVA）was used for outcome measures on the 4\u003csup\u003eth\u003c/sup\u003e week after intervention between two groups.All tests were 2-sided and a \u003cem\u003ep\u003c/em\u003e value\u0026lt;0.05 was considered as statistically significant.SPSS statistical \u0026nbsp;software version 28.0 was used to perform statistical analyses.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eBaseline Characteristics of Participants\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 2\u003c/strong\u003e shows the flow of study.70 participants with subacute mechanical neck pain who met the inclusion criteria and signed informed consent were randomly assigned into intervention or control groups. After 4 weeks of intervention,63 participants (intervention group n=32, control group n=31) completed the study.In intervention group,one participant refused to continue intervention, one participant drop out due to travel, and one participant had dizziness attack and stopped intervention. In control group,2 participants refused to continue intervention and 2 participants requested intervention modification.The mean age of the participants was 38.5 (standard deviation 8.4) years, 30 (47.6%)were women,the mean disease duration was 8.0 (standard deviation 1.9) weeks,the baseline value of VAS was 6.4 (standard deviation\u0026nbsp;1.3).The baseline value of NDI was 28.8 (standard deviation 5.3), the baseline value of the Neck flexion range of motion was 41.1 (standard deviation 3.9)degrees, and the baseline value of the extension was 41.8 (standard deviation 3.9)degrees.Pain side lateral flexion was 33.8 (standard deviation 7.7)degrees,healthy side lateral flexion was 41.1 (standard deviation 5.5)degrees,pain side rotation was 41.5 (standard deviation 5.0)degrees,the healthy side rotation was 36.9 (standard deviation 7.3)degrees.The baseline value of maximal isometric strength of cervical flexion was 11.6 (standard deviation 3.1)lbs,the baseline value of maximal isometric strength of cervical extention was 14.5 (standard deviation 3.4)lbs and the baseline value of F/E R was 0.93 (standard deviation 0.24).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u0026nbsp;\u003c/strong\u003edescribes the characteristics of the participants in two groups at baseline. Both groups had similar demographic and sociodemographic characteristics, pain levels,neck strength,and cervical motor function.There is also no significant difference in VAS, NDI,ROM,MIS except for F/E R(\u003cem\u003ep\u003c/em\u003e\u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e Baseline Characteristics of Participants in the\u0026nbsp;intervention and control groups\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eIntervention Group\u003c/p\u003e\n \u003cp\u003e（N=32）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eControl Group\u003c/p\u003e\n \u003cp\u003e（N=31）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eAge，y，mean（SD）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e38.4（7.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e38.8（9.5）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e15（46.9）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e15（48.4）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eHight，cm，mean（SD）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e166.3（6.7）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e165.5（6.8）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eWeight，kg，mean（SD）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e64.2（9.6）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e65.2（7.9）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003ePain on the left side\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e15（46.9）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e17（54.8）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eDisease duration，wk，mean（SD）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e8.0（1.9）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e7.8（1.9）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eBody Mass Index, mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e23.1（2.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e23.8（2.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eVisual Analogue Scale，mean（SD）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e6.7（1.4）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e6.1（1.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eNeck Disability Index，mean（SD）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e29.0（5.5）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e28.5（5.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eRange of motion，degree，mean（SD）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eFlexion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e41.6（3.8）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e40.5（4.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e\u0026nbsp; Extention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e41.7（4.5）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e41.9（3.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003ePain side lateral flexion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e34.7（7.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e32.9（8.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eHealthy side\u0026nbsp;Lateral flexion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e42.7（3.1）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e39.4（6.6）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003ePain side rotation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e42.5（1.8）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e39.5（6.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eHealthy side\u0026nbsp;rotation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e37.5（6.4）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e36.2（8.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eMaximal Isometric Strength，lb，mean（SD）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eFlexion\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e12.2（3.5）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e11.0（2.5）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eExtension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e14.7（3.9）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e14.4（2.9）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eThe flexion/extension strength ratio，mean（SD）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e1.05（0.21）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e0.81（0.22）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eWhole sample\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter 4\u0026nbsp;weeks,NDI\u0026nbsp;decreased from\u0026nbsp;29.0（5.5）to\u0026nbsp;4.1(1.2) in intervention\u0026nbsp;group and decreased from\u0026nbsp;28.5（5.3）to 9.3(2.9)in control group.\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003eand \u003cstrong\u003eFigure 3\u003c/strong\u003e show the changes in NDI before and after intervention between intervention group and control group.Compared with the control group,the intervention group showed more significant improvement in the NDI after 4 weeks of intervention[5.69, 95% confidence interval (CI): 3.05 to 8.31,\u003cem\u003ep\u003c/em\u003e\u0026lt;0.001].\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;As an important indicator of clinical symptom improvement,pain symptoms are also evaluated by the NDI.\u003cstrong\u003eFigure 4\u003c/strong\u003e describes participants\u0026apos; pain symptoms improved significantly after 4 weeks of intervention.The scores of VAS decreased from 6.7（1.4）to 2.1（0.9）in intervention group and decreased from 6.1（1.2）to 3.5（1.1）in control group，Intergroup comparison showed that the improvement was more significant in the intervention group after 4 weeks of intervention[1.99，95% confidence interval (CI):1.03 to 2.93,\u003cem\u003ep\u003c/em\u003e\u0026lt;0.05].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e Comparison of Neck Disability Index before and after intervention between intervention group and control group\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eIntervention Group（n=32）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eControl Group（n=31）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eBaseline，Mean（SD）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e29.0（5.5）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e28.5（5.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eAfter 4\u003csup\u003eth\u003c/sup\u003e week，Mean（SD）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e4.1(1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e9.3(2.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eChange，Mean（95% CI）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e24.88(19.67,30.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e19.19(13.95,24.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.274647887323944%\"\u003e\n \u003cp\u003eBetween group difference change，\u003c/p\u003e\n \u003cp\u003eMean（95% CI）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"66.72535211267606%\"\u003e\n \u003cp\u003e5.69（3.05，8.31）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.274647887323944%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003evalue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"66.72535211267606%\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eMobility Deficits is another reason to seek medical attention.\u003cstrong\u003eFigure 5\u0026nbsp;\u003c/strong\u003eshows that after 4 weeks of\u0026nbsp;intervention, the range of cervical motion in both groups were increased.The comparison between two groups showed that the progress of intervention group was significantly better than that of control group, which was\u0026nbsp;closer to the normal range of cervical motion.The difference between two groups was statistically significant (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.05),except healthy side rotation (\u003cem\u003ep\u003c/em\u003e=0.096).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMaximal isometric neck extension and\u0026nbsp;flexion strength of the participants in both groups were improved after\u0026nbsp;intervention, and the\u0026nbsp;maximal isometric neck extension and\u0026nbsp;flexion strength of the participants\u0026nbsp;in\u0026nbsp;intervention group were ahead of the control group in both speed and amplitude of recovery after\u0026nbsp;intervention. \u003cstrong\u003eFigure 6\u0026nbsp;\u003c/strong\u003eshows that after 4 weeks of\u0026nbsp;intervention,\u0026nbsp;maximal isometric neck flexion strength\u0026nbsp;in\u0026nbsp;intervention group increased from 12.2 (3.5)lbs\u0026nbsp;to 16.6 (1.6)lbs,maximal isometric neck extension strength increased from 14.7 (3.9)lbs\u0026nbsp;to 22.6 (2.0)lbs.Maximal isometric neck flexion strength\u0026nbsp;in\u0026nbsp;control group increased from 11.0 (2.5)lbs\u0026nbsp;to 14.5 (2.2)lbs,\u0026nbsp;maximal isometric neck extension strength increased from 14.4 (2.8)lbs\u0026nbsp;to 19.9 (2.7)lbs.Intergroup comparison showed that the\u0026nbsp;improvement was more significant in intervention group after 4 weeks of intervention，maximal isometric neck flexion strength[0.91，95% confidence interval (CI):\u0026nbsp;0.38 to 2.20,\u003cem\u003ep\u003c/em\u003e\u0026lt;0.05\u0026nbsp;]and maximal isometric neck extension strength[2.42，95% confidence interval (CI):\u0026nbsp;0.72 to 4.13,\u003cem\u003ep\u003c/em\u003e\u0026lt;0.05\u0026nbsp;].\u003c/p\u003e\n\u003cp\u003eAt the same time, \u003cstrong\u003eFigure 7\u003c/strong\u003e shows F/E R Decreased after\u0026nbsp;intervention, another indicator of improved cervical stability, from 1.05(0.21) to 0.74(0.81) in intervention group and from 0.81(0.22) to 0.74(0.14) in control group.The improvement was more significant in intervention group compared with control group after 4 weeks of intervention [difference=0.24，95% confidence interval (CI): 0.13 to 0.35,\u003cem\u003ep\u003c/em\u003e\u0026lt;0.05].\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePossible mechanisms of subacute mechanical neck pain\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSubacute mechanical neck pain often results in cervical spine dysfunction,including moderate pain,mobility deficits,neck muscles weakness,\u003csup\u003e27\u0026nbsp;\u003c/sup\u003eand neuromuscular control of neck and back muscles decreased,which lead to changes in proprioception and postural stability of the cervical spine.\u003csup\u003e28\u0026nbsp;\u003c/sup\u003eIt is mainly caused by the musculoskeletal injuries,coupled with factors such as cold, excessive desk work,abnormal posture and ergonomics,etc.\u003csup\u003e29、30、31\u003c/sup\u003e It was found that muscles and fascia imbalance in the neck,shoulder and back,and neuromuscular control efficiency decreased.\u003csup\u003e32\u003c/sup\u003eMost people who lack of regular and timely treatment develop myofascial pain syndrome(MPS).\u003csup\u003e33\u003c/sup\u003e Meanwhile,the\u0026nbsp;deep cervical flexors\u0026nbsp;are inhibited,resulting in spasticity and excessive activation of cervical trapezius and erectus spinae, and lower trapezius and serratus anterior are weakened.\u003csup\u003e34\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eThe pain symptoms were more effective relieved\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on our results,the neck pain symptoms of the participants in the control group with\u0026nbsp;ultrasound therapy\u0026nbsp;was improved,but the assessment of the intervention group were superior to the control group.the immediate effect in the intervention group were significant,which may be due to the immediate effect of ESWT.Studies have shown that ESWT can increase the pain threshold of healthy people after one session, and last for 3 hours.\u003csup\u003e35\u0026nbsp;\u003c/sup\u003eLuan S et al.reported that the VAS of patients with neck pain decreased significantly after one session of ESWT,showing the same analgesic effect as Dry Needling.\u003csup\u003e36\u0026nbsp;\u003c/sup\u003eGezginaslan M conducted randomized controlled trials with 7 sessions of ESWT with an intensity of 0.26 mJ/mm\u003csup\u003e2\u003c/sup\u003e,and found that the VAS and Pittsburgh Sleep Quality Index (PSQI) in the intervention group were better than traditional physical therapy.\u003csup\u003e26 \u0026nbsp;\u0026nbsp;\u003c/sup\u003eESWT works on the human body through high frequency mechanical waves,the analgesia mechanism is not well established,is probably the ESWT improve the local blood supply,\u003csup\u003e37\u0026nbsp;\u003c/sup\u003eeliminates the pain induced the release of the material, to prevent muscle pain receptors activation and selectivity of the myelin sheath fiber damage.\u003csup\u003e38\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eWuqinxi exercise can effectively improve cervical mobility deficits\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe monkey exercise in Wuqinxi exercise improved joint range of motion,body flexibility and stability by imitating monkeys looking around,including neck extension,retraction,lateral flexion and rotation,as well as coordinated shoulder the contraction of shoulder and back muscles.\u003csup\u003e39\u003c/sup\u003e We can see the improvement of ROM in the intervention group was significantly better than the control group after 4 weeks of intervention.The ROM of the cervical spine in all directions was improved more effectively,while the healthy side rotation was not significantly different between the two groups.This maybe result from the insufficient sample\u0026nbsp;size.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn order to perform Wuqinxi exercise better,participants in the intervention group were required to complete ESWT first.ESWT can release fascia tension obviously,\u003csup\u003e30\u003c/sup\u003eand reverses the vicious cycle of pain-spasticity-ischaemia-pain.Combined with the analgesic effect and myofascial release effect of ESWT, participants felt more relaxed and easy when performing Wuqinxi exercise, and the neck, shoulder and back muscles were more fully involved in the training.Xiao Z et al.reported that Wuqinxi exercise can effectively enhance muscle strength and endurance,and improve joint stability and flexibility.\u003csup\u003e15\u0026nbsp;\u003c/sup\u003eThis study backs up our findings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eThe strength of the cervical spine was effectively restored\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMonkey exercise is a good Craniocervical Flexion Exercise (CFE).CFE\u0026nbsp;need to\u0026nbsp;contract the deep cervical flexors of the upper cervical part of the spine.\u003csup\u003e40\u003c/sup\u003eJull et al.suggested that the low-load CFE effectively trains the deep cervical flexors in the early stages of rehabilitation.\u003csup\u003e41\u003c/sup\u003e Rotation in neck with retraction can effectively trains the deep cervical flexors\u0026nbsp;without recruitment of the superficial flexors,and the contraction of cervical trapezius muscle can be coordinated with shoulder lifting while breathing,so as to effectively improve the nerve control ability of muscles around cervical spine and scapula,and enhance the muscle strength.\u003csup\u003e28\u003c/sup\u003e The American Physical Therapy Association guidelines for neck pain suggest that neck and shoulder muscles endurance training should be provided for patients with subacute mechanical neck pain.\u003csup\u003e2\u003c/sup\u003e Studies reported that Wuqinxi exercise can effectively reduce low back pain by\u0026nbsp;activating the vitality of multifidus muscle and enhancing the stability of spine.\u003csup\u003e42、43\u0026nbsp;\u003c/sup\u003eAfter\u0026nbsp;intervention\u0026nbsp;with Wuqinxi,Maximal isometric neck extension and flexion strength increased significantly in the intervention group compared with the control group,Moreover,the F/E R decreased more than that in the control group, indicating that the\u0026nbsp;motor\u0026nbsp;function of the cervical spine recovered better.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eNDI reflects the motor function of the cervical spine as well as the ability to perform daily activities.\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe NDI measured pain, daily care, work, recreation and sleep, reflecting the ability include pain, ROM and muscle strength in real life.\u003csup\u003e21\u003c/sup\u003eTherefore,cervical pain,mobility deficits, or muscle weakness can affect the score of NDI.At the same time,the decrease of the NDI score indicates that the cervical motor function have been restored and the treatment is effective.The analgesic effect of ESWT and the effect of Wuqinxi exercise on increasing ROM and muscle strength combined to influence the NDI.Repeated measure analysis of variance\u0026nbsp;showed that the improvement of NDI was more significant in the intervention group.This indicated that ESWT combined with Wuqinxi exercise was more effective than ultrasonic therapy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eOutlook on Wuqinxi exercise\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Wuqinxi exercise is popular in China,where people practice it to improve their immune system and prevent disease.Studies reported that Wuqinxi exercise has an effect on improving state of mind,increasing the activity of NK cells and effectively adjusting the balance of immune.\u003csup\u003e44\u0026nbsp;\u003c/sup\u003eBut people were not aware of Wuqinxi exercise could heal musculoskeletal injuries in neck.At present our research is the first study using Wuqinxi exercise in the treatment of subacute mechanical neck pain.\u003c/p\u003e\n\u003cp\u003eAs a relatively interesting bionic exercise, the monkey exercise of Wuqinxi exercise is simple and easy to learn.It is a\u0026nbsp;safe and effective \u0026nbsp;treatment,which can be used as a rehabilitation training exercise for patients with subacute mechanical neck pain at home,it is helpful to improve the symptoms of neck pain.We followed up the participants one month after finishing intervention and found that many of them would continue to practice Wuqinxi exercise for the prevention of neck pain recurrence and symptomatic management of mild neck pain.\u003c/p\u003e\n\u003cp\u003eLimitations of our study:①Since it is difficult for patients with subacute mechanical neck pain to qualify for inpatient care, the majority of participants are outpatients. This poses a challenge to quality control of participants during intervention and may introduce some bias.②We failed to add inclusion criteria that participants need to have good imitation ability.Some participants need repeated instructions on the movement essentials of monkey exercise.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eESWT combined with Wuqinxi exercise can relieve pain,increase joint range of motion and muscle strength better than conventional ultrasound therapy.It can significantly improve the motor function of cervical spine.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the participants of this study and the\u0026nbsp;colleagues\u0026nbsp;and interns\u0026nbsp;in the outpatient of rehabilitation medicine.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eShaoping Lin completed the assessment of participants and the writing of the study.Tingting Lun was responsible for teaching and supervising participants to perform Wuqinxi exercise.Shixiong Wang administered extracorporeal shock wave therapy.Jin Yu completed the study design and\u0026nbsp;intervention\u0026nbsp;content setting.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received the following financial support for the research, author status, and/or publication of this article: (1) Guangdong University Scientific Research Platform and Project of Education Department of Guangdong Province (no.2019KZDZX1041); (2) Guangzhou Health Science and Technology Project(no.20221A010004).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article [and its supplementary information files].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants signed an informed consent. The study was approved by the Ethics Committee in\u0026nbsp;Guangzhou First people\u0026rsquo;s hospital\u0026nbsp;(reference number:K-2022-133-01)and conducted in accordance with the declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNie HY (participant for Figure 1) declares his consent to the publication of identifying information/images in BMC (open access online publication).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eClinical school of Acupuncture,Moxibustion and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou,China. \u003csup\u003e2\u003c/sup\u003eDepartment of Rehabilitation Medicine, Guangzhou First People\u0026apos;s Hospital, Guangzhou, China.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMahajan R,Kataria C,Bansal K.Comparative Effectiveness of Muscle Energy Technique and Static Stretching for Treatment of Subacute Mechanical Neck Pain.\u003cem\u003eInt J Health Rehab Sci(IJHRS)\u003c/em\u003e,2012;1(1):16-24.doi:10.5455/ijhrs.00000004.\u003c/li\u003e\n\u003cli\u003eBlanpied PR,Gross AR,Elliott JM,et al.Neck Pain: Revision 2017.\u003cem\u003eJ Orthop Sports Phys Ther\u003c/em\u003e.2017;47(7):A1-A83.doi:10.2519/jospt.2017.0302.\u003c/li\u003e\n\u003cli\u003eBovim G,Schrader H,Sand T.\u003cem\u003eNeck pain in the general population\u003c/em\u003e.\u003cem\u003eSpine\u003c/em\u003e,1994;19(12):1307-1309.doi:10.1097/00007632-199503010-00023.\u003c/li\u003e\n\u003cli\u003eD\u0026iacute;az-Pulido B,P\u0026eacute;rez-Mart\u0026iacute;n Y,Pecos-Mart\u0026iacute;n D,et al.Efficacy of Manual Therapy and Transcutaneous Electrical Nerve Stimulation in Cervical Mobility and Endurance in Subacute and Chronic Neck Pain: A Randomized Clinical Trial.\u003cem\u003eJ Clin Med\u003c/em\u003e.2021;10(15):3245.doi:10.3390/jcm10153245\u003c/li\u003e\n\u003cli\u003eAnt\u0026uacute;nez S\u0026aacute;nchez LG,de la Casa Almeida M,Rebollo Rold\u0026aacute;n J,Ram\u0026iacute;rez Manzano A,Mart\u0026iacute;n Valero R,Su\u0026aacute;rez Serrano C.Effectiveness of an individualised physiotherapy program versus group therapy on neck pain and disability in patients with acute and subacute mechanical neck pain.\u003cem\u003eAten Primaria\u003c/em\u003e.2017;49(7):417-425.doi:10.1016/j.aprim.2016.09.010\u003c/li\u003e\n\u003cli\u003eCohen SP.Epidemiology,diagnosis,and treatment of neck pain.\u003cem\u003eMayo Clin Proc\u003c/em\u003e.2015;90(2):284-299.doi:10.1016/j.mayocp.2014.09.008.\u003c/li\u003e\n\u003cli\u003eSchmitz C, Cs\u0026aacute;sz\u0026aacute;r NB, Rompe JD, Chaves H, Furia JP. 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Sport\u003c/em\u003e.2008;32(1):56-58.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Extracorporeal shock wave therapy, Wuqinxi exercise, neck pain, cervical motor function","lastPublishedDoi":"10.21203/rs.3.rs-2582526/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2582526/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e This study aims to observe the effects of extracorporeal shock wave therapy combined with Wuqinxi exercise on cervical motor function in patients with subacute mechanical neck pain.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: 70 participants with subacute mechanical neck pain were randomly assigned into an intervention or control groups.The intervention group was treated with extracorporeal shock wave therapy and Wuqinxi exercise,while the control group was received ultrasound therapy,for 4 weeks.The Visual Analogue Scale(VAS),Neck Disability Index(NDI) and Maximal Isometric Strength(MIS) were used for assessment at baseline,after one session,1\u003csup\u003est\u003c/sup\u003e week,and 4\u003csup\u003eth\u003c/sup\u003e week after intervention.The flexion/extension ratio(F/E R)was calculated through MIS.The range of motion was measured at baseline and 4th week after intervention.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003e63 participants (intervention group n=32, control group n=31) completed the study.Intervention group showed more significant improvement in the Neck Disability Index after intervention[5.69, 95% confidence interval (CI): 3.05 to 8.31,\u003cem\u003ep\u003c/em\u003e\u0026lt;0.001].The improvement was more significant in intervention group on the Visual Analogue Scale[1.99，95% confidence interval (CI):1.03 to 2.93,\u003cem\u003ep\u003c/em\u003e\u0026lt;0.05].Neck muscle strength recovered better in intervention group.Flexion/Extention Strength Ratio decreased more significant in intervention group [0.24，95% confidence interval (CI): 0.13 to 0.35,\u003cem\u003ep\u003c/em\u003e\u0026lt;0.05].At the same time, intervention group showed greater increase in range of motion(\u003cem\u003ep\u003c/em\u003e\u0026lt;0.05),except healthy side rotation (\u003cem\u003ep\u003c/em\u003e=0.096).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eExtracorporeal shock wave therapy combined with Wuqinxi exercise can relieve pain, increase joint range of motion and muscle strength better than ultrasound therapy.It can significantly improve the motor function of cervical spine.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration:\u003c/strong\u003e Registration Number:ChiCTR2200064781(17/10/2022)\u003c/p\u003e","manuscriptTitle":"Effects of extracorporeal shock wave therapy combined with Wuqinxi exercise on cervical motor function in patients with subacute mechanical neck pain","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-04-04 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