Effects of Shoulder Exercises with and Without Cervical Exercises on Pain and Function in the Patients with Cervical Spondylosis: Randomized Controlled Trial

Background: Cervical spondylosis is a chronic, degenerative, progressive disease of osteocartilagenous component of cervical spine that is usually age related and more common in men than in women, with a peak incidence between the ages of 40 and 60 years for both men and women. Objective: The aim of the study is to determine effects of shoulder exercises with and without cervical exercises on pain and function in patients with cervical spondylosis. Methods: Sixty eight diagnosed cervical spondylosis patients with 30-60 years of age were selected and randomly allocated in experimental and control groups, 34 in each group. The study was conducted in the physical therapy department of WAPDA hospital, Lahore. All participants were following the 6 weeks supervised exercise program, 4 sessions per week. Experimental group received shoulder exercises with cervical exercises while the control group received cervical exercises. Clinical outcomes were measured with visual analog scale for pain and neck disability index for function. Results: Analysis of final 61 patients were included, 31 in experimental and 30 in control (3 and 4 patients did not follow the study completely). Mean aged for experimental and control group was 49.39 ±7.022 and 49.23 ±6.704 respectively. Results showed that there was statically and clinically significance difference that as observed in from of reduction of pain P=0.001 and improvement of function P= 0.01 Conclusion: Overall improvement was observed in both groups, results of study shows that shoulder exercises with cervical isometric exercises were more beneficial for outcomes of pain and function in experimental group. So we can conclude that shoulder exercise should be an integral part of treatment for cervical spondylosis patients.


Introduction
C ervical spondylosis is a degenerative process of the cervical spine that involves degeneration of disc, facet joint, cervical vertebra and surrounding soft 1 tissues.Cervical spondylosis is directly related to the age, as the age increases the wear and tear in osteo-cartilagenous parts of spine shows the degenerative changes on radiographs and the most common site for degenerative changes are intervertebral disc and facet joints in prolonged use of computer, abnormal posture during reading, excessive bending, traumatic injuries like flexion injury 3 are the risk factors for cervical spondylosis.The possible reason for cervical spondylosis is the compressional forces that cause wear and tear in spine and 4 loss of normal spinal height and curve.

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In the 4 and 5 decade of life, more symptomatic changes are most commonly observed in cervical spine (1) and remain asymptomatic under the age of 40. 5 The incidence of cervical spondylosis is 83 per 100000 and prevalence is 3.3 per 1000 in population and more 6 common in male than female with the ratio of 3:2.Clinically cervical spondylosis are represented with mechanical neck pain/axial pain and pain aggravated by movement and relieved by the rest is main sign of cervi- Shoulder exercises with cervical isometric exercises are effective for the management of neck pain, as previously used for patients with chronic neck pain and reported that shoulder exercises with cervical exercise are more effective than only cervical isometric exercises 20 for the management of chronic neck pain.However the effects of shoulder exercises remains questionable, number of studies has focused on the significance of neck strengthening in cervical spondylosis, no study so far as we know that determine the effects of shoulder strengthening in patients with cervical spondylosis.Some previous studies demonstrated the effect of shoulder training on pain and function and reports that the shoulder strengthening exercises do not only reduce pain and improve function of the cervical spine.So, in the current study, an exercise program was carried out that includes the neck exercises with and without shoulder strengthening exercises to determine the effects on pain and function in the patients with cervical spondylosis.The primary aim of this study was to determine the effects of cervical isometric exercises with shoulder exercises on pain and the secondary aim was effect of cervical isometric exercises with shoulder exercises to improve on function in cervical spondylosis patients.

Methods
Randomized controlled trial was conducted in the physical therapy department of WAPDA teaching hospital, Lahore.The participants of the current study were diagnosed patients of cervical spondylosis referred by the orthopedic.The inclusion criteria of the current The rules and regulations set by the ethical committee of university of Lahore were followed while conducting the research.Informed consent (attached) was taken from all the participants, Participants remained anonymous throughout the study and subjects were informed that there are no disadvantages or risks of the procedure.
Once the above mentioned inclusion and exclusion criteria were taken into account, potential participants were considered.The researcher took a complete history of the demographic characteristic of participants; patients with cervical spondylosis were assessed for clinical outcomes by using visual analog scale (VAS) for pain and Neck Pain Disability Index Questionnaire for function at baseline.Participants were randomly allocated into the experimental and control group by lottery method, 34 in one of each group.
Isometric exercise protocol was used in current study; experimental group received a combined exercise protocol which includes cervical isometrics with shoulder isometrics.The component of isometric exercise program for experimental group includes cervical flexors, cervical extensors rotator and side flexors of cervical with shoulder flexors, shoulder extensor, shoulder rotators and shoulder adductor and abductors isometrics.However the control group received cervical isometrics only, component of cervical isometrics includes cervical flexors, cervical extensors, cervical rotator and side flexors of cervical.The progression in exercise plan was made in three stages by increases the repetition and sets of exercises for both group.First stage consist on the 3 sets, 10 repetitions with10 seconds hold for each exercise for first 2 weeks (1st and 2nd week). 1 min rest was given after each set of exercise.Second stage consist on the 4 sets, 20 repetitions with 15 seconds hold for next two weeks (3rd and 4th week) 1 min rest was given after each set of exercise.Third and final stages consist on the 5 sets, 30 repetitions with 20 seconds hold for last two week (5th and 6th week) Each exercise plan includes four sessions per week, total of 24 sessions over 6 weeks of period.Each session lasted for 40-50 minutes.All exercises were performed by therapist while patient was in sitting position.
The researcher reassessed the patient and completed Neck Pain Disability Index Questionnaire with VAS rd th at 3 and 6 week of treatment as the part of the subjective assessment.The data was tabulated and analyzed using a statistical package for social sciences (SPSS) version 24.The qualitative variables like gender, marital status, and socio economic status were presented with frequency and bar charts or pie charts.The quantitative variables age, height, weight, body mass index and visual analog scale were presented with mean and standard deviation.After checking the normality of the data was checked by using test Kolmogorov Semenov, data was not normally distributed so non-parametric test was used to compare the outcome variables at different follow ups.P value less than and equal to 0.05 was considered as significant.ficance was observed in both groups but more changes were observed in the experimental group with P=0.001.

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Results showed that the exercise protocol that was neck isometric exercises with shoulder exercises were more statistically and clinically effective for the patient with cervical spondylosis.

Discussion
The current study was a comparative study to investigate the effects of cervical isometric exercises with and without shoulder exercises on pain and function in patients with cervical spondylosis.Results demonstrated the positive measures in pain and function in both experimental and control groups.More reduction of pain and more improvement in function were seen in the experimental group, so we can state that cervical isometric exercises with shoulder exercises were more significant for the patients with cervical spondylosis to improve the subjective measures.
Literature 7 supported that neck pain in neck is one of the most common clinical representations of cervical spondylosis so pain was the main outcome for current study, measured by using VAS.Participants of the current study were represented with moderate to severe neck pain.A marked reduction in neck pain was observed clinically and statistically P=0.001 by using the combined protocol of cervical isometric with

11 study
includes both male and female, aged 30-60 years , no previous history of trauma, surgery and diagnosed 21 patients by orthopedic.Pregnant women, history of previous cervical surgery, vertebral compression fracture, neurological deficit, history of malignancy, rheumatoid disorder and other systemic problems, any infectious disease like osteomyelitis, tuberculosis, ankylosing spondylitis were excluded.Purposive sampling was January -March 2024 | Volume 30 | Issue 01 | Page 92 used in the current study, which is type of non-probability sampling technique, to counter the sample size.The calculation of sample size was done by open epi tool, that was 28 in each group after adding 20% dropout 34 in each group, 68 overall.

Figure 2 :Figure 3 :
Figure 2: Mean Change in Pain in Both Groups Stretching and post isometric relaxation are the techniques that was used for pectoralis major and serratus anterior muscle with cervical isometric exercises and reported that have effective in decrease pain and improve func- 5of cervical spondylosis cases represented as neck pain.Cervical spondylosis with radiculopathy (due to compression and inflammation of cervical nerve roots) and myelopathy (due to the inflammation and compression 7 of cervical cord) are two other representations.Prevalence of cervical spondylosis is high in sub-continent 10 54% in Pakistan in general sitting 9 and 56% India.Cervical spondylosis is highly prevalent and continued with age, therefore different protocols are used for the management of degenerative pain, that includes pharmacological and non-pharmacological and as well as sur-11 gical.The patients with no neurologic symptoms commonly treated by the oral analgesics, muscle relaxant, glucocorticoid injections and brief immobilization by 12 cervical collar and physical therapy.Physical therapy is effective for the management of pain with and without neurological defects and includes electrotherapy and exercise therapy and some manual procedure neural 13 tissue mobilization, manual traction mulligan techniques.17bilateralstretches are commonly used program.
-eighth diagnosed patients with cervical spondylosis referred by orthopedic were included in the study.The study was carried out in the physical therapy department of WAPDA Teaching Hospital, Lahore.Patients' inclusions occurred in April 2022 to August 2022.All patients were randomly allocated in the experimental and control group, 34 in each group.There were three dropouts in the experimental group and four dropouts in the control group due to health related problems and some personal reasons.Final analysis of sixty one patients (31 in experimental group and 30 in control group) was carried out and represented in results, shown in study flow Figure I.
Table II and Figure III describe the mean change in pain in both groups with SD, the statistical and clinical signi-January -March 2024 | Volume 30 | Issue 01 | Page 93

Table 4 :
Mean Of Neck Disability Index at Different Follow Up

Table 2 :
Represented quantitative variables with mean and standard deviation for both groups.

Table III
TableII: Represented the qualitative variables like gender, marital status, and socio economic status were presented with frequency.

Table 3 :
Mean pain intensity at Different Follow Up The current study was conducted to find the combined effect of cervical isometric with shoulder exercises on the patients with cervical spondlyosis because as far as we know no previous study demonstrated the effects of shoulder exercise on patients with cervical spondylosis.Clinical outcome, pain and function were measured and found positive results, so findings of current study show that shoulder exercises should be used as treatment for cervical spondylosis patients because shoulder exercises have positive effects on clinical outcome.There are some limitations of the study such as no isolated effects of cervical and shoulder strengthening treatment groups were included.Long lasting effects of shoulder exercises were not assessed in current study.The medications used before and during study were not controlled.Recommendation for upcoming research should assess the long lasting effects of shoulder exercises on cervical spondylosis.Isolated effects and mechanism of shoulder strengthening exercises should be measured in further research.Current study results show that cervical isometric with shoulder exercises have more positive effects in patients with cervical spondylosis on subjective outcomes such as pain and function.Overall improvement was observed in both groups, more reduction in pain and enhancement of function were seen in the experimental group P= 0.001 and P-0.01 respectively.So we can conclude that shoulder exercise should be an integral part of exercise therapy for cervical spondylosis patients.The Research Ethical Committee of University of Lahore approved this study vide letter no.REC-UOL/149-06/2022/ 24, 25As far as we know all previous studies pain and functional improvement in cervical spondylosis measured January -March 2024 | Volume 30 | Issue 01 | Page 95