Submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Durban University of Technology, Durban, South Africa, 2016. / Background: Musculoskeletal disorders (MSDs) are a significant and common occupational health concern, consequently impacting work attendance and performance. High prevalence rates of MSDs have been reported amongst school teachers. Studies have linked these higher prevalence rates to typical daily teaching activities including prolonged standing, awkward postures, heavy lifting, bending and repetitive movements. Objectives: To determine the prevalence of neck, shoulder and low back pain among primary school teachers in the Central Durban area; to identify any risk factors associated with neck, shoulder and low back pain; and to establish the relationship, if any, between the prevalence and risk factors of neck, shoulder and low back pain among primary school teachers. Methods: This was a quantitative, descriptive and cross-sectional study, conducted in 12 selected public primary schools within the Central Durban area. Volunteers who met the inclusion criteria (n = 97) were invited to complete self-administered questionnaires. Results: Of the 97 completed questionnaires 83.1 percent (%) reported neck and shoulder pain and 71.0% low back pain. Neck and shoulder pain were significantly associated with a forward-bent head posture (p = 0.001), ethnicity (p = 0.001), and history of a severe trauma/injury (p = 0.006). Similarly, significant associations were noted with regards to medical conditions (p = 0.006), a backward-bent head posture (p = 0.016), lifting of heavy loads (p = 0.045) and treatment for severe injury (p = 0.047). Associations were also noted between low back pain and prolonged standing (p = 0.000), ethnicity (p = 0.008), transportation methods (p = 0.023), medical conditions (p = 0.031) and a history of a severe trauma/injury (p = 0.049). Conclusion: This is a first South African study, to our knowledge that highlights increased prevalence rates for both neck and shoulder pain and low back pain amongst teachers, with a variety of associated risk factors. This draws attention to the urgent need for intervention programs to be implemented to prevent/reduce the development of musculoskeletal pain amongst teachers. / M

EFFECTS OF THORACIC SPINAL MANIPULATIVE THERAPY ON THORACIC SPINE AND SHOULDER KINEMATICS, THORACIC SPINE FLEXION/EXTENSION EXCURSION, AND PRESSURE PAIN SENSITIVITY IN PATIENTS WITH SUBACROMIAL PAIN SYNDROME By Joseph R. Kardouni, Ph.D., PT A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy, at Virginia Commonwealth University. Virginia Commonwealth University, 2013. Major Director: Lori A. Michener, PhD, PT, ATC, Professor, Department of Physical Therapy In patients with shoulder pain, the use of manual therapy directed at the spine and shoulder have been reported to provide superior outcomes to exercise based interventions or usual care without the use of manual therapy. Clinical trials have also reported improved pain and disability after thoracic spinal manipulative therapy (SMT) as a stand-alone treatment for shoulder pain. Although clinical efficacy is reported for the use of thoracic SMT for the treatment of shoulder pain, the mechanisms underlying the clinical benefits are not well understood. This limits the directed use of SMT. The benefits could be due to changes in spine or shoulder motion or neurophysiologic mechanisms of pain modulation. Elucidating the mechanism of manual therapy will aid the directed use of thoracic SMT for treating patients with shoulder pain. The research described in chapters 3 and 4 was performed to assess the effects of thoracic SMT in patients with subacromial pain syndrome with regard to biomechanical changes at the thoracic spine and shoulder and effects on central and peripheral pain sensitivity. Subjects with shoulder impingement pain symptoms were randomly assigned to receive 1 visit of thoracic SMT or sham SMT, applied to the lower, middle, and upper (cervicothoracic junction) thoracic spine. A 3-dimensional electromagnetic tracking system was used to measure thoracic and scapular kinematics during active arm elevation, and thoracic excursion at end-range of flexion and extension pre- post-treatment. Pressure pain threshold (PPT) was measured at the painful shoulder (deltoid) and unaffected regions (contralateral deltoid and bilateral lower trapezius areas) immediately pre- and post-treatment. PPT measures at the painful shoulder were used to assess peripheral and/or central pain sensitivity, and PPT at unaffected regions measured central pain sensitivity. Patient-rated outcomes measures of pain (Numeric Pain Rating Scale-NPRS), function (Pennsylvania Shoulder Score-Penn), and global rating of change (GROC) were used to assess changes in clinical symptoms following treatment. No significant differences were found between treatment groups for the thoracic kinematics or excursion, shoulder kinematics, PPT measures, or patient-rated outcomes. No differences were noted pre- to post-treatment in either group for thoracic kinematics or excursion or PPT measures. In both groups, there was a decrease in mean scapular external rotation over time during ascending arm elevation, but the change was less than measurement error. Outcome measures of NPRS, Penn and GROC indicated clinical improvements in both groups following treatment, but there were no differences between the thoracic SMT or sham SMT groups. There were no meaningful correlations between thoracic and scapular kinematics or thoracic excursion with the outcome measures of NPRS, Penn, or GROC. There was a significant positive correlation (r=0.52 , p=0.009) between change in PPT at the lower trapezius on the unaffected side and baseline Penn scores. Biomechanically, thoracic spine extension and excursion did not change following thoracic SMT, and the SMT group had no greater changes in shoulder kinematics or patient-rated pain and function than the sham SMT group. Additionally, thoracic SMT did not improve peripheral or central pain sensitivity as measured by PPT. Furthermore, improvements in patient-rated outcomes were not found to be related to changes in thoracic spine mobility, or shoulder kinematics with SMT. The single correlation between change in PPT and baseline Penn may indicate a neurophyciologic effect of SMT in patients with higher baseline function scores, but the since no other significant relationships between PPT and outcome were seen, the implications of this finding are limited. Overall, alterations in thoracic spine mobility and pressure pain sensitivity do not appear to be responsible for improved outcomes in patients with subacromial pain syndrome. Future studies should explore the effects of SMT using other measures of thoracic spine motion and experimental pain modalities, as well as greater dosing of SMT over a longer follow-up.

The glenohumeral joint is the most dislocated joint in the body due to the lack of bony constraints and dependence on soft tissue, primarily muscles and ligaments, to stabilize the joint. The goal of this study was to develop a computational model of the glenohumeral joint whereby joint behavior was dictated by articular contact, ligamentous constraints, muscle loading, and external perturbations. Validation of this computational model was achieved by comparing predicted results from the model to the results of a cadaveric experiment in which the relative contribution of muscles and ligaments to anterior joint stability was examined. The results showed the subscapularis to be critical to stabilization in both neutral and external rotations, the biceps stabilized the joint in neutral but not external rotation, and the inferior glenohumeral ligament resisted anterior displacement only in external rotation. Knowledge gained from this model could assist in pre-operative planning or the design of orthopedic implants. Use of this model as a companion to cadaveric testing could save valuable time and resources.

Title: The Comparison of Muscle Timing of Chosen Shoulder Girdle Muscles During Breaststroke Inside and Outside the Water Objectives: The aim of this thesis was to compare timing and activation of chosen shoulder girdle muscles during breaststroke in the pool with counterflow and during excercise with rubber expander. Methods: It was analyzed timing and level of muscle activation during swimming and simulating the same movement of upper extremities in the air against the power of rubber expander. As an objetification was used surface electromyography. One profesional swimer took part in this experiment Results: Based on results it seemed that the movement of upper extremities are different in the pool and in the air during swimming stroke of breaststroke. Most of the measurement were different in the pool and in the air. Keywords: swimming, breaststroke, EMG, WaS-EMG, electromyography, shoulder girdle muscles, timing

Title: The comparative kineziologic analysis of forward stroke on wheelchair and crawling. Objectives of the Thesis: The aim of the thesis is to compare muscle activity of selected muscles in shoulder girdle during forward stroke on wheelchair and crawling. Method: Surface electromyography combinated with kinematography analysis used synchronized video recording. Results and Conclusions: As the research shows, there is a difference in muscle activity (timing) between forward stroke on wheelchair and during crawling. It was proved that the activity of forward stroke on wheelchair does not have natural locomotive character. Keywords: Forward stroke on wheelchair, crawling, shoulder girdle, surface electromyography, kinematics analysis.

AABBSSTTRRAACCTT Title: Comparative analysis of selected coordinate indicators in front crawl swimming technique and crawling. Purposes: The first aim of thesis is to compare coordinate indictors of average swimming cycle and average crawling cycle. Methods: Surface electromyography of muscular activity combined with cinematography analysis used synchronized video recording. Intraindividual comparative analysis and subsequent interindividual comparison of timing muscular activation in one average swimming and crawling cycle. Results: The timing of muscular activity of m. pectoralis major and m. latissimus dorsi during swimming cycle was identical for all probands. This phenomenon was not found in crawling . Key words: Swimming technique, Front Crawl, crawling, EMG, muscle, locomotion, shoulder girdle

Title: The effect of shoulder girdle stabilization exercises on muscle activity during direct impact in rugby players with sub-acromial impingement syndrome Objectives: Comparison of muscle activity during direct impact while performing the rugby tackle to tackle bag and to player using amplitude analysis of electromyographic signal (EMG) before and after intervention programme for players with subacromial impingement syndrome (SIS). Application of intervention programme consisting stabilization excercises for shoulder complex and activation of deep stabilization muscles of the spine. Methods: Theoretical part contains topics about shoulder girdle, rugby and rugby injuries, mainly subacromial impingement syndrome and electromyography. Mentioned issues are included into the thesis due to the research of current literature from international sources and studies. Practical part regards the aplication of three- months long intervention programme for eight rugby players at junior national level with diagnosis of SIS, when pre-testing a post-testing is realized by clinical tests and EMG measurement. Results: Intervention programme was sufficient for changes of EMG amplitude values expressed as percentage of maximal voluntary isometric contraction (MVIC) in some of rugby players with SIS only for some...

Le but de ce travail est de déterminer les liens éventuels existant entre la force et l’équilibre agoniste / antagoniste des muscles rotateurs médiaux et latéraux de l’articulation scapulohumérale, et la stabilité scapulo-humérale. La première partie de ce travail est un rappel d’anatomie fonctionnelle, de physiologie articulaire et de biomécanique de l’articulation scapulo-humérale, ainsi que des aspects pathologiques en rapport avec la problématique de sa stabilité et de son exploration. La deuxième partie propose une analyse critique de la technique d’exploration de la force musculaire par dynamométrie isocinétique, afin de déterminer un protocole d’évaluation fiable et reproductible. Ainsi, nous choisissons d’utiliser la position d’évaluation la plus reproductible et la plus adaptée pour l’évaluation de sujets pathologiques : la position assise avec 45° d’abduction dans le plan de la scapula avec correction de la gravité. La troisième partie a pour objet de rechercher, à partir d’études cliniques originales, les liens existant entre la force musculaire des rotateurs médiaux et latéraux de l’épaule et l’instabilité antérieure chronique post-traumatique d’une part, et les adaptations de cette force avec certaines sollicitations sportives d’autre part. Bien qu’un déficit de la force musculaire des rotateurs médiaux et latéraux soit associé à l’instabilité antérieure chronique, nos études ne rapportent pas d’association entre le déséquilibre agoniste/antagoniste et l’instabilité antérieure chronique. Dans le cadre de la pratique de sports sollicitant les membres supérieurs, les adaptations de la force, avec une augmentation de la force des muscles rotateurs médiaux et latéraux du côté dominant, sont inconstantes, et surtout, nos résultats ne rapportent aucun déséquilibre agoniste/antagoniste induit par la pratique sportive. En conclusion, notre travail de thèse met en évidence des adaptations de la force musculaire sans perturbation de l’équilibre agoniste/antagoniste des rotateurs médiaux et latéraux de l’articulation scapulo-humérale, associées à l’instabilité scapulo-humérale ou induites par la pratique de sports sollicitant cette articulation. Prenant en compte les limites de notre expérimentation, on peut faire l’hypothèse que les adaptations physiologiques induites par la pratique sportive n’interviendraient pas comme un mécanisme de désadaptation, ou un facteur de risque prédisposant, à l’origine des pathologies de l’articulation scapulo-humérale. Ainsi, notre conclusion serait que l’équilibre agoniste / antagoniste aurait un rôle protecteur de la stabilité articulaire ; la survenue d’un déséquilibre musculaire agoniste / antagoniste serait alors secondaire à une lésion anatomique et marquerait le signe de son évolution longue et/ou péjorative / The aim of this work is to determine the possible links between strength and agonist/antagonist balance of the shoulder internal and external rotators muscle, and the glenohumeral stability. The first part of this work is a reminder of functional anatomy, joint physiology and biomechanics of the glenohumeral joint, and pathological aspects related to the problem of its stability and its exploration. The second part propose a critical analysis of technical exploration of muscular strength by isokinetic dynamometer to determine a reliable and reproducible protocol. We choose to use the more reliable and more suitable position for evaluation of pathological subject: the seated position with 45° of shoulder abduction in the scapular plane, with gravity corrected. The third part is aimed to research, from original clinical studies, the relationship between shoulder internal and external rotators muscle strength and balance, and shoulder instability on the one hand, and adaptations of this strength with sports practice on the other hand. Although a deficit in rotators muscle strength is associated with recurrent anterior instability, our work reporte no association between agonist/antagonist imbalance and recurrent anterior instability. In overhead sports and sports seeking the upper limbs, adaptations of strength, with a rotator strength increase on the dominant side, are inconsistent, and most importantly, our results reporte no agonist/antagonist imbalance induced by the sports practice. In conclusion, this work highlights adaptations in strength and balance of the shoulder internal and external rotators muscle associated with the glenohumeral joint instability, or induced by the sports practice. Tacking into account the limits of our experiment, we can hypothesis that any physiological adaptations induced by sport practice would not intervene as a pathophysiological mechanisms of desadaptation, or not be considered a risk factor predisposing, to glenohumeral joint diseases. Thus, our conclusion is that the agonist/antagonist balance would have a protective role of the joint stability; the occurrence of a muscle agonist / antagonist imbalance may be secondary to an anatomical lesion and mark the sign of its long and/or pejorative evolution

O objetivo desta pesquisa foi avaliar e comparar a atividade eletromiográfica de sete músculos da cintura escapular e braço durante a realização dos exercícios wall-press, bench-press e push-up sobre uma superfície estável e com carga axial controlada em dois níveis de esforço isométrico, um máximo (100%) e outro submáximo (80%). Os exercícios foram realizados com o braço em 90° de flexão no plano sagital, 0° de extensão do cotovelo e 90° de flexão da mão. Vinte voluntários do sexo masculino, saudáveis, destros e sem história de trauma no membro superior participaram da pesquisa. Os registros eletromiográficos e de força foram adquiridos, respectivamente, por sete canais para eletromiograma e por um canal auxiliar de um sistema de aquisição simultânea, ganho total de 50 vezes, 12 bits de faixa de resolução dinâmica e freqüência de amostragem por canal de 4 KHZ. Os sinais mioelétricos foram captados por eletrodos ativos simples diferencial, ganho de 20 vezes, impedância de entrada de 10G? e CMRR mínimo de 130 dB, colocados nos músculos serrátil anterior, porção anterior e posterior do músculo deltóide, porção clavicular do peitoral maior, fibras superiores do trapézio, cabeça longa do bíceps e tríceps braquial. Os exercícios foram realizados aleatoriamente, nos dois níveis de esforço isométrico, com intervalados entre si por 5 minutos. Os voluntários realizaram três repetições de cada exercício, com duração de 6 segundos cada, intervaladas entre si por 1,5 minutos e manutenção da força dentro dos valores previamente definidos, orientadas por um feedback sonoro. Os sinais brutos foram filtrados por um passa faixa de 20-500Hz, derivando os valores de amplitude eletromiográfica pelo cálculo da Root Mean Square (RMS). Os valores de RMS foram normalizados pelo valor máximo obtido de três contrações isométricas voluntárias máximas obtidas em prova de função muscular. A comparação dos valores normalizados entre os três exercícios nos dois níveis de esforço isométrico e entre o mesmo exercício nos dois níveis de esforço isométrico foi realizada através do Modelo Linear de Efeitos Mistos, com nível de significância de 5%. Os valores normalizados de RMS dos músculos estudados, em valores percentuais, foram usados para graduar o nível de atividade elétrica obtido em cada exercício. Os resultados demonstraram que houve uma diferença nos valores de RMS normalizados dos músculos avaliados nas comparações feitas entre os três exercícios, não confirmando a hipótese inicial deste trabalho, pois os dois níveis de esforços isométricos não foram capazes de influenciar a resposta eletromiográfica. Diferenças entre amplitudes de ativação normalizadas foram constatadas, variando entre os níveis mínimo e alto. O bench-press gerou maiores níveis de atividade eletromiográfica para a maioria dos músculos, possivelmente pelo maior esforço isométrico realizado. O wall-press gerou maior atividade eletromiográfica para a maioria dos músculos quando comparado ao push-up, apesar do esforço isométrico gerado ser menor. Este trabalho concluiu que, apesar de exercícios com carga axial, mesmo com esforço isométrico controlado, causaram diferentes níveis de atividade eletromiográfica nos músculos avaliados. / The purpose of this research was to investigate if biomechanically similar exercises produce similar myoelectric activation when the same level of maximal isometric effort is produced. Twenty volunteers participated in the study. All volunteers were right-handed, healthy men with no history of previous upper limb trauma. Electromyographic (EMG) recordings were obtained using a seven-channel simultaneous acquisition system, with gain of 50, 12 bit A/D converter board with a 4 KHz frequency. To monitor produced force, a load cell was attached through an auxiliary channel and force recording was accomplished simultaneously with the acquisition of EMG signal. Myoelectric signals were obtained using simple differential electrodes, with gain of 20, input impedance of 10 G? and minimum CMRR of 130 dB, placed on the serratus anterior, posterior and anterior deltoid, clavicular portion of the pectoralis major, upper trapezius, and biceps and triceps brachii muscles, following the European Recommendations for Surface Electromyography by SENIAM project, and instructions by Hintermeinster et al. (1998). EMG signals were recorded while performing push-up, bench-press, and wall-press exercises at different force levels (100% and 80% maximum isometric effort) with the dominant upper limb supported on a stable surface. Exercises were randomly performed with five-minute intervals between each exercise. Volunteers performed three repetitions of each exercise, each lasting six seconds, with 1.5-minute intervals, and maintaining the force within previously determined values, guided by audio feedback. Raw EMG signals were filtered by a 20-500 Hz pass-band in order to derivate EMG amplitude values by intervals calculating the Root Mean Square (RMS). RMS values were normalized by the maximum value obtained in three maximal voluntary isometric contractions during muscle testing. Normalized values were compared between the three exercises at both torque levels and between the same exercise at both isometric effort levels through the mixed-effects linear model, with a 5% level of significance. Normalized RMS values of the studied muscles (%) were used to rank the level of electric activity obtained during each exercise. Results indicate that maximal isometric effort levels had no influence on results from the comparison of EMG activity in any of the proposed exercises. Differences between normalized activation amplitudes were observed. However, the values reached levels between minimal and high, that is, under 60% of the activity generated during maximal voluntary isometric contraction. This study concludes that biomechanically comparable exercises did not necessarily produce similar EMG activity, in spite of controlling isometric effort. Moreover, exercises were capable of generating different EMG activity levels in the evaluated muscles. Therefore, such exercises are indicated for different rehabilitation program phases.

O esvaziamento cervical faz parte do tratamento oncológico de pacientes portadores de neoplasias da cabeça e pescoço, onde o ombro está sob risco de alterações relacionadas ao procedimento. A morbidade pós-operatória está diretamente relacionada com a extensão cirúrgica, na qual podem estar associados deslocamentos de retalhos e ressecções de tecidos e estruturas neuromusculares. Sendo assim, a doença nesta região apresenta potencial suficiente para afetar a função e a qualidade de vida relacionada ao ombro dos pacientes. Altos índices de complicações funcionais são encontrados após o esvaziamento cervical, os quais variam de 18 a 77% nas cirurgias com a preservação do nervo acessório. As seqüelas mais comumente encontradas são a dor, disfunção na amplitude de movimento e força muscular do ombro, déficit funcional e piora da qualidade de vida. Este estudo teve por objetivo avaliar a função do ombro, a dor e a qualidade de vida em pacientes portadores de câncer de cabeça e pescoço submetidos a esvaziamento cervical, bem como avaliar os resultados do protocolo de reabilitação fisioterápica proposto. Foram avaliados prospectivamente 88 pacientes (120 ombros) no pré-operatório, 1º mês e no 3º mês após o procedimento, os quais foram submetidos a esvaziamento cervical unilateral ou bilateral por doença maligna na região da cabeça e pescoço. A maioria dos pacientes foi do sexo masculino e com idade média de 56,7 anos (mediana de 56,5 anos). Destes 120 ombros, o nervo acessório foi preservado em 108. Observou-se que a função do ombro apresentou-se significativamente afetada após o esvaziamento cervical, sendo o esvaziamento cervical seletivo, o estadiamento clínico inicial (I/II), a não realização de rotação de retalho miocutâneo de peitoral maior e a não realização de radioterapia os fatores relacionados a uma menor perda relativa para os movimentos do ombro bem como das forças musculares, principalmente de trapézio. Especificamente, o esvaziamento cervical seletivo foi associado a uma menor perda relativa nos movimentos de extensão (p=0,004) e rotação interna (p=0,043) no 1º mês e flexão (p=0,027) e rotação externa (p=0,008) no 3º mês; o estadiamento clínico I/II à abdução (p=0,045), força de trapézio médio (p=0,005), trapézio inferior (p=0,007) e rombóides (p<0,001) no 3º mês; a não realização de rotação de retalho de peitoral maior à flexão (p=0,003) no 1º mês e rotação externa (p=0,006) no 3º mês; e a não realização de radioterapia à abdução (p=0,007) no 3º mês. Verificou-se também que após a cirurgia, os movimentos de flexão e abdução, as forças de trapézio médio, trapézio inferior e rombóides e o Escore de Constant são os principais fatores relacionados à dor; assim como a flexão, extensão, rotação interna e rotação externa, forças de trapézio médio, serrátil anterior e rombóides são os fatores relacionados a qualidade de vida (domínios dor, atividade, recreação e ombro). Observou-se ainda que o protocolo de reabilitação fisioterápica, quando realizado de forma completa, pode ser benéfico para os pacientes, minimizando a perda da função pós-operatória e reduzindo no 3º mês após a cirurgia a seqüela instalada no 1º mês nos movimentos de flexão e abdução, bem como na força de trapézio, estes que são os movimentos e força muscular principalmente limitados após o esvaziamento cervical / Neck dissection is the treatment of head and neck cancer patient in whom the shoulder is at risk for changes related to the procedure. The postoperative morbidity is directly related with the surgery, which can be associated with displacement of flaps and resection of tissue and neuromuscular structures. The disease in this region has sufficient potential to affect the function and quality of life related to the shoulder of these patients. High rates of functional complications are found after neck dissection, which vary from 18 to 77% in surgery sparing the accessory nerve. The most common sequels found are pain and changes on range of motion and muscle strength in shoulder function, functional deficits and worsening quality of life. This study aimed to evaluate the shoulder function, pain and quality of life in head and neck cancer patients undergone neck dissection, and evaluate the results of the protocol physiotherapy rehabilitation proposed. We prospectively evaluated 88 patients (120 shoulders) preoperatively, 1st month and 3rd months after the unilateral or bilateral neck dissection due to malignancy in the head and neck region. Most of the patients were male and mean age was 56.7 years (median 56.5 years). Of 120 shoulders, the accessory nerve was preserved in 108. It was observed that the shoulder function had to be significantly affected after neck dissection, being the selective neck dissection, the initial clinical staging (I/II), not undergone the pectoral myocutaneos flap and not submitted to postoperative radiotherapy were the factors related to a lower relative loss on the shoulder movements and the muscle strength, especially considering the trapezius muscle. Specifically, the selective neck dissection was associated with a lower relative loss on the extension (p=0.004) and internal rotation (p=0.043) at 1st month and flexion (p=0.027) and external rotation (p=0.008) in the 3rd month; the clinical staging I / II for abduction (p=0.045), strength of middle trapezius (p=0.005), lower trapezius (p=0.007) and rhomboid (p<0.001) at 3rd month, patients not undergone pectoral myocutaneos flap showed lower losses for flexion (p=0.003) at 1st month and external rotation (p=0.006) at 3rd monts, and patients not submitted to postoperative radiotherapy were at lower risk for losses at abduction (p=0.007) in the 3rd month. It was found that after surgery, the movement of flexion and abduction, the strength of middle trapezius, lower trapezius and rhomboid and the Constant Score were the main factors related to pain, as well as flexion, extension, internal rotation and external rotation, strength the middle trapezius, serratus anterior and rhomboid are the factors related to quality of life (domains pain, activity, recreation and shoulder). Considering the protocol of physiotherapy rehabilitation it was observed that, if done in full, it might be beneficial to patients, minimizing the loss of function and reducing postoperative at 3rd months after surgery the sequel installed at 1st month in the movements of flexion and abduction, as well as the muscle strength of trapezius, which are the movements and muscle strength mainly affected after neck dissection