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July2005 Vol.42 Issue:      2 Table of Contents
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Chronic Neck Pain: A Comparison Between Two Different Physical Therapy Modalities

M.N. El-Bahrawy1, G. Mousa1, A. Rashad2
Departments of Neuromuscular Disorders and its Surgery1, Basic Sciences2, Faculty of Physical Therapy ,Cairo University


The purpose of this study was to compare the efficacy of hot pack followed by thermal ultrasound and iontophoresis with calcium gluconate in treatment of patients with chronic neck pain. Thirty patients with chronic mechanical neck pain (mean age 34.40±5.40) from both genders participated in this study. Pain and cervical range of motion were measured by using VAS and CROM respectively. The treatment protocol consisted of 24 sessions as three sessions per week. The patients were classified into two equal groups. Both groups received exercises program, the first group received hot pack on neck for ten minutes followed by continuous ultrasound application on spasmodic area for ten minutes with 1.5 w/cm2 intensity while the second group received iontophoresis with calcium gluconate on spasmodic area for 20 minutes. The results revealed improvement in pain and cervical mobility in both groups after treatment program, but it was highly significant in the second group compared to the first group. It can be concluded that both ultrasound application and iontophoresis in addition to exercises program are effective in reducing neck pain as well as increasing cervical mobility but the application of iontophoresis with calcium gluconate was more effective.

(Egypt J. Neurol. Psychiat. Neurosurg., 2005, 42(2): 333-339).




Neck pain is a common symptom among workers in several occupations. Beside the subjective distress, the pain may cause gone abroad from work and subsequent costs of society1. This patient population tends to develop a head forward posture. Holding a head and neck in a fully flexed position causes neck and head pain that may radiates over the shoulders and arms2.

Weakness of the cervical flexor muscles occurs secondary to reflex inhibition via the muscle spindle system. A lack of inhibition of the cervical extensors keeps these muscles in spasm3. This weakness, in turn, predisposes the patient to develop a head forward posture  which cause persistent chronic pain in the neck region4.

Cervicocephalic kinesthetic sensibility is week in patients with chronic cervical pain compared to healthy subjects5. This finding justifies the use of exercises aiming to improvement of neck proprioception in   rehabilitation program for cervicalgic patients6. There is evidence to support that there is a significant relation between neck pain and cervical mobility, consequently, it will influence the functional activity, mood and work state2,7.

Iontophoresis with calcium gluconate is one of muscle spasm relief modality. Meanwhile, it has a quiet influence on neck pain, then increasing the cervical mobility and reducing spasm in the trapezius muscle8. Other modality is ultrasound application on painful area and tensed muscles, especially the trapezius muscle which represent one of the main neck musculature9. The goal of this study was to compare the efficacy of iontophoresis versus hot pack followed by continuous ultrasound therapy on neck pain and mobility.




A)            Subjects selection:

Thirty patients with chronic neck pain from both genders were enrolled in this study. They were  recruited  from  various workplaces through their respective occupational health care systems.

-       General inclusion criteria: All patients had (l) Chronic neck pain that lasted longer than three months duration, (2) Age ranged from 30 to 50 years, (3) A clinical diagnosis of mechanical neck pain based on neurological examinations and computed tomography (C.T) or Magnetic Resonance Imaging (MRI) on the cervical spine.

-       Exclusion criteria included : (1) Known neural tissue involvement (2) Malignancy, (3) Sever disorder of the cervical spine such as instability, (4)  Known  anomaly  of the  cervical  spine, (5)  Sever osteoporosis, (6) Recent cervical fractures, (7) Sever diseases preventing physical  loading (e.g. uncontrolled  diabetes  mellitus ) (8) Acute infection, (9) A recent major operation (10) Rheumatoid arthritis, (11) Ankylosing spondylities, (12) Any sign of cervical radiculopathy or myelopathy, and (13) Refusal to cooperate.


B)            Instrumentation:

1.    Instrumentation for evaluation:

-       The Cervical Range of motion instrument (CROM, Basic instrument, Performance Attainment Associates, Vadnais Heights, MN) was used to measure active cervical mobility (10).

2.    Instrumentations for treatment

a.      Hot pack (ENRF hot pack, al delft, Holland)

b.     Ultrasonic apparatus (U0278, Preors Marston, England)

c.      Iontophoresis (Phoresor II Auto, Model No-850PM, 35773, USA).


C)            Procedures:

The patients were receiving common symptomatic medical treatment including non-steroidal anti-inflammatory drugs in sequentioal manner to allow successful participation in the treatment program. All the patients were asked to avoid taking medication less than four hours prior to treatment appointment. After signing a written consent form, all patients underwent the same evaluation protocol which included the followings:

1.      History taking (name, age, current behavior of the symptoms, critical  factors  surrounding the  onset of symptoms  and current duration of neck pain) and neurological examinations including sensory and motor examinations.

2.      Observation of posture (alignment of the head, neck and shoulder girdles) while patient was in standing position with back straight. Abnormalities such as asymmetry of shoulders, forward head, a laterally flexed posture of the neck were noted and recorded.

3.      Palpation of the common trigger points associated with neck pain (commonly located in upper trapezius2.

4.      The patients were  instructed to mark the visual analoge scale VAS (0-100 mm.)11 to represent' their pain intensity (pre and post treatment program).The mark corresponds with the level of the patient's level of comfort. A mark on the left of the scale indicated "no pain" whereas a mark on the far right indicated "unbearable pain".

5.      Active cervical range of motion (ROM) was measured with the CROM instrument according to the manufacturer's instructions. Total ROM was assessed in flexion, extension, lateral flexion, and rotation (Fig. 1). The physical therapist manually stabilized the patient in sitting position with back support and the movements of the upper thoracic and trunk were controlled. The patient practiced each movement three times before the measurement. Each motion was measured twice in succession and then averaged. The patient moved through his ROM to the point where pain began to increase and stopped movement at that point, then the range was recorded. If no increase in pain was experienced, the patient moved to the physiological end point of the active range. This test was performed twice (pre and post treatment program). Left and right rotation were summed to provide a measure of motion in the horizontal plane, and left and right lateral flexion were also summed to provide a measure of motion in the frontal plane while flexion and extension ranges were summed in the sagittal plane.



Fig. (l): Position of cervical range of motion instrument (CROM).


Treatment protocol:

After  the  baseline  measurements, the  patients  were randomly assigned into two equal groups. The treatment program involved three sessions per week for total eight weeks. The first group (Gl) received superficial heat in the form of hydro-collator hot pack on the neck for ten minutes followed by continuous ultrasound application on upper trapezius, for ten minutes with 1.5 w/cm2 intensityl2. The second group (G2)  exposed to iontophoresis with calcium gluconat. The electrode injected with calcium gluconat and applied on the spasmodic area (most tender point on upper trapezius) for 20 minutes with continuous direct current.



Fig. (2): Application of iontophoresis

on upper trapezius


Both groups received exercises program13 lasted approximately 30 minutes in the form of;

1.     Warm up with free arms, shoulders and neck movements.

2.     Relaxation training for the neck musculature in the form of hold-relax technique in different directions (forward, backward and laterally) for ten repetitions in each direction .

3.     Stretching exercises for the neck extensor muscles.

4.     Isometric technique to improve strength of neck flexors.

5.     Eye fixation exercises14 aiming to improve cervicocephalic kinesthesia via eye head coordination which included:

a.     Automatic movements of the neck to maintain the gaze on a fixed target while the physical therapist passively moved the trunk.

b.     The patient was instructed to fix a target for a few seconds and to memorize the head -neck position. Then the patient performed a maximal rotation of the head (with closed eyes), tried to find the initial position and then opened the eyes. The exercise was repeated to relocate as accurately as possible the initial head position.

6.     All the patients received explanatory  pictures  about  modification  of activities  at  the workplace.


Statistical analysis:

The data are described and presented as mean±SD. Comparisons of means were done using Student t-test. Mann Whitney test was used to compare values of VAS within each group and between both groups. A Pearson product moment correlation coefficient was calculated between VAS scores and mobility values. The level of significance was at P<0.05.




The patients included in the study (13 women and 17 men) were 32 to 49 years old, The duration of the history of the neck pain ranged from five to sixteen months, 60% with recurrent pain and 25% with continuous pain. There was no significant difference between the two groups in age duration and intensity of pain (Table 1).

The improvement in pain intensity described as the mean difference between the values obtained before and after treatment program according VAS (mm.). In the Gl , the difference between the mean value before treatment (68±9) and after treatment (48±10) was significant at P=0.004. In the G2 , the difference was highly significant (P=0.000) between the mean value before treatment (70±10) and after treatment (37±8). results revealed that neck pain reduced in the G2 (mean difference =33±8.5) than in Gl ( 20±9) with P=0.005 (Table 2).

Cervical mobility in different plans (sagittal, frontal and horizontal)tended to increase in both groups (G1 & G2) after treatment program compared to before treatment values. Comparison between both groups revealed a statistically significant increase in sagittal and horizontal mobility in G2 compared to G1 while no statistical difference was observed between both groups in frontal mobility (Table 3).

All correlations of the Pearson product moment correlation coefficient between VAS scores and cervical mobility (sagittal, horizontal and frontal) in both groups were statistically significant with p<0.05. Decreased neck mobility were associated with higher pain scores and vice versa.


Table 1. Baseline characteristics in both groups (G1 & G2).




Mean ± SD


Mean ± SD


Age (years)

39.40± 5.50



Duration of pain (months).


23.00± 3.40


Intensity of pain on VAS (mm.)

68.00± 9.00

70.00± 10.00


SD = Standard deviation                                     NS = Not significant with P > 0.05.


Table 2. Improvement of neck pain (VAS mm.) in both groups (G1 & G2).




Mean difference ±SD


Mean difference ±SD


Pain intensity VAS (mm.).





Significance at p<0.05

Table 3. Comparisons of cervical mobility in different plans (sagittal, frontal and horizontal) before and after treatment within each group and between both groups (G1 & G2).



Mean difference ± SD


Mean difference ±SD

p-value (Between G1&G2)


Sagital mobility (degree)








p-value (within G1&G2)





Horizontal mobility (degree)








p-value (within G1&G2)





Frontal mobility (degree)








p-value (within G1&G2)




Significance * at p<0.05





The current study was a comparative trail between two forms of physical therapy to determine their efficacy on chronic neck pain. The primary findings were that cervical mobility (CROM) and neck pain (VAS) were  improved after exercises program in both groups (G1 & G2). The results supported the findings of the previous study13 which proved that multimodal emphasizing exercises are beneficial for chronic non specific neck problems as the ability to work differed significantly among these patients.

The exercises program intended to improve postural control, strength, muscle length as well as  kinesthetic accuracy. Harms-Ringdahl  and Ekholm15 have shown that held the head between full flexion and upright, leading to overuse of cervical erector spinae to maintain head in position. This constant contraction   of erector spinae accompanied by weakness of anterior cervical flexor muscles leading to chronic neck pain16,17,18. So strengthening of weak  muscles and stretching of  extensors improved both pain and cervical mobility19,20. Brosseau et al.6, postulated that therapeutic exercises that included proprioceptive reeducation demonstrated higher significant improvement in both pain and functional status. Considering the goal of rehabilitation program, it is noted worthy that in addition to retinal information, extraretinal signals, coming from extraoccular and neck muscles, proprioceptive receptors could also participate in eye-head coupling during gaze orientation21. The functional organization of the neck and mainly of its proprioceptive apparatus supported the inclusion of exercises based on eye-neck coordination in exercises program for cervicalgic patients6,13.

The findings of the current study agreed with the previous studies which concluded that thermal ultrasound treatment is typically used to decrease muscle spasm, pain and increase circulation22,23 and tissue extensibility24. Lehman and Delateur25 studied the temperature effects on muscle spasm, and demonstrated that the rate of firing of the group Ia afferents was increased by warming. The secondary afferents responded via a similar manner whereas those with a low initial discharge rate showed a cessation of firing. Increasing firing from golgi tendon organs occurs which in turn leading to increase the inhibitory impulses.   

The results of this study revealed a highly significant effect of iontophoresis with calcium gluconate on spasm of upper trapezius which consequently increase the cervical mobility. The neurophysiological response of the effect of iontophoresis with Ca+2 gluconate justified by the effect of C+2 on permeability which consequently decreaseing the excitability of neuromuscular tissue, therefore the muscle would be relaxed26.

In addition, Kahm27, concluded that iontophoresis of Ca+2 was effective in reducing spasm of the paravertebral muscles. Delterzo et al.28, also investigated the effect of Ca+ iontophoresis in treatment of spasmodic torticollus of neck muscles. A significant reduction in pain, and increasing neck range of motion were recorded.



Iontophoresis with calcium gluconate is effective in reducing neck pain and increasing cervical mobility in comparison to hot pack followed by continuous ultrasound in patients with mechanical chronic neck pain.




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الملخص العربى


ألم الرقبة المزمن: مقارنة بين وسيلتين مختلفتين من وسائل العلاج الطبيعى


أجريت الدراسة على ثلاثين مريضاً ممن يعانون من الم الرقبة المزمن لأسباب ميكانيكية وقد تم تقسيمهم عشوائياً لمجموعتين متساويتين عددياً حيث تم علاجهم كالتالي:

1.    تم علاج المجموعتين ببرنامج خاص من التمرينات العلاجية لمنطقة الرقبة.

2.    تم علاج المجموعة الأولى بالإضافة لبرنامج التمرينات العلاجية بكمادة ساخنة لمنطقة الرقبة لمدة 10 دقائق يتبعها علاج بالموجات فوق الصوتية المتصلة لمدة 10 دقائق أخرى.

3.    تم علاج المجموعة الثانية بنفس برنامج التمرينات العلاجية بالإضافة الى العلاج بالتحليل الكهربى لجلوكونات الكالسيوم على العضلة المشدودة بالرقبة لمدة 20 دقيقة.

وقد أسفرت النتائج عن تحسن درجة الألم والمدى الحركى للرقبة فى كلا المجموعتين إلا أن التحسن واضح إحصائيا فى المجموعة الثانية عند مقارنتة بالمجموعة الأولى. 

وقد أوضحت الدراسة أنة يمكن إضافة عملية التحليل الكهربى لجلوكونات الكالسيوم لتصبح جزء من البرنامج العلاجى لحالات آلام الرقبة المزمنة.

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