Journal of Medical Sciences

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 41  |  Issue : 3  |  Page : 123--128

Impaired pulmonary function in patients with chronic neck pain


Mohamed Fawzi Awadallah1, Eman Sobh2, Mohamed Abdelhalim Shendy3, Abdullah M Al-Shenqiti4, Talal M Al-Jeraisi5, Reda S Eweda6,  
1 Department of Respiratory Therapy, College of Medical Rehabilitation Sciences, Taibah University, Medina, Saudi Arabia; Department of Chest Diseases, Faculty of Medicine, Al-Azhar University, Damietta, Egypt
2 Department of Respiratory Therapy, College of Medical Rehabilitation Sciences, Taibah University, Medina, Saudi Arabia; Department of Chest Diseases, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
3 Department of Respiratory Therapy, College of Medical Rehabilitation Sciences, Taibah University, Medina, Saudi Arabia; Departments of Cardiovascular Respiratory Disorder and Geriatrics, Faculty of Physical Therapy, Cairo University, Giza, Egypt
4 Department of Physical Therapy, College of Medical Rehabilitation Sciences, Taibah University, Medina, Saudi Arabia; Centre for Rehabilitation Sciences, University of Manchester, Manchester, England, UK
5 Department of Otorhinolaryngology, Head and Neck Surgery, Faculty of Medicine, Taibah University, Medina, Saudi Arabia
6 Department of Physical Therapy, College of Medical Rehabilitation Sciences, Taibah University, Medina, Saudi Arabia; Physical Therapy Department for Musculoskeletal Disorders and its Surgery, Faculty of Physical Therapy, Cairo University, Giza, Egypt

Correspondence Address:
Prof. Eman Sobh
Department of Chest Diseases, Faculty of Medicine for Girls, Al-Azhar University, Al-Zahraa University Hospital, Abbassia, Cairo 11517

Abstract

Background: Neck pain is a common problem in the medical practice, and the limited movement of the neck muscles can result in impaired chest movement. This study aimed to investigate the relationship between neck pain and pulmonary function using spirometry. Methods: We included 75 patients with chronic neck pain and 75 age- and sex-matched healthy controls. We performed spirometry and recorded forced-vital capacity (FVC), forced expiratory volume in the first second of FVC (FEV1), forced expiratory flow at 25%–75% (FEF 25–75), and peak expiratory flow rate (PEFR). We also measured the neck active range of motion in all positions (flexion, extension, lateral flexion, and rotation) and administered the Neck Disability Index (NDI) and Visual Analog Scale (VAS) for pain. Results: Neck movements were significantly limited in all directions in patients with chronic neck pain. Pulmonary function (FVC, FEV1, FEF25–75, and PEFR) was significantly lower, and FEV1/ FVC was significantly higher in the neck pain group compared with the control group. In the neck pain group, restrictive pattern in spirometry was found in 39 participants (52%). The pulmonary function parameters (FVC, FEV1, FEF25–75, and PEFR) had a significant positive linear relationship with neck movement and a significant negative linear relationship with VAS and NDI scores. Conclusions: Patients with chronic neck pain had limited pulmonary function, which was related to a limited range of cervical movement.



How to cite this article:
Awadallah MF, Sobh E, Shendy MA, Al-Shenqiti AM, Al-Jeraisi TM, Eweda RS. Impaired pulmonary function in patients with chronic neck pain.J Med Sci 2021;41:123-128


How to cite this URL:
Awadallah MF, Sobh E, Shendy MA, Al-Shenqiti AM, Al-Jeraisi TM, Eweda RS. Impaired pulmonary function in patients with chronic neck pain. J Med Sci [serial online] 2021 [cited 2021 Jun 22 ];41:123-128
Available from: https://www.jmedscindmc.com/text.asp?2021/41/3/123/305054


Full Text



 Introduction



Musculoskeletal neck pain is common worldwide, with a prevalence ranging from 0.4% to 86.8%, and chronic neck pain is associated with disability and social, psychological, and economic impacts.[1] The close anatomical, physiological, neurological, and musculoskeletal connection between the cervical and thoracic regions has led researchers to propose that chronic neck pain is associated with the changes in the rib cage and thoracic spine causing respiratory dysfunction.[2],[3] Some musculoskeletal disorders result in torticollis or kyphosis, which alter breathing mechanisms, including diaphragm mobility.[4] Some authors have reported decreased sniff nasal inspiratory pressure in forward head posture and torticollis,[5] and others have found reduced maximal voluntary ventilation (MVV)[2] and reduced maximal inspiratory and expiratory pressures in chronic neck pain patients.[3] These researchers reported a relationship between isometric neck extensor muscle strength and forward head posture.[2],[3] Chronic neck pain can also add to respiratory compromise because of neck muscle weakness and fatigue, reduced cervical mobility, postural abnormalities, diminished proprioception, and psychological issues.[2],[6] Limited thoracic cage movement, interference with the accessory respiratory muscles, such as the trapezius, sternocleidomastoid, and anterior scalene muscles, can affect diaphragm movement.[4]

Because of their neuromuscular disabilities, patients with neck pain are usually managed at musculoskeletal clinics, and they are rarely referred to respiratory clinics.[7] Few studies have examined pulmonary function in patients with chronic neck pain, and the clinical evaluation of patients with neck pain is usually limited to cervical musculoskeletal assessment.[8] Kahlaee et al. conducted a systematic review to investigate the association between chronic neck pain and respiratory functions and found few applicable studies. They concluded respiratory dysfunction and cervical spine impairment appeared to be related in patients with chronic neck pain.[9] However, these studies examined a small number of patients and lacked clinical and functional assessments of respiratory and musculoskeletal parameters. To address this research need, the current study aimed to investigate the relationship between pulmonary function and neck pain and disability in a larger sample size.

 Methods



Study design and participants

This prospective case–control study was conducted from January 2018 to October 2019. We recruited 199 consecutive participants, and 150 (75 with neck pain and 75 healthy controls) fulfilled the inclusion criteria. Inclusion criteria: Participants were required to be 18 years of age or older and have chronic neck pain (more than 6 months) as a chief complaint without arm pain or structural malformations. Exclusion criteria: Participants were excluded from the study if they had clinical abnormalities or a history of respiratory disease, musculoskeletal disease, tumor, infection, spinal fractures, spinal cord compression that required urgent surgery, or surgery of the vertebral column. Current or past smokers and those who were obese (body mass index [BMI] >30) or underweight (BMI <18.5) were also excluded.

Data management

Measures

We collected information regarding demographic data, smoking history, and neck pain presence and durationWe measured height (in meters) and weight (in kilograms) and calculated BMI as height/weight[2] (kg/m2)We performed pulmonary function tests (PFT) using a portable spirometer (Discovery-2 spirometer, Futuremed, Granada Hills, California, USA) with a disposable mouthpiece and nasal clip according to the American Thoracic Society/European Respiratory Society guidelines.[10] We chose the best of three technically acceptable trials[10] and recorded forced-vital capacity (FVC), forced expiratory volume in the first second of the FVC maneuver (FEV1), FEV1/FVC, forced expiratory flow at 25%–75% of FVC (FEF 25%–75%), and peak expiratory flow rate (PEFR). A normal PFT pattern is defined as normal FVC and FEV1 values (equal to or > 80%) with an absolute FEV1/FVC ratio >0.7. An obstructive PFT pattern is defined as a normal or decreased FVC with decreased FEV1 and FEV1/FVC < 0.7 of the predicted value. A restrictive PFT pattern occurs when FVC is decreased and FEV1 is normal or decreased with absolute FEV1/FVC > 0.7.[11] All the pulmonary functions were measured by the same operatorWe measured the cervical active range of motion (ROM) for all individuals using. We used a handheld goniometer because it was available, simple, and easy to use. The goniometer has been proven to be a valid and reliable tool to measure cervical ROM.[8],[12],[13] Participants were asked to sit on a chair with their backs straight, their hips, knees, and ankles at right angles, and their arms flexed at 90° on the chair arms. Their trunks were supported by the back of the chair to minimize motion and avoid errors.[14] After proper education and instruction, we measured the following actions: flexion, extension, right side flexion, left side flexion, right rotation, and left rotation. For the flexion and extension movements, the examiner stood to the side of the participant and set the axis of the goniometer over the external acoustic meatus and aligned the fixed arm in a vertical position and the movable arm with the base of the nares. For rotation, the examiner stood behind the participant with the goniometer axis centered over the vertex and aligned the fixed arm with the imaginary line between the participant's acromion process and the movable arm with the tip of the participant's nose [Figure 1]. For lateral flexion, the examiner stood behind the participant with the axis of the goniometer over the C7 spinous process and aligned the fixed arm over the spinous process of the thoracic vertebrae and the movable arm with the dorsal midline of the head [Figure 2]a, [Figure 2]b, [Figure 2]c.[8],[15] All measurements were performed by the same operator to avoid variabilityNeck function was assessed using the self-reported Neck Disability Index (NDI), which is a valid and reliable test for measuring neck disability. The NDI consists of 10 items referring to daily activities (work, lifting, driving, sleeping, reading, headaches, recreation, concentration, personal care, and pain intensity). Each item has six different scores (ranging from 0 to 5, with a score of 0 for no pain and no limitation and a score of 5 for maximum pain and limitation).[16],[17] The total maximum score is 50Pain severity was assessed by the self-reported Visual Analog Scale (VAS). The VAS is a valid and reliable tool to determine pain intensity. It is composed of a horizontal line 10 cm (100 mm) in length. The left end corresponds to no pain, and the right end corresponds to the worst pain imaginable. The patient is asked to place a line perpendicular to the VAS line to indicate their pain intensity. We used a ruler to determine the distance between the no pain end and the patient mark.[18],[19]{Figure 1}{Figure 2}

Statistical analysis

All the data were coded and entered into Excel, and statistical analysis was performed using the Statistical Package for the Social Sciences, version 15.0 (SPSS, Armonk, NY, USA: IBM Corp.). The confidence interval was set at 95%, and the accepted margin of error was set at 5%. The level of significance was considered at a P value below 0.05. Independent t-tests and Mann-Whitney tests were used for between-group comparisons as appropriate. A linear regression analysis was used to identify the strength of the relationship cervical ROM and the pulmonary function values.

Ethical approval and consent

The study protocol was approved by the ethics committee of Taibah University (Approval No. CMR-RT-2018-04). Each participant gave informed consent before enrolling into the study. The authors certify that they obtained all appropriate patient consent forms. In the consent form, the participants agreed for their images, and other clinical information to be reported in a journal. The participants understood that their names and initials will not be published and that, although due efforts will be made to conceal their identity, their anonymity cannot be guaranteed.

 Results



Our study included 75 patients with chronic neck pain and 75 age-and sex-matched healthy individuals as a control group. The participants were between 20 and 49 years old, and most were male. The control group included 68 males (90.7%) and the neck pain group included 70 males (93.3%). No significant differences were found between the neck pain group and control group regarding height, weight, or BMI. For the neck pain group, VAS scores ranged from 1 to 10, and NDI scores ranged from 2 to 47 [Table 1]. Cervical movement was significantly limited in all directions in the neck pain group compared with the control group [Table 2]. PFT values (FVC, FEV1, FEF 25–75, and PEFR) were significantly lower in the neck pain group compared with healthy controls, whereas the FEV1/FVC value was significantly higher in the chronic neck pain group, indicating restrictive lung disease [Table 3].{Table 1}{Table 2}{Table 3}

A linear regression analysis showed that FVC and FEF 25–75 had a significant negative linear relationship with VAS, whereas FVC, FEV1, FEF 25–75, and PEFR had a significant negative linear relationship with NDI.

In addition, FVC had a significant positive linear relationship with neck movement in all directions, FEV1 had a significant positive linear relationship with neck movement (flexion, left rotation), FEF 25–75 had a significant positive linear relationship with neck movement in all directions except right lateral rotation, and PEFR had a significant positive linear relationship with neck movement in all directions except lateral flexion [Table 4].{Table 4}

 Discussion



The relationship between chronic neck pain and pulmonary function has gained researchers' interest because of the close connection between the cervical and thoracic regions. However, few studies exist in this area, and most of them are concerned with evaluating the musculoskeletal system and included a small number of patients. In our study, we examined the relationship between respiratory function and chronic neck pain and found that patients with chronic neck pain had significantly decreased pulmonary function parameters (FVC, FEV1, FEF 25–75, and PEFR) compared with age- and sex-matched healthy controls. Besides, FEV1/FVC was significantly higher in those with neck pain, and a significant proportion of the neck pain participants had restrictive lung disease. Similar results have been reported in previous studies. For example, Dimitriadis et al.[7] found a significant decrease in some pulmonary function parameters (vital capacity: VC, FVC, and MVV) in patients with chronic neck pain, and non-significant decrease of other values(FEF 25–75, FEV1, FEV1/FVC, and PEFR). Similarly, Kapreli et al.[2] reported significantly reduced pulmonary functions (MVV, VC, FVC, FEV1, and PEFR) in patients with chronic neck pain. While the values of FEV1/FVC were lower in those with neck pain, the difference was nonsignificant.[2] Wirth et al.,[4] however, found no statistical difference in PFTs between healthy controls and those with chronic neck pain. Their study is limited by the small sample size (19 healthy controls and 19 participants with chronic neck pain). Furthermore, they used the spinal mouse for the measurement of spinal spine mobility which has been validated in the standing position only.[20]

In the current study, we found a significant positive linear relationship between PFT values and neck movements, whereas the relationship was negative with VAS and NDI [Table 4]. Dimitriadis et al.[7] found that decreased lung volumes were also related to neck flexor and extensor strength and pain intensity. These effects on respiratory function may be attributed to weakness of the deep neck flexor and extensor muscles, resulting in decreased stability of cervical and thoracic spines,[4] changes in thoracic cage mechanics,[4] and hyperventilation secondary to pain.[21] The presence of restrictive pulmonary function pattern found in this study may be attributed to neck muscle weakness, which may directly influence respiratory function because the sternocleidomastoid, trapezius, and scalene muscles participate in both neck movement and inspiration.[22] In addition, weak inspiratory muscles can lead to restricted thoracic movement[23] and weak neck muscles are believed to lead to the changes in force-length curves and muscle imbalances.[24] The discrepancies among research results may be attributed to the variations in methods and the small number of study participants,[4] resulting in the findings that are not statistically significant.

Yozbatira et al.[25] reported improved PEFR values in patients with chronic neck pain and low back pain after physiotherapy which supports the relationship between neck pain and impaired PFTs. The authors explained that the PEFR values improved because the hot packs and interferential current used during treatment resulted in a relaxing and analgesic effect, excitation of non-noxious sensory nerve fibers, and activation of the analgesic neuropeptides. This relaxing effect also increased the compliance of the chest wall and the muscle length-tension relation, and relieving pain increased the number of active muscle fibers. All these factors contributed to increased rib cage movement.[21]

Kahlaee et al. found that some respiratory volumes were lower in patients with chronic neck pain. Cervical ROM, muscle strength, and endurance were significantly correlated with pulmonary function parameters. They suggested further investigation of the effect of neck pain management on pulmonary functions.[9]

Previous research and the current study support the theory that chronic neck pain is a contributing factor in decreased pulmonary functions and that every case of chronic neck pain should be fully evaluated for possible respiratory system involvement. Patients with chronic neck pain should be screened with a spirometer, and abnormal results should be sent for further evaluation.

The strengths of this study include the case–control nature and adequate number of participants. Furthermore, all case and control subjects were nonsmokers, eliminating other possible causes for respiratory impairment. The main limitation of this study is that it is observational, and we therefore did not investigate respiratory function improvement after treating neck pain. However, we plan to do so in future research.

 Conclusions



Chronic neck pain may be associated with pulmonary function abnormalities. Clinical evaluation and pulmonary function testing should be incorporated into the management plan for patients with neck pain.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Hoy DG, Protani M, De R, Buchbinder R. The epidemiology of neck pain. Best Pract Res Clin Rheumatol 2010;24:783-92.
2Kapreli E, Vourazanis E, Billis E, Oldham JA, Strimpakos N. Respiratory dysfunction in chronic neck pain patients. A pilot study. Cephalalgia 2009;29:701-10.
3Dimitriadis Z, Kapreli E, Strimpakos N, Oldham J. Respiratory weakness in patients with chronic neck pain. Man Ther 2013;18:248-53.
4Wirth B, Amstalden M, Perk M, Boutellier U, Humphreys BK. Respiratory dysfunction in patients with chronic neck pain–Influence of thoracic spine and chest mobility. Manual Ther 2014;19:440-4.
5Zafar H, Albarrati A, Alghadir AH, Iqbal ZA. Effect of Different Head-Neck Postures on the Respiratory Function in Healthy Males. Biomed Res Int 2018;2018:4518269.
6Falla DL, Jull GA, Hodges PW. Patients with neck pain demonstrate reduced electromyographic activity of the deep cervical flexor muscles during performance of the craniocervical flexion test. Spine (Phila Pa 1976) 2004;29:2108-14.
7Dimitriadis Z, Kapreli E, Strimpakos N, Oldham J. Pulmonary function of patients with chronic neck pain: a spirometry study. Respir Care 2014;59:543-9.
8Youdas JW, Carey JR, Garrett TR. Reliability of measurements of cervical spine range of motion–comparison of three methods. Physical Ther 1991;71:98-104.
9Kahlaee AH, Ghamkhar L, Arab AM. the association between neck pain and pulmonary function: A systematic review. Am J Phys Med Rehabil 2017;96:203-10.
10Miller MR, Hankinson J, Brusasco V, Burgos F, Casaburi R, Coates A, et al. Standardisation of spirometry. Eur Respir J 2005;26:319-38.
11Barreiro TJ, Perillo I. An approach to interpreting spirometry. Am Fam Physician 2004;69:1107-14.
12Agarwal S, Allison GT, Singer KP. Validation of the spin-T goniometer, a cervical range of motion device. J Manipulative Physiol Ther 2005;28:604-9.
13Whitcroft KL, Massouh L, Amirfeyz R, Bannister G. Comparison of methods of measuring active cervical range of motion. Spine (Phila Pa 1976) 2010;35:E976-80.
14Yankai A, Manosan P. Reliability of the universal and invented gravity goniometers in measuring active cervical range of motion in normal healthy subjects. Int J Applied Biomed Eng 2009;2:49-53.
15Goniometry of the Cervical Spine. Available from: http://at.uwa.edu/gon/cspine.htm. [Last accessed on 2020 Aug 14].
16Vernon H, Mior S. The neck disability index: A study of reliability and validity. J Manipulative Physiol Ther 1991;14:409-15.
17Vernon H. The neck disability index: State-of-the-art, 1991-2008. J Manipulative Physiol Ther 2008;31:491-502.
18Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual analog scale for pain (vas pain), numeric rating scale for pain (nrs pain), mcgill pain questionnaire (mpq), short-form mcgill pain questionnaire (sf-mpq), chronic pain grade scale (cpgs), short form-36 bodily pain scale (sf-36 bps), and measure of intermittent and constant osteoarthritis pain (icoap). Arthritis Care Res 2011;63:S240-52.
19MacDowall A, Skeppholm M, Robinson Y, Olerud C. Validation of the visual analog scale in the cervical spine. J Neurosurg Spine 2018;28:227-35.
20Mannion AF, Knecht K, Balaban G, Dvorak J, Grob D. A new skin-surface device for measuring the curvature and global and segmental ranges of motion of the spine: reliability of measurements and comparison with data reviewed from the literature. Eur Spine J 2004;13:122-36.
21Dimitriadis Z, Kapreli E, Strimpakos N, Oldham J. Hypocapnia in patients with chronic neck pain: association with pain, muscle function, and psychologic states. Am J Phys Med Rehabil 2013;92:746-54.
22Palastanga N, Field D, Soames R. Anatomy and Human Movement. 4th ed.. Edinburgh, UK: Butterworth Heinemann; 2002
23De Troyer A, Borenstein S, Cordier R. Analysis of lung volume restriction in patients with respiratory muscle weakness. Thorax 1980;35:603-10.
24Gossman MR, Sahrmann SA, Rose SJ. Review of length-associated changes in muscle. Experimental evidence and clinical implications. Phys Ther 1982;62:1799-808.
25Yozbatiran N, Gelecek N, Karadibak D. Influence of physiotherapy programme on peak expiratory flow rate (PEFR) and chest expansion in patients with neck and low back pain. J Back Musculoskelet Rehabil 2006;19:35-40.