Musicians report a high prevalence of annual musculoskeletal pain (86-89%), attributed to prolonged playing times consisting of repetitive static and dynamic muscle activity. The aim of this study was to explore, compare and synthesise evidence on electromyographic (EMG) muscle activity in neck, shoulder and spinal musculature between painful and asymptomatic instrumental musicians. Ovid, Wiley, Web of Science and Scopus databases were searched in August for cross-sectional studies that compared EMG activity of neck, shoulder and spinal musculature between musicians with musculoskeletal pain and asymptomatic comparisons. An updated search was performed in May , adding a further study. Two authors independently assessed papers for inclusion and then quality, determined using a modified Downs and Black Checklist. Means and standard deviations were extracted from each study to calculate effect sizes and compare results. Six studies were found to fulfil inclusion criteria. Five studies were deemed high-quality with one being low-quality. Conflicting evidence was found supporting increases in upper trapezius EMG muscle activity in musicians reporting of pain. Moderate-quality evidence indicates increased SCM activity in musicians reporting pain. There was limited evidence supporting increased activity of deltoids, lower trapezius and the upper cervical extensors in musicians reporting of musculoskeletal pain. Meta-analysis of results of three studies assessing upper trapezius activity were conflicting with these not being statistically significant. Further studies with prospective designs, larger population sizes and on broader instrumental groups are warranted.
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This was a prospective quasi-experimental two groups pre-posttest study. Due to the nature of the intervention, we could not blind the participants or investigators to the intervention. The participants, however, were randomly assigned to the two experimental groups. Therefore, we followed a quasi-experimental design. The study was conducted at the Faculty of Physical therapy, Misr University for Science and Technology (MUST). It was approved by the institutional review board (IRB) of the Faculty of Physical Therapy, Cairo University (approval number: PT.REC/012/) and was registered on clinicaltrials.gov (registration number: NCT), registration date 28/01/.
Thirty-three college male and female students were randomized to receive either IASTM on the upper trapezius and levator scapulae muscles (group A) or myofascial release on the same muscles (group B). Both groups received postural correction and strengthening exercises for neck and scapular stabilizers in addition to their assigned treatment. The inclusion criteria were college students between 18 and 25 years old with CMNP localized to the cervical and periscapular regions, who report at least one trigger point in the upper trapezius and/or levator scapulae muscles, and who use the computer daily for at least two hours and are involved in distance learning of at least three months. CMNP was defined as having vague, dull, achy pain in the neck for more than three months with an intensity of at least 30 mm on a 100 mm visual analog scale (VAS) line. Only college students using distant learning during Coronavirus pandemic restriction as stipulated by the school rules were included in the study.
Subjects were excluded if they have any specific neck pathology, radiculopathy, paresthesia, cervical disc pathologies, neurological signs, cervical myelopathy, vertebrobasilar insufficiency (VBI), or acute or subacute neck pain of any nature. Subjects were also excluded if they have any systemic diseases such as rheumatoid arthritis, ankylosing spondylitis, hemorrhage tendency and/or anticoagulation treatment, or spinal instability. Subjects who did not meet the inclusion criteria were also excluded from participation.
To detect an effect size of Cohen's d'='0.80 with 80% power (alpha'='0.05), G*power software (version 3.1.9.7) suggested we need 52 participants (26 in each group) in an independent sample t-test. We ended up, however, with 33 subjects. A flow diagram according to the Consolidated Standards of Reporting Trials (CONSORT) statement is presented in Fig. 1 to illustrate the progression of this clinical trial [17].
Fig. 1Flow chart outlining the progression of the clinical trial
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After signing the consent form, subjects were screened for eligibility to participate. Their demographic data was then collected. It was important to us after screening for eligibility to apply clearing tests to exclude any red flags. We used the Sharp-Purser [18] and alar ligaments [19, 20] tests for ligamentous hyperlaxity/subluxation/dislocation of the proximal cervical spine. They were also screened for VBI by putting the subjects' heads in extension, side bending and rotation for 30 sitting from supine and sitting positions and assessed VBI signs and symptoms of dizziness, vertigo, nystagmus, and nausea. The screening was performed for both sides.
When the subject was cleared, he/she was asked to place a mark on the VAS line to indicate the level of pain intensity. A ruler was then used to measure the distance from zero, and the recorded number was rounded to the nearest number. For example, a measure of 5.7 cm was rounded to 6 cm.
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Subjects' functional status was evaluated using the neck disability index (NDI). The NDI is a widely used self-reported outcome measure that assesses functional limitations in patients with neck pain. It has 10 items answered on a 0'5 Likert scale for each item. The total raw score is 50 with higher scores indicating greater disability. Psychometric properties for the NDI are well established in the literature [26,27,28]. We asked the subjects to choose the answer that best described his/her condition for each item of the NDI. Scores were then tallied, and the total score was calculated.
The subjects were then assessed for the presence or absence of MTrPs. We used previously published criteria for evaluation. This includes the presence of a palpable taut band in a muscle, presence of a hypersensitive point in a taut band, a twitch in a muscle caused by palpation, referred pain produced as a result of compression on a tender point, and/ or presence of classical referred pain pattern. Four out of five findings classified the trigger point as latent, while the five findings classified the trigger point to be active [29].
The pressure algometer (model: FPX 50, S/N: 2,010,600,173, JTECH Medical, Midvale, Utah, USA) was then applied perpendicular to the trigger point (Fig. 2). The subject was asked to report when he/she first felt the first discomfort. The compression was then stopped and the value on the algometer screen was recorded. The average of three readings with an interval of 1 min between the trials was recorded [22, 23]. Assessment of pain, function, and pain pressure threshold were performed pre and post-treatment.
Fig. 2Procedure used in the study. left: assessment of pain pressure threshold, center: application of instrument-assisted soft tissue mobilization (group A), right: manual soft tissue release (group B)
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Subjects in group A received the IASTM technique using an M2T blade twice a week for four weeks. The subject assumed a comfortable sitting position leaning on a treatment table with the arm crossed to rest the head (Fig. 2). After cleaning the skin of the subject and the blade with alcohol swabs, a lubricant (Vaseline) was applied, and a sweeping technique was used to apply a deep yet comfortable soft tissue mobilization on the upper trapezius from origin to insertion for approximately 3 min. The technique was adjusted if needed to allow the subject to take a break if a sense of burning was felt or if the treatment was uncomfortable. The skin was then cleaned and wiped with tissues. Subjects were instructed that slight hyperemia on the skin is a normal feeling and should subside before the next session [12, 13, 22]. Treatment was applied bilaterally.
Subjects in group B received MRT twice a week for four weeks. While the subject was in a supine position with his/her head supported, the subject's head was rotated away from the side to be treated, and the therapist crossed her hands as shown in Fig. 2 to take up the slack of the upper trapezius muscle until the tissue barrier was felt. A stretching force was maintained for 30 s at the tissue barrier before moving to a new barrier. The technique was repeated until the end range is reached. Lateral bending of the head was avoided and if more stretching was needed, the therapist depressed the shoulder more at the same time the head was rotated. The subjects were continuously assessed for any discomfort or pain beyond comfortable stretching pain [15, 16]. Both sides of the neck were treated.
In addition, both groups received postural correction and strengthening for neck and scapular stabilizer muscles following the guidelines of Noormohammadpour et al. [31] and Harbut et al. [32] The exercises consisted of active cervical retraction with chin tuck and scapular retraction exercises. Also, manual resistance was applied for cervical lateral bending, extension, and rotation. All these exercises were performed for 3 sets of 10 repetitions with the same frequency of the treatment for each group (twice a week for 4 weeks).
Data were analyzed using the statistical package for social sciences (SPSS) computer program version 27 software for Windows (IBM SPSS Inc., Chicago, IL, USA). Descriptive statistics were expressed as mean'±'standard deviation for continuous variables and frequency distribution (%) for categorical variables. The normality of the data was examined using the Kolmogorov Smirnov statistical test. Comparisons between the two groups were performed using unpaired student t-tests pre and post-intervention for pain, function, and pressure threshold. The alpha level was set at p'='0.05. For the effect size, we used the Cohen's recommended criteria [24] which is as follows: d'''0.2 indicates a small effect and negligible clinical importance, d'''0.5 indicates a medium effect and moderate clinical importance and d'''0.8 indicates a large effect and high clinical importance.
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