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Introduction: Musculoskeletal pain is a common problem in the working population. In Sweden, 40% of women and 30% of men report suffering from neck and shoulder pain weekly. The underlying cause for neck pain is often not known and the treatment is commonly guided by the individual’s symptoms. However, there is a lack of knowledge on how to receive the best effect based on the individual’s symptoms and functional limitations, and therefore this has been scarcely evaluated in research. Furthermore, the impact of work exposure and stress on long-term treatment for persons with neck pain is not clear. Aims: To develop (paper 1) and to evaluate a decision model for tailored treatment in women with neck pain (paper 2). Moreover, to determine if risk factors at work and stress influence intermediate and long-term treatment results (paper 3). Further, to investigate if changes in self-reported pain and disabilities are associated with changes of physical test outcomes of the neck and shoulder region after treatment (paper 4). Methods: In an RCT, 120 working women with non-specific neck pain were randomized to three different groups – tailored treatment (TT), non-tailored treatment (NTT) or treatment-as-usual (TAU) for an 11 weeks intervention with short-term, intermediate-term and long-term follow-ups. The TT group was guided by a decision model with cut-off levels to indicate impairments. The NTT group received two established treatment components randomly from those not indicated, and TAU group did not receive any treatment within the study. The RCT primary outcomes were self-reported neck pain and neck disability. A linear mixed model was used for analysing the effects. One week after the end of intervention work exposure and stress were assessed at a work-place visit and associations to treatment results were tested for, and mixed models were used to estimate longitudinal associations. Associations between self-reported neck problems and physical outcomes were estimated with univariate and multiple regressions analysis. Results: No differences between TT and NTT were revealed for neck pain and disability. In comparison to TAU, the TT and NTT groups both showed improvements at short-term follow-up, but not at intermediate and long-term follow-up. High stress level and low self-estimated control at work were associated with more pain and disability at the intermediate and long-term follow-ups. After intervention and at the intermediate-term follow-up, reduced neck pain, disability and frequency of symptoms were associated with increased peak speed of head rotation and cervical range of motion. Conclusion: Tailored treatment according to the decision model was not superior to the non-tailored treatment in women with non-specific neck pain. One explanation for this can be the weak relationships found between neck pain and disability and physical test outcomes. Further, perceived stress and psychosocial work exposure were associated with self-reported neck problems and should be taken into account to optimize the effects in neck pain rehabilitation. / Bakgrund: Nack- och skulder-smärta är ett vanligt tillstånd som förekommer över hela världen. I Sverige skattar 30-40% besvär från nacke och skuldror mätt under en veckas tid. Generellt rapporterar kvinnor mer nack- och skulder-besvär än män. I avhandlingen är det ospecifik nacksmärta som har studerats, det inkluderar inte t.ex. Whiplash-skador, diskbråck eller andra mer specifika diagnoser. Den bakomliggande orsaken till ospecifik nacksmärta är, precis som beteckningen antyder, ofta inte känd och individens symptom och funktion är istället vägledande i undersökning och behandling samt utvärdering av behandling. Studier har visat att i jämförelse med friska har individer med ospecifika nackbesvär ofta sämre muskulär nackstyrka, minskad rörlighet i nacken och är något långsammare vid test av huvudrörelser. Behandlingen riktar sig ofta mot något av dessa fynd med bl.a. styrketräning av nackmuskler och/eller manuella tekniker för rörelseökning. Studier har dock visat att behandlingen endast ger måttliga resultat och att de positiva resultaten bara är kortvariga. I kliniken försöker man individanpassa behandlingen utifrån patientens behov men det finns väldigt lite forskning om detta utan studier utvärderar likadan behandling för hela grupper. Det saknas fortfarande kunskaper om hur man på bästa sätt individanpassar behandling så att den blir skräddarsydd utifrån individens symptom och funktion samt utvärderar detta. Syftet med avhandlingen var att undersöka om en intervention med skräddarsydd behandling (som också innehöll specifik aktiv träning) utifrån en beslutsmodell med fysiska tester och frågor om symtom är effektivt för att uppnå positiva effekter i självskattad smärta och funktion (artikel 1 och 2).  Den skräddarsydda behandlingen jämfördes mot en grupp som fick samma upplägg men inte skräddarsydd behandling. Vidare undersöktes om båda dessa behandlingsgrupper var effektivare än en grupp som inte fick någon behandling i studien. Dessutom undersöktes om påverkan från arbetsmiljön i form av fysisk och psykosocial belastning samt upplevd stress påverkade behandlingsresultaten efter interventionen (artikel 3). Slutligen undersöktes om de fysiska testerna och den självskattade smärtan, funktionen och symptomen hade koppling till varandra dels före interventionen och dels i termer av förändringar efter interventionen (artikel 4). Metod: I en randomiserad kontrollerad interventionsstudie (RCT) inkluderades 120 kvinnor i åldrarna 20-65, alla i arbete, och som hade ospecifika nackbesvär.  De lottades till tre grupper, (1) skräddarsydd behandling (Tailore treatment, TT), (2) icke-skräddarsydd behandling (Non-tailored treatment, NTT) och (3) en kontrollgrupp (Treatment-as-usual, TAU) som inte fick någon behandling i studien men var fria att söka vård på egen hand. Kvinnorna i TT-gruppen fick behandlings-komponenter utifrån testresultaten i beslutsmodellen. Det kunde läggas till någon behandlingskomponent om det visade sig behövas utifrån individens behov i vardagen. Detta undersöktes genom en strukturerad intervju-teknik som kallas Problem Elicitation Technique (PET). Kvinnorna i NTT-gruppen fick två lottade behandlings-komponenter som inte matchade deras behov utifrån testerna i beslutsmodellen. För båda behandlings-grupperna var interventionen 11 veckor med inbokade behandlingstillfällen 2-3 gånger per vecka, samtliga tillfällen vägledda av fysioterapeut. Data för alla tre grupper samlades in innan interventionen samt 3, 9 och 15 månader efter start av interventionen. Gruppskillnaderna analyserades med en ”linear mixed model”. En vecka efter intervention gjordes ett arbetsplatsbesök hos individerna i alla tre grupper. En erfaren ergonom observerade individernas fysiska arbetsbelastning med ett ergonomiskt bedömningsinstrument, Quick Exposure Check (QEC), och individerna skattade också den psykosociala arbetsmiljön i ett frågeformulär, QPS Nordic, samt upplevd stress. För att undersöka om den fysiska och psykosociala arbetsbelastningen samt stress påverkade resultaten från interventionen analyserades data med linjär regression och mixed model. För att undersöka om de fysiska testerna och den självskattade smärtan, funktionen och symptomen hade något samband användes linjär regressionsanalys. Resultat: Att skräddarsy behandlingen utifrån den testade beslutsmodellen var inte effektivare än att inte skräddarsy. I jämförelse med kontrollgruppen självskattade båda behandlingsgrupperna mindre smärta, bättre funktion och mindre symptom efter interventionen. I de länge uppföljningarna (9 och 15 månader) var dock skillnaderna mellan grupperna inte längre signifikanta förutom att båda behandlingsgrupperna, till skillnad från kontrollgruppen, upplevde sig bättre än innan behandling. Det visade sig att upplevd hög stressnivå och låg kontroll på arbetet hade samband med mer självskattad nacksmärta, sämre funktion och lägre arbetsproduktivitet. De fysiska testerna och självskattade nackbesvär hade bara svaga samband. På baslinjenivå, innan interventionen, fanns det samband mellan hög nackstyrka och låg självskattad funktion och låg frekvens på symptomen, samt mellan att vara långsam i testet av snabba huvudrörelser och hög smärta. Efter interventionen hade individernas förändring i självskattad smärta fortfarande bara samband med snabba huvudrörelser. Förbättring i självskattad funktion och symptom hade samband till ökad hastighet i snabba huvudrörelser och ökat rörelseutslag nackrotation. Sammanfattning: För kvinnor i arbete med ospecifika nackbesvär var det inte mer effektivt att skräddarsy behandling/träning utifrån en beslutsmodell jämfört med att slumpmässigt välja ut behandlingskomponenter från samma behandlingsarsenal. En förklaring kan vara att det fanns endast låga samband mellan självskattad smärta och funktion och de fysiska testerna. Upplevd stress och kontroll i arbetet visade sig ha samband med självskattad smärta, funktion och arbetsproduktivitet och bör tas i beaktande i framtida interventioner för individer med nacksmärta.

Title: Effect of proprioceptive neuromuscular facilitation on strengthening of deep neck flexors in patients with cervicogenic headache Objectives: The aim of this diploma thesis is to investigate the effectiveness of proprioceptive neuromuscular facilitation on relieving or reduction headaches in patients diagnosed with cervicogenic headache. Methods: This is a pilot study involving 10 patients diagnosed with cervicogenic headache in the age range of 23-41 years. Patients participated in proprioceptive neuromuscular head and neck therapy, which took place 3 times per week for 5 weeks. Patients on the first and last therapy completed the Neck Disability Index, the measurements were done twice a week. It was a measurement of performance index of deep neck flexors by means of a craniocervical flexion test and evaluation of pain on visual analogue scales. The statistical method - paired t-test was used to analyze the obtained data. Results: The results of this thesis show that proprioceptive neuromuscular facilitation therapy is effective in elimination or reduction of headaches in patients diagnosed with cervicogenic headache. Keywords: cervicogenic headache, proprioceptive neuromuscular facilitation, craniocervical flexion test, Neck Disability Index, physiotherapy

The pain related to temporomandibular disorders (TMD) and cervical disorders have high prevalence in the population and the association between signs and symptoms of TMD and cervical dysfunction is widely explored in the literature. Nevertheless, two systematic reviews have recently been published regarding this topic and both were inconclusive, emphasizing the need for further evidence. Objective: To study the correlation between cervical disability, masticatory myofascial pain and generalized mechanical hypersensitivity in subjects with and without temporomandibular myofascial pain dysfunction. Casuistry and Methods: Two groups composed this controlled cross-sectional study: group I consisted of 27 individuals diagnosed with myofascial pain according to the criteria of the Brazilian version of diagnostic research for TMD (RDC / TMD), and group II consisting of 28 asymptomatic control patients. The clinical variables evaluated were: self-reporting of cervical disability determined using the Neck Disability Index (NDI); pain intensity measured by visual analogue scale (VAS); the pain threshold pressure of the temporomandibular joint, the anterior temporalis, masseter, sternocleidomastoid, upper trapezius and Achilles tendon, measured by a digital algometer. Results: Neck disability was significantly higher in patients with myofascial pain (11.8 ± 7.0) compared with the asymptomatic control group (2.7 ± 2.4). In contrast the PPT was significantly lower in group I when compared to group II, in the different measurement areas, anterior temporalis (2.0 ± 0.8 vs. 2.6 ± 1.1), upper trapezius (2.6 ± 1.2 vs. 3.8 ± 1.8) and Achilles tendon (5.6 ± 1.4 vs. 6.9 ± 2.3). The study verified a negative correlation between neck disability and PPT in all studied structures and a positive correlation between the values of PPT on trigeminal and extra-trigeminal areas (p <0.05).Conclusion: Individuals with TMD masticatory myofascial pain show widespread mechanical hypersensitivity, which is also associated to the report of cervical incapacity. / As dores relacionadas às disfunções temporomandibulares (DTM) e desordens cervicais possuem alta prevalência na população e a associação entre os sinais e sintomas de DTM e disfunção cervical é bastante explorada na literatura. Apesar disso, duas revisões sistemáticas foram publicadas recentemente a respeito deste tópico e ambas foram inconclusivas, destacando a necessidade de novas evidências. Objetivo: Verificar a existência de associação entre a incapacidade cervical, a dor miofascial mastigatória e a hipersensibilidade mecânica generalizada em sujeitos com e sem disfunção temporomandibular do tipo dor miofascial. Casuística e Métodos: Dois grupos compuseram este estudo controlado e de corte transversal: grupo I foi composto por 27 indivíduos diagnosticados com dor miofascial de acordo com os critérios da versão brasileira de diagnóstico em pesquisa para DTM (RDC/DTM), e grupo II, composto por 28 controles assintomáticos. As variáveis clínicas avaliadas foram: o auto-relato de incapacidade cervical determinado por meio do Neck Disability Index (NDI); a intensidade da dor medida pela escala visual analógica (EVA); o limiar de dor à pressão da articulação temporomandibular, dos músculos temporal anterior, masseter, esternocleidomastóideo, trapézio superior e do tendão de Aquiles, mensurado por meio de um algômetro digital. Resultados: A incapacidade cervical foi significativamente maior no grupo com dor miofascial (11,8 ± 7,0) em relação ao grupo de controles assintomáticos (2,7 ± 2,4). Em contraste o LDP foi significativamente menor no grupo I em relação ao grupo II, nas diferentes áreas de mensuração como temporal anterior (2,0 ± 0,8 vs. 2,6 ± 1,1), trapézio superior (2,6 ± 1,2 vs. 3,8 ± 1,8) e tendão de Aquiles (5,6 ± 1,4 vs. 6,9 ± 2,3). Foi verificada uma correlação negativa entre incapacidade cervical e o LDP de todas as estruturas avaliadas e uma correlação positiva ocorreu entre os valores de LDP de áreas trigeminais e extra-trigeminais (p<0,05). Conclusão: Os indivíduos com DTM do tipo dor miofascial mastigatória apresentam hipersensibilidade mecânica generalizada, que também está associada com o auto-relato de incapacidade cervical.

Neck pain is the second most common musculoskeletal disorder after low back pain adding to the global burden of disease. A focus on evaluating outcomes for musculoskeletal conditions is imperative to evaluate the effect of interventions and to track the progression of disease. As evidence based practice and associated use of patient-based outcomes are taken up across different countries, it becomes imperative for cross-cultural translation studies. Given the uptake of technology in workplaces, it is also important to understand the prevalence of neck pain in this context. This thesis has focused on two objectives: 1. Translating a newly developed patient-report outcome measure of neck-related disability and testing its psychometric properties. 2. Estimating the prevalence of neck pain in computer-using workers. The first manuscript focusses on cross cultural translation and validation of ND10 (Neck difficulty10) that was designed to measure neck-related disability. A new English outcome measure for neck disability (ND10) was cross culturally translated and validated in computer users in India using forward and backward translation, and cognitive interviewing to determine a final version. The ND10-H demonstrated high reliability (ICC= 0.93) and convergent construct validity with the NDI and DASH (r= 0.78 and 0.86) The second manuscript reported the prevalence of neck pain in computer users in India. Sampling was performed in two different companies: A Spiritual Media Publication Organization (SMPO) and an Information Technology (IT) company. The companies were selected based on computer use and their willingness to participate. The survey was administered to all employees (n=150 & n=54) at these two companies. The overall prevalence of neck pain was 64%. In the IT company, 78% of employees reported neck pain; and in the SMPO the prevalence was 40%. There were no significant differences in prevalence based on gender or age. All of the IT company computer users worked more than seven hours at their computers, while 38% of the SMPO workers did so. Chronic pain was present in 48%of the total sample. The ND10-H can be used to assess neck-related disability in Hindi-speaking individuals. It should be accompanied by a valid pain measure when assessing patient outcomes. The prevalence of neck pain is high in computer-using workers in India. / Thesis / Master of Science Rehabilitation Science (MSc) / 1. Translating a newly developed patient-report outcome measure of neck-related disability and testing its psychometric properties. 2. Estimating the prevalence of neck pain in computer-using workers. The first manuscript focusses on cross cultural translation and validation of ND10 (Neck difficulty10) that was designed to measure neck-related disability. A new English outcome measure for neck disability (ND10) was cross culturally translated and validated in computer users in India using forward and backward translation, and cognitive interviewing to determine a final version. The ND10-H demonstrated high reliability (ICC= 0.93) and convergent construct validity with the NDI and DASH (r= 0.78 and 0.86)