Manual Therapy xxx (2015) 1e7

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Manual Therapy
journal homepage: www.elsevier.com/math

Original article

Cervical and scapulothoracic stabilization exercises with and without

connective tissue massage for chronic mechanical neck pain: A
prospective, randomized controlled trial*
Seyda Toprak Celenay a, Derya Ozer Kaya b, *, Turkan Akbayrak c
a
b
c

Yildirim Beyazit University, Health Sciences Faculty, Department of Physiotherapy and Rehabilitation, Ankara, Turkey
Izmir Katip Celebi University, Health Sciences Faculty, Department of Physiotherapy and Rehabilitation, Izmir, Turkey
Hacettepe University, Health Sciences Faculty, Department of Physiotherapy and Rehabilitation, Ankara, Turkey

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 19 January 2015
Received in revised form
1 July 2015
Accepted 8 July 2015

This study was planned to assess and compare the effectiveness of cervical and scapulothoracic stabilization exercise treatment with and without connective tissue massage (CTM) on pain, anxiety, and the
quality of life in patients with chronic mechanical neck pain (MNP). Sixty patients with chronic MNP (18
e65 years) were recruited and randomly allocated into stabilization exercise with (Group 1, n 30) and
without the CTM (Group 2, n 30). The program was carried out for 12 sessions, 3 days/week in 4 weeks.
Pain intensity with Visual Analog Scale, pressure pain threshold with digital algometer (JTech Medical
Industries, ZEVEX Company), level of anxiety with Spielberger State Trait Anxiety Inventory, and quality
of life with Short Form-36 were evaluated before and after the treatment. After the program, pain intensity and the level of anxiety decrease, physical health increase in Group 1 and 2 were found (p < 0.05).
Pressure pain threshold and mental health increase were detected in only Group 1 (p < 0.05). The
intergroup comparison showed that signicant difference in pain intensity at night, pressure pain
threshold, state anxiety and mental health were seen in favor of Group 1 (p < 0.05). The study suggested
that stabilization exercises with and without the CTM might be a useful treatment for patients with
chronic MNP. However, stabilization exercises with CTM might be superior in improving pain intensity at
night, pressure pain threshold, state anxiety and mental health compared to stabilization exercise alone.
2015 Elsevier Ltd. All rights reserved.

Keywords:
Neck pain
Stabilization exercise
Connective tissue massage

1. Introduction
Mechanical neck pain (MNP) is dened as generalized neck and/
or shoulder pain with symptoms provoked by neck movement,

lezneck postures, or palpation of the cervical muscles (Gonza
Iglesias et al., 2009). It has become an increasing problem (Lin
et al., 2010) causing functional disability in large populations
(Viljanen et al., 2003; Juul-Kristensen et al., 2006). The underlying
causes of chronic MNP are not completely clear (Viljanen et al.,
2003; D'Sylva et al., 2010). Strong evidence suggests biomechanical factors, including prolonged computer use, and posture and
repetitive movements are associated with the development of neck

Clinical trial number: NCT02424032.

* Corresponding author. Izmir Katip Celebi University, Health Sciences Faculty,
Department of Physiotherapy and Rehabilitation, Cigli, Izmir, Turkey. Tel.: 90 232
329 35 13x4711; fax: 90 232 325 33 57.
E-mail address: deryaozer2000@yahoo.com (D.O. Kaya).

^ te

et al., 2008). In addition to biomechanical factors, psypain (Co
chosocial stress may contribute to neck pain (Bongers et al., 2006).
Activation of trapezius muscle motor units has been observed
during mentally stressful tasks performed in the absence of physical demands (Stephenson et al., 2011), and the combination of
mental and physical stress has been demonstrated to increase
trapezius muscle activity more than the summed effect of each
stressor alone (Lundberg et al., 1994). Thus, chronic exposure to
biomechanical and psychosocial stressors may potentially result in
pain and muscle spasm (Bruat et al., 2012). Over time, functional
conditions, activity levels, and job performance may decrease, and
psychological problems, such as anxiety and depression, may
develop, all of which negatively affect the quality of life (Porta,
2000; Lin et al., 2010).
Treatments for this condition typically aim to decline muscular
spasm and pain (Holtermann et al., 2008). However, recent studies
suggest that, in patients with chronic neck pain, consideration of
not only the neck region but also the whole body physical tness,

http://dx.doi.org/10.1016/j.math.2015.07.003
1356-689X/ 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Celenay ST, et al., Cervical and scapulothoracic stabilization exercises with and without connective tissue
massage for chronic mechanical neck pain: A prospective, randomized controlled trial, Manual Therapy (2015), http://dx.doi.org/10.1016/
j.math.2015.07.003

S.T. Celenay et al. / Manual Therapy xxx (2015) 1e7

and also anxiety and depression parameters might be more benecial for the management strategies (Yalcinkaya et al., 2014). In this
context, chronic MNP has been addressed with a variety of interventions including heat, traction, laser, manual therapy, and
exercise (Sherman et al., 2009; Miller et al., 2010; Graham et al.,
2013).
Exercise was considered as one of the evidence-based modality
to decrease pain, prevent further injury, increase muscle strength,
endurance and exibility, improve proprioception, and contribute
and sustain normal life activities (Saal, 1992; Hides et al., 2001; Chiu
et al., 2005; Kay et al., 2012). In addition, recent studies suggest that
exercises including not only neck but also scapulothoracic region
might be more benecial for the management of patients with
chronic MNP (Sarig-Bahat, 2003). Exercise approaches, especially
spinal stabilization exercises, have been popular for treating and
preventing musculoskeletal spinal disorders by activating deep
muscles and arranging the over-activity of surface muscles (Jull and
Richardson, 2000; Reeves et al., 2007). Applications of specic
stabilization exercises have become common (Chung et al., 2013;
Hosseinifar et al., 2013). However, there is a lack of randomized
controlled trial (RCT) investigating the efcacy of progressive
structured cervical and scapulothoracic stabilization exercises for
the management of MNP (Jull and Richardson, 2000; Drescher
et al., 2008; Dusunceli et al., 2009).
Manual therapy techniques include a variety of procedures
directed for the treatment of the musculoskeletal structures,
especially for MNP. Two major subcategories exist: those that
produce joint motion and those that do not. The rst subcategory includes manual traction, manipulation, and mobilization. The second subcategory involves both focal soft tissue
therapy and generalized soft tissue therapies, such as many
types of massages (Vernon et al., 2007). Connective tissue
massage (CTM) is a manual reex therapy focusing on
stretching connective tissue layers (Ebner, 1978; Goats and
Keir, 1991; Holey and Dixon, 2014). The treatment is based
on a reex effect on the autonomic nervous system, which is
induced by manipulating the fascial layers within and beneath
the skin (Holey and Dixon, 2014). The specicity of CTM as a
treatment approach warrants some explanations. Based on
clinical experience, the stretch applied to connective tissue
may stimulate cutaneo-visceral reexes through the autonomic nervous system (Ebner, 1978; Goats and Keir, 1991;
Holey, 1995; Holey and Lawler, 1995; Holey and Dixon, 2014)
and mechanoreceptors in the skin. This stimulation of the
receptors may close the pain gate via pre- and postsynaptic
inhibition (Frazer, 1978). In addition, it has been found to
induce release of endogenous opiates (Kaada and Torsteinbo,
1989) CTM generates local mechanical effects on mast cells
in the connective tissue by the stretch and so creates vasodilation by reducing the sympathetic activity. Subsequently,
parasympathetic activity increases, thus muscle relaxation
occurs and the improvement in the circulation promotes
healing process (Holey, 2000; Holey et al., 2011). Furthermore,
it has been reported that CTM reduces stress and anxiety by
decreasing pain and increasing parasympathetic nervous system activity (Goats and Keir, 1991; Brattberg, 1999; Langevin
and Sherman, 2007). Holey et al. focused on increased skin
temperature after the application of CTM. They declared that
novel thermographic evidence might have effects on autonomic function (Holey et al., 2011). Although the CTM applications have been used in the management of a variety of
diseases, such as bromyalgia (Brattberg, 1999; Citak-Karakaya
et al., 2006; Ekici et al., 2009), headaches (Akbayrak et al.,
2001; Demirturk et al., 2002), constipation (Holey and
Lawler, 1995), and peripheral arterial disease (Ulger et al.,

nchez et al., 2011), low level to fair evidence

2002; Castro-S a
has been shown in the literature for the treatment of chronic
MNP by CTM (Bakar et al., 2014) or CTM with exercise (Yagci
et al., 2004), and a need for new trials has been suggested.
Therefore, the aims of this prospective RCT were to assess and
compare the effectiveness of a 4-week cervical and scapulothoracic
stabilization exercise treatment with and without connective tissue
massage on pain, anxiety, and the quality of life in chronic MNP
patients. The following hypotheses were investigated: 1. Stabilization exercises either with or without CTM would be effective for the
treatment of chronic MNP. 2. Adding CTM to the stabilization exercise program would change the outcomes.
2. Methods
2.1. Subjects
Patients with MNP diagnosed by their physicians and referred to
the University Physiotherapy and Rehabilitation clinic were
included in the study. Patients with neck pain with movement
coordination impairments who had substantial activity limitation
and restricted participation were included according to the clinical
practice guidelines on neck pain, linked to the International Classication of Functioning, Disability, and Health (ICF). Neck
Disability Index (NDI), active cervical range of motion and
segmental mobility tests were used for the activity limitation and
participation restriction (Childs et al., 2008). The inclusion criteria
were as follows: volunteers in an age range of 18e65, having neck
pain for more than 3 months, and having a baseline NDI score of at
least 20% (10 points) (Masaracchio et al., 2013). The exclusion
criteria were as follows: stenosis, traumatic injury history, previous
surgery related to cervical spine, hypermobility, or cancer, having
inammatory rheumatologic diseases, severe psychological disorders, being pregnant, and intervention including exercise or physical therapy in the last 3 months.
Block randomization was carried out by a computer-generated
random number list prepared by an investigator with no clinical
involvement in the trial. The patients were randomly assigned to
one of the following two groups: Stabilization exercise with CTM
(Group 1) or without CTM (Group 2).
A prospective RCT design was used. This study was conducted in
accordance with the rules of the Declaration of Helsinki. Written
informed consent was obtained from each patient. It was approved
by the Ethics Committee of Hacettepe University, Faculty of Medicine in Ankara, Turkey (Approval number: GO 13/381). The study
protocol was registered at http://clinicaltrials.gov (NCT02424032).
2.2. Assessments
Prior to randomization, demographic data, namely age, height,
weight, gender, exercise habit, smoking and alcohol consumption,
history, and mechanism of injury (if any), were collected via an
assessment form, which was specically designed for this study by
experienced physical therapists.
Before and after treatment, evaluations related to neck pain
intensity, pressure pain threshold, anxiety, and quality of life were
carried out. All evaluations were conducted by the same physical
therapist using a standardized protocol to ensure the consistency in
patient positioning, instructions, and overall testing procedures,
and the examiner herself was blinded to the intervention modalities administered to the groups (DOK).
The Visual Analog Scale (VAS), whose reliability was studied and
established by Clark et al. (2003), was used to measure the pain
intensity at rest, during activity, and at night. A 10-cm scale was

Please cite this article in press as: Celenay ST, et al., Cervical and scapulothoracic stabilization exercises with and without connective tissue
massage for chronic mechanical neck pain: A prospective, randomized controlled trial, Manual Therapy (2015), http://dx.doi.org/10.1016/
j.math.2015.07.003

S.T. Celenay et al. / Manual Therapy xxx (2015) 1e7

marked with 0 (no pain) and 10 (worst imaginable pain), and

the patients were instructed on how to use the scale.
The pressure pain threshold (PPT) was evaluated bilaterally
using a digital algometer (JTech Medical Industries, ZEVEX Company) with a surface area of 1 cm2 at the round tip. Reliability of
digital algometer was studied by Chung et al. (1992). The tip of the
algometer was placed between C7 and acromion at the middle
point of the upper trapezius muscle, perpendicular to the skin, and
pressure was applied at a rate of 1 kg/cm2 per second. After the
explanation of the measurement with a demonstration at the
thenar region of the hand, three consecutive PPT measurements
were performed at each location with 30-s rests between measurements. The mean of the measures was recorded (Lluch et al.,
2014).
The Spielberger State Trait Anxiety Inventory (SSTAI), Turkish
version (Oner and Le Compte, 1985), was used for evaluating the
level of anxiety. The SSTAI, shown to have high internal consistency
as well as adequate validity (Spielberger et al., 1970), is a 40-item
self-report inventory designed to measure both state anxiety
(current feelings of apprehension, worry, etc.) and trait anxiety
(continuous feelings of apprehension, worry, etc.). Each section is
scored on four levels of anxiety intensity from 1 not at all to
4 very much and with a sum score between 20 and 80. A higher
total score indicates a more severe anxiety level.
The quality of life was assessed with the Short Form-36 (SF-36).
The validity and reliability of the Turkish version was established by
Kocyigit et al. (1999). It includes mainly the physical component
summary (PCS) and the mental component summary (MCS). The
best score is 100 and the worst score is 0. Higher scores indicate
better physical or mental functioning (Ware, 2000).

and bipedal) in the cervical spine (Kisner and Colby, 2002). The
contraction was kept for 10 s at each position with 6e10 repetitions.
Upper extremity range of motion exercises were conducted while
maintaining stabile spine at the specic positions. All exercise
repetitions were increased progressively from 8 to 12. Then, cervical dynamic isometric exercises were performed directly forward,
obliquely, toward right and left, and directly backward by maintaining stabile spine with elastic resistive bands with 10 repetitions,
each involving 6e10 s holding period. Moreover, the exercises
included functional training with elastic resistance and exercise
balls on unstable surfaces to enhance unconscious activation of the
muscles. The spine was kept in neutral position in all stabilization
exercises and activities.
Scapulothoracic stabilization exercises included specic exercises for the muscles affecting scapular orientation related to neck
pain. The exercises were selected on the basis of previous studies
(Ylinen et al., 2003; Gross et al., 2009; Ozer Kaya et al., 2012). Firstly,
the thoracic bracing technique with postural alignment and minimal multidus muscle activation with scapular orientation for
scapulothoracic stabilization was taught (Mottram et al., 2009). The
patients were asked to maintain the positions and contractions
during the exercises including scapular retraction, eccentric scapular retraction, combined scapular retraction with shoulder lateral
rotation, forward punch, and dynamic hug (Ylinen et al., 2003;
Murphy and Ierna, 2006; Gross et al., 2009). The patients began
exercising using yellow or red latex bands and a 200-cm-long
precut section of Thera-Band (Hygenic Corporation, Akron, OH)
with mild or medium tension. When they performed 15 repetitions
without serious pain or fatigue, they progressed to the next color
resistance band in the sequence of green and blue. They had 10
repetitions with a holding period of 6e10 s each.

2.3. Interventions
2.3.1. Progressive structured cervical and scapulothoracic
stabilization exercise program
The exercise program was carried out 3 days a week for four
weeks by an experienced physical therapist (STC). Each exercise
session took 40e45 min. It was composed of 10 min warm-up exercises, 25 min stabilization exercises, 5e10 min cool-down, and
stretching exercises including neck and shoulder girdle muscles. All
exercises were performed in groups of maximum 5 participants.
After the baseline assessments, sessions began with postural
education by placing patients in a spot in sitting position with two
mirrors reecting their front and side views for them to nd a
neutral balanced position of the lumbar, thoracic and cervical spine
(O'Sullivan, 2004). Before performing the cervical stabilization exercise, they were taught to perform the contraction of deep neck
exor muscle activity with the help of Stabilizer Pressure Biofeedback Unit (Chattanooga, USA). The intra-class correlation coefcients for deep exor muscles activation and performance
measurements with the biofeedback unit were declared to be 0.81
and 0.93, respectively (Jull et al., 1999; Jull, 2001). It was revealed
that the device could provide biofeedback for correct deep neck
exor muscles contraction (Jull et al., 2008). The program aimed to
create a neutral spine and activate deep muscles of the spine.
The cervical bracing technique with the activation of deep neck
exors for cervical stabilization exercise (Falla et al., 2007) was
performed. The patients were asked to maintain neutral spine
during the exercises and throughout the day as much as possible.
The combination and progression of the exercises were designed
according to the literature (Ylinen et al., 2003; Murphy and Ierna,
2006; Dusunceli et al., 2009; Gross et al., 2009; Ozer Kaya et al.,
2012). The exercises to improve kinesthetic awareness and
conscious activation of the deep muscles included work outs of the
bracing in neurodevelopment stages (supine, prone, quadrupedal,

2.3.2. CTM applications

The treatment commenced with a series of short strokes over
the sacrum, lumbar spine and posterolateral pelvis, which were
developed into longer paravertebral and subcostal strokes. Therefore, the treatment was started with the application on the
lumbosacral area (basic section). Once the condition of the subcutaneous tissues in the massaged region returned to normal, treatment progressed to the thoracic (scapular and inter-scapular area)
and cervical (cervico-occipital area) regions of the spine (Goats and
Keir, 1991). As the stretch applied to the connective tissue,
reddening on the skin occurs due to the vascular response with the
activation of mast cell secretion, potentially of histamine and
heparin, which is considered as normal (Theoharides et al., 2010).
In cases where tension or stiffness occurred on the skin, reddening
on the skin did not appear or slight reddening appeared. In this
study, we applied the CTM according to the vascular response of the
connective tissue. After 2 to 4 sessions, next region was treated.
Treatments were performed by a trained physical therapist and
took approximately 5e20 min depending on the treated area.
During CTM applications, the patient was sitting on a stool in upright position, with 90 exion of the hips, knees, and ankles. The
thighs and feet were fully supported. A pillow was placed on the
patient's lap for forearm support. The back was unclothed and
straight for optimal tension of the connective tissue. For creating
traction between cutaneous tissues, the middle ngers of both
hands were used during application (Bakar et al., 2014). The pressure was high and felt like an uncomfortable scratching or slitting.
2.4. Statistical analyses
Before the present study, we performed a pilot study. Ten participants from each group were randomly recruited for the pilot
study. The effect size was calculated according to the results of

Please cite this article in press as: Celenay ST, et al., Cervical and scapulothoracic stabilization exercises with and without connective tissue
massage for chronic mechanical neck pain: A prospective, randomized controlled trial, Manual Therapy (2015), http://dx.doi.org/10.1016/
j.math.2015.07.003

S.T. Celenay et al. / Manual Therapy xxx (2015) 1e7

these participants. The effect size has been calculated as d jX1 e

X2j/SD, where X represents the average change score and SD represents common standard deviation between the groups. The
strength of the effect size denes ds of 0.2, 0.5, and 0.8 as small,
medium, and large effects, respectively (Chinn, 2000; Faul et al.,
2007). All nontrivial effect sizes (small to large) with 95% condence intervals that did not include zero were considered to
represent a signicant treatment effect (Hopkins et al., 2009).
We used the G*Power package software program (G*Power,
Version 3.0.10, Franz Faul, Universit
at Kiel, German) to determine
the necessary sample size for this study. We calculated that a
sample consisting of 60 patients (30 per group) was needed to
obtain 80% power with d 0.65 effect size, a 0.05 type I error, and
b 0.20 type II error (Chinn, 2000; Faul et al., 2007; Hopkins et al.,
2009).
SPSS 20 for Windows (SPSS Inc. Chicago, IL, USA) was used to
analyze the outcomes. The variables were investigated using visual
(histograms, probability plots) and analytical methods (ShapiroeWilks test) to determine whether or not they were normally
distributed. Descriptive analyses were presented using mean and
standard deviation (SD), and frequency tables for the ordinal variables. Paired Student's t-test was used to compare the measurements of the pain intensity, PPT, SSTAI and SF-36 scores before and
after treatment programs. Pain intensity, PPT, SSTAI and SF-36
scores between groups were analyzed by the independent sample
t test. An overall p-value of less than 0.05 was considered to be
statistically signicant.
3. Results
The patients were recruited from February 2013 to May 2014. Of
the 74 patients, 12 patients did not meet the inclusion criteria. The
study included 62 patients. One patient in each group dropped out
due to personal reasons. Sixty patients completed the study. The
owchart is provided in Fig. 1. There were no adverse events reported with any intervention. There was no statistical difference
between the groups in terms of baseline physical characteristics
(p > 0.05), as displayed in Table 1.
At the beginning, there were no differences between groups in
terms of pain intensity at rest and activity, PPT on the left side,
SSTAI, and SF-36 scores (p > 0.05), while there were differences
with regards to pain intensity at night and PPT on the right side
(p < 0.05). Before and after treatment, signicant differences were
observed between groups in terms of pain intensity at rest, during
activity and at night (p < 0.05) (Table 2). After treatment, SSTAI
scores decreased and PCS scores of the SF-36 increased (p < 0.05).
However, PPT and the MCS scores of the SF-36 increased in Group 1
(p < 0.05), no signicant difference in Group 2 was observed
(p > 0.05) (Table 2).
The intergroup comparison showed signicant differences in
the pain intensity at night, PPT, state anxiety, MCS scores in favor of
Group 1 (p < 0.05). No signicant differences were detected for the
other parameters between the groups (p > 0.05) (Table 3).
4. Discussion
The following ndings were observed in the present study: (i)
Stabilization exercises with and without CTM decreased pain intensity and anxiety, and improved physical health in patients with
chronic MNP, (ii) PPT and mental health increased in only stabilization exercises with CTM, (iii) Stabilization exercises with CTM
were more effective in improving pain intensity at night, PPT, state
anxiety and mental health compared to stabilization exercise alone.
Studies examining patients with MNP reported reduction in the
strength and endurance capacity of the cervical deep muscles, joint

position sense, an increase in the activity of the cervical supercial

muscles, and impairment of scapulothoracic dysfunction (Falla
et al., 2004; Sheard et al., 2012; Zakharova-Luneva et al., 2012;
Schomacher and Falla, 2013). Therefore, recent studies focused on
the effects of different exercise interventions for the management
of patients with chronic MNP. Ylinen et al. (2003) showed the
effectiveness of strength and endurance training including neck,
shoulder, and upper extremity for decreasing pain and disability in
women with chronic MNP. However, stretching and aerobic exercising alone were proved to be a less effective form of training
compared to strength training. Mallin and Murphy (2013) stated
that Pilates had a role in reducing pain and disability in neck pain.
Michalsen et al. (2012) showed that Yoga was effective in chronic
neck pain and thus yielded an increase in psychological well-being
and quality of life. Recently, stabilization exercises were also reported to be benecial for neck/shoulder pain (Jull et al., 2002;
Dusunceli et al., 2009; Falla et al., 2013). Similarly, in the current
study it was found that cervical and scapulothoracic stabilization
exercises might be effective for improving pain, anxiety and
physical health component of quality of life in patients with chronic
MNP. The results may be related to activating deep muscles and
strengthening the whole scapulothoracic region throughout the
progressive structured stabilization exercise application.
A variety of studies investigated the effects of CTM. Brattberg
(1999) concluded that CTM resulted in pain relief, decreased
depression, and increased quality of life in patients with bromyalgia. It was reported that CTM had a gradual analgesic effect in the
rst 15 sessions. Citak-Karakaya et al. (2006) showed that CTM
combined with ultrasound therapy was helpful in reducing tiredness, pain level, and sleeping problems and increasing quality of life
in patients with bromyalgia after 20 sessions. Yagci et al. (2004)
presented that CTM (15 sessions) with exercise intervention
improved pain intensity, number of trigger points, and cervical
range of motion in patients with cervical myofascial pain syndrome. Bakar et al. (2014) emphasized that CTM increased muscle
relaxation in women with chronic neck pain after one session. It
was declared that the benecial effects of CMT might be observed
after prolonged CTM sessions (between 10 and 20 sessions) (Holey
and Dixon, 2014). Thus, we carried out stabilization exercises with
CTM for 12 sessions. Our results obtained from stabilization exercises with CTM group were in line with these studies. Moreover, it
was observed in the present study that stabilization exercises with
CTM might be more effective in improving pain intensity at night,
PPT, state anxiety and mental health compared to only stabilization
exercises. Reducing pain at night might be connected to antiinammatory changes since night pain is generally associated
with inammatory processes (Magee, 2002; Hopps et al., 2011;
Crane et al., 2012). Furthermore, changes in physiological variables of the patients after treatment might be because CTM yields
in general body relaxation and thus increases plasma b-endorphins
(Citak-Karakaya et al., 2006). Furthermore, touches on the skin
might have positive effects by decreasing stress hormones and
muscle tension, and thus increasing PPT (Brattberg, 1999). Consequently, combined treatment including stabilization exercises with
CTM might be superior in treating patients with severe night pain.
Moreover, improvements in anxiety and mental component of
quality of life might be other positive effects of CTM.
The current study had some limitations. First of all, according to
the inclusion criteria, the included patients were with MNP and had
substantial activity limitation and restricted participation (ICF
criteria). These limitations and restrictions greatly affected the
participants, who did not respond to the medical treatments, which
should be taken into account for the generalizability of the study.
Secondly, although the groups were statistically similar in terms of
physical characteristics, it was observed that the patients in Group

Please cite this article in press as: Celenay ST, et al., Cervical and scapulothoracic stabilization exercises with and without connective tissue
massage for chronic mechanical neck pain: A prospective, randomized controlled trial, Manual Therapy (2015), http://dx.doi.org/10.1016/
j.math.2015.07.003

S.T. Celenay et al. / Manual Therapy xxx (2015) 1e7

Assessed for eligibility (n= 74)

All participants referred to the participating were assessed with
clinical examination for eligibility to the exclusion criteria.

Enrollment
Randomized
(n=62)

Excluded (n=12)
Age>65years (n=5)
Stenosis (n=3)
Surgery related to cervical spine
(n=1)
Not accepted to participate (n=3)

Allocated to Stabilization
exercise with CTM
(Group 1)
(n=31)

Allocated to Stabilization
exercise
(Group 2)
(n=31)

Lost to follow up
(n=1)
Left the program because
of personal causes

Lost to follow up
(n=1)
Left the program
because of personal
causes

Analyzed (n=30)

Analyzed (n=30)
Fig. 1. The owchart diagram for the patients.

Table 1
Physical characteristics of the patients.
Physical characteristics

Group 1 (n 30)

Group 2 (n 30)

Age (years, X SD)

Weight (kg, X SD)
Height (m, X SD)
BMI (kg/m2, X SD)
NDI score
Gender (n, %)
Female
Male
Exercise habits (n, %)
No
Yes
Smoking (n, %)
No
Yes

50.10 10.25
78.93 13.46
1.68 0.08
27.86 3.63
15.23 4.99

45.20 10.98
74.51 12.85
1.63 0.08
27.84 4.83
17.30 7.20

0.079
0.199
0.061
0.988
0.236

16, 53.3
14, 46.7

23, 76.7
7, 23.3

0.058

25, 83.3
5, 16.7

19, 63.3
11, 36.7

0.080

22, 73.3
8, 26.7

27, 90.0
3, 10.0

0.095

Thirdly, a pre- and post-intervention design were executed as a 4week program due to the health insurance concerns and patients'
social-cultural conditions. Previous studies reported that exercise
training could be effective in long term applications, such as 6e8
weeks (Falla et al., 2013; Mallin and Murphy, 2013). However, 4
weeks of treatment was observed to be sufcient to reveal the
differences. Moreover, no long term follow-up was carried out in
the present study. Long term effects should be observed with
follow-up studies. Finally, the difference in baseline pain intensity
at night between groups could be had an impact on the results. It
may be considered as a limitation. However, this difference may not
be similar between the groups since the groups were recruited
randomly.

*p < 0.05; X: Mean; SD: Standard Deviation, BMI: Body mass index, NDI: Neck
Disability Index.

5. Conclusion

1 smoked slightly more and exercised less at the beginning of the

treatment. Additional healthcare or treatment might have been
effective in bringing out the potential of this group. However, we
did not assess the effects of the treatments on the patients' habits.

In this study, it was observed that stabilization exercises with

and without CTM might be effective for reducing pain, anxiety and
physical health while increasing the quality of life in patients with
chronic MNP. In addition, stabilization exercises with CTM might be

Please cite this article in press as: Celenay ST, et al., Cervical and scapulothoracic stabilization exercises with and without connective tissue
massage for chronic mechanical neck pain: A prospective, randomized controlled trial, Manual Therapy (2015), http://dx.doi.org/10.1016/
j.math.2015.07.003

S.T. Celenay et al. / Manual Therapy xxx (2015) 1e7

Table 2
Differences between pain intensity, PPT, level of anxiety and quality of life of groups' before and after treatment.
Group 1 (n 30)
Before X SD
Pain intensity (VAS, cm)

PPT (kg/cm2)
Level of anxiety (SSTAI)
Quality of life (SF-36)

Rest
Activity
Night
Trapezius (R)
Trapezius (L)
State Anxiety
Trait Anxiety
PCS
MCS

3.65
5.39
6.29
7.74
7.05
37.46
44.76
40.56
43.31

3.32
2.85
4.05
3.47
2.92
11.67
12.03
7.44
12.81

95% CI

Group 2 (n 30)

After X SD
1.13
2.96
2.84
10.08
9.80
31.20
41.23
44.45
48.92

Before X SD

1.68
2.83
2.99
4.35
3.90
10.85
10.15
7.62
10.99

(1.50, 3.53)
(1.17, 3.66)
(2.10, 4.78)
(3.58, 1.08)
(3.91, 1.59)
(2.94, 9.58)
(1.58, 5.48)
(5.69, 2.07)
(8.41, 2.81)

<0.001
<0.001
<0.001
0.001*
<0.001
0.001*
0.001*
<0.001
<0.001

4.64
6.72
3.20
5.91
5.74
36.70
44.10
37.83
41.56

3.19
2.62
3.69
2.02
2.30
9.72
9.09
8.68
12.99

95% CI

(1.62, 3.65)
(2.05, 3.94)
(0.62, 2.20)
(1.18, 0.43)
(1.32, 0.41)
(0.70, 3.82)
(0.28, 2.58)
(4.63, 1.34)
(4.17, 0.35)

<0.001
<0.001
0.001*
0.348
0.294
0.006*
0.016*
0.001*
0.096

After X SD
2.00
3.72
1.78
6.29
6.20
34.43
42.66
40.82
43.47

2.38
2.56
2.61
2.74
2.96
10.28
8.17
10.63
11.78

*p<0.05; VAS: Visual Analog Scale, PPT: Pressure Pain Threshold, R: Right, L: Left, SSTAI: Spielberger State Trait Anxiety Inventory, SF-36: Short Form-36.
PCS: Physical Component Summary, MCS: Mental Component Summary, CI: Condence Interval.

Table 3
Differences between groups' before and after treatment programs.
Parameters
Pain intensity (VAS, cm)

PPT (kg/cm2)
Level of anxiety (SSTAI)
Quality of life (SF-36)

Rest
Activity
Night
Trapezius (R)
Trapezius (L)
State Anxiety
Trait Anxiety
PCS
MCS

Group1 (n 30)
X SD

Group2 (n 30)
X SD

95% CI

2.52
2.42
3.44
2.33
2.75
6.26
3.53
3.88
5.61

2.64
3.00
1.41
0.37
0.45
2.26
1.43
2.95
1.90

(1.52, 1.28)
(2.10, 0.94)
(0.52, 3.53)
(3.41, 0.49)
(3.72, 0.88)
(0.40, 7.59)
(1.11, 4.32)
(3.32, 1.46)
(7.19, 0.21)

0.865
0.449
0.009*
0.009*
0.002*
0.030*
0.063
0.441
0.038*

2.66
3.27
3.52
3.35
3.10
8.89
5.22
4.58
7.08

2.71
2.53
2.10
2.17
2.32
4.17
3.08
4.43
6.06

*p<0.05; VAS: Visual Analog Scale, PPT: Pressure Pain Threshold, R: Right, L: Left, SSTAI: Spielberger State Trait Anxiety Inventory.
SF-36: Short Form-36, PCS: Physical Component Summary, MCS: Mental Component Summary, CI: Condence Interval.

superior in improving pain intensity at night, PPT, state anxiety and

mental health compared to stabilization exercises alone.

Funding sources and potential conicts of interest

No funding sources or conicts of interest were reported for this
study.

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massage for chronic mechanical neck pain: A prospective, randomized controlled trial, Manual Therapy (2015), http://dx.doi.org/10.1016/
j.math.2015.07.003