Effects of Exercise on Pain and Quality of Life in Office Workers With Neck Pain

• INTRODUCTION

With the digitalization of working life, the center of gravity of work-related musculoskeletal disorders has shifted from occupational sectors dominated by heavy physical loads to office environments characterized by prolonged static loads. The office worker spends the majority of the day in a sitting position, with the head and neck fixed toward the screen and the upper extremities relatively immobile over the keyboard and mouse. When considered individually, this working pattern appears harmless; however, it creates a cumulative mechanical and neuromuscular load on the cervical region, with neck pain emerging as the most visible clinical outcome.

Neck pain ranks among the top contributors to years lived with disability worldwide among musculoskeletal conditions. Global Burden of Disease data show that neck pain is a widespread and persistent public health burden, and this burden will continue to rise as working patterns become increasingly digitalized. A problem so prevalent in the general population becomes even more pronounced in groups with concentrated exposure, such as office workers, where the annual prevalence of neck pain in this population is reported to range between 42% and 63%. Research conducted on computer-using office workers in Turkey also confirms that the most frequently reported musculoskeletal symptom occurs in the neck region.

The vast majority of neck pain observed in office workers is non-specific in nature; meaning no specific identifiable structural pathology can be shown as the source of pain. Nevertheless, the pain significantly impacts the individual's daily living activities, work performance, and psychological well-being. A cluster of interacting mechanisms plays a role in its pathogenesis. Under prolonged static posture, activation of the deep cervical flexor muscles decreases, while compensatory hyperactivation develops in the superficial muscles. This neuromuscular reorganization weakens the dynamic support of the cervical segments, impairs proprioceptive feedback, and creates a vicious cycle that contributes to the persistence of pain. Viewing the issue solely through a biomechanical lens provides an incomplete framework; evidence is growing stronger that psychosocial factors-such as job stress, low job satisfaction, and lack of support-play a decisive role in the onset and chronicity of neck pain.

In the management of non-specific neck pain, exercise currently holds the strongest evidence base among intervention methods. Strengthening, stretching, and motor control exercises targeted at the cervical and scapulothoracic regions have been shown to exert positive effects on pain, disability, and quality of life, while also improving psychosocial outcome measures such as job stress.

The fundamental unanswered question is **how this exercise should be delivered**. The delivery mode of exercise can directly influence clinical outcomes. Exercise conducted under the supervision of a physiotherapist offers advantages such as real-time correction of movement quality, individualization of progressive loading, and direct monitoring of exercise adherence. In contrast, self-directed exercise supported by videos and mobile reminders stands out for its low cost, temporal/spatial flexibility, and scalability to large populations. However, studies directly comparing physiotherapist-supervised exercise against video/mobile-supported self-directed exercise across multidimensional measures-including pain, disability, range of motion, job stress, and quality of life-remain limited.

This study aims to investigate the effects of a six-week exercise program on pain intensity, neck-related disability, cervical range of motion, job stress, and health-related quality of life in office workers with non-specific neck pain, and to compare these effects between two different delivery modes (physiotherapist-supervised vs. video/mobile-supported).

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## 2. CONCEPTUAL FRAMEWORK

### 2.1. CERVICAL REGION ANATOMY AND BIOMECHANICS

The cervical spine is the most mobile and mechanically sensitive segment of the spinal column. Consisting of seven vertebrae, this segment is responsible for supporting the head-which weighs an average of 4-5 kg-orienting it across a wide range of motion in three planes, while simultaneously protecting the spinal cord and vertebral arteries passing through it. This mandatory trade-off between mobility and stability is key to understanding the clinical problems of the cervical region: anatomical adaptations made in favor of mobility reduce the load on passive stabilizers and increase the load on active stabilizers (muscles and neuromuscular control).

#### Anatomical Segmentation and Joint Complexes

• **Upper Cervical Region (Craniocervical Junction):** Encompasses the Occiput, Atlas (C1), and Axis (C2) structures.

• *Atlas (C1):* Lacks a vertebral body and spinous process. It articulates with the occipital condyles to form the atlanto-occipital joint, which is primarily responsible for the flexion-extension ("nodding") movement of the head.

• *Axis (C2):* Distinguished by a vertical cylindrical projection called the dens (odontoid process). The dens articulates with the anterior arch and transverse ligament of the atlas, forming the anatomical axis for head rotation. The atlanto-axial joint complex alone provides approximately 50% of total cervical rotation.
• **Lower Cervical Region (C3-C7):** Possesses typical vertebral morphology.

• Uncinate processes on the superior-lateral margins of the vertebral bodies form the uncovertebral joints (joints of Luschka), limiting lateral flexion and providing segmental stability.

• *Zygapophyseal (Facet) Joints:* Their 45-degree orientation close to the horizontal plane permits broad rotation and lateral flexion. They possess rich nociceptive innervation.

• *Intervertebral Discs:* Play a role in absorbing axial loads and distributing segmental movement.

#### Layered Structure of the Muscular System

Cervical region muscles are categorized functionally into two main groups:

• **Deep Cervical Muscles (Segmental/Local Stabilizers):** Anteriorly, the *longus colli* and *longus capitis*; posteriorly, the suboccipital muscles (*rectus capitis posterior major/minor*, *obliquus capitis superior/inferior*), *multifidus*, and *semispinalis cervicis*. They have short moment arms and are responsible for the "neutral zone" stability of the spine. Suboccipital muscles, due to their high muscle spindle density, play a critical role in the proprioceptive control of head-neck position.
• **Superficial Cervical Muscles (Global Torque Generators):** Muscles with long moment arms, such as the *sternocleidomastoid (SCM)*, *anterior scalene*, *trapezius* (especially upper fibers), and *levator scapulae*. They are responsible for rapid movement and force production. In individuals with neck pain, excessive and continuous activation (compensation) develops in superficial muscles to compensate for deep muscle insufficiency.

• Cervicoscapular Biomechanical Interaction

Scapular positioning directly impacts the cervical spine. The *levator scapulae* and *trapezius* muscles attach directly to the cervical spine. Upper trapezius dominance combined with lower trapezius and *serratus anterior* weakness-frequently observed in computer workers-leads to scapular protraction and elevation (scapular dyskinesia), thereby increasing cervical loading.

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### 2.2. NECK PAIN

Neck pain is defined as discomfort felt in the region bounded by the superior nuchal line superiorly and the spinous process of the first thoracic vertebra inferiorly, which may radiate to the head or upper extremities. Clinically, cases lasting longer than three months are classified as **chronic neck pain**.

#### Classification and Grading

The Bone and Joint Decade Task Force classifies neck pain into four grades:

• **Grade I:** No major structural pathology, no or minimal interference with daily activities.

• **Grade II:** No major structural pathology, but significant interference with daily activities *(forms the target population of this thesis)*.
• **Grade III:** Presence of neurological signs indicating nerve root compression (radiculopathy).
• **Grade IV:** Major structural pathology such as tumor, fracture, infection, or myelopathy.

• Etiology and Risk Factors

Non-specific neck pain has a multifactorial etiology:

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• **Individual Factors:** Female gender, older age, elevated BMI, smoking, and history of previous musculoskeletal pain.
• **Physical / Occupational Factors:** Prolonged static sitting posture, continuous duration spent at computer workstations, forward head posture, and repetitive microtraumas.
• **Psychosocial Factors:** High job demands, low decision latitude, insufficient social/managerial support, job stress, anxiety, and pain catastrophizing.

#### Pathophysiological Mechanisms

• **Peripheral Nociception and Ischemia:** Continuous static muscle contraction increases intramuscular pressure, impairing microcirculation and leading to tissue ischemia, metabolic waste accumulation, and local nociceptor sensitization.
• **Neuromuscular Dysfunction:** Delayed or weakened activation of deep flexors (*longus colli/capitis*) during craniocervical flexion results in overactivity of superficial muscles (*SCM*).
• **Central Sensitization:** In chronic cases, increased neuronal excitability and impaired nociceptive inhibition lead to the development of allodynia and hyperalgesia.

### 2.3. ERGONOMICS AND WORKPLACE LOADING IN OFFICE WORKERS

The exposure profile of office workers is characterized by "low-intensity but prolonged static loading". As time spent at computer workstations increases, mechanical torque on the cervical spine rises; even a 2-3 cm forward shift of the head from neutral posture multiplies the load placed on the extensor musculature.

#### Ergonomic Risk Factors and Adjustment Principles

• **Monitor Alignment:** Position the top edge of the screen at or slightly below eye level to prevent excessive cervical flexion.

• **Keyboard and Mouse Placement:** Support the upper extremities with shoulders relaxed and elbows bent at 90 degrees.

• **Seating Support:** Adjustable-height chairs that support lumbar lordosis positively influence the overall postural cascade.

• **Active Breaks:** Taking short movement breaks every 30-60 minutes to interrupt static loading restores intramuscular blood flow.

While ergonomic adjustments alone show limited evidence in preventing pain, their combination with targeted exercise interventions has been shown to enhance clinical success and functional recovery.

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### 2.4. EXERCISE APPROACHES IN NECK PAIN MANAGEMENT

Exercise holds Level A (First-Line) evidence in the conservative management of neck pain.

#### Components of Therapeutic Exercise

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• **Deep Cervical Flexor (Craniocervical Flexion) Training:** Re-education of *longus colli* and *longus capitis* muscles using proprioceptive biofeedback principles while inhibiting superficial muscles.
• **Scapulothoracic and Cervical Strengthening:** Progressive resistance exercises (isometric or dynamic) targeting the *lower/middle trapezius*, *serratus anterior*, and posterior cervical extensors.
• **Stretching and Mobility Exercises:** Stretching shortened *upper trapezius*, *levator scapulae*, and *pectoralis major* muscles to improve tissue compliance.
• **Relaxation and Breathing Exercises:** Increasing parasympathetic tone to reduce sympathetic-induced muscle tension and the physical manifestations of occupational stress.

#### Exercise Delivery Modes: Supervised vs. Digital/Self-Directed

• **Physiotherapist-Supervised Exercise:** Delivers direct physical and verbal feedback, immediate correction of compensatory movements, and precise progression of loading parameters.

• **Video and Mobile Reminder-Supported Exercise:** Uses notifications to maintain compliance; provides a cost-effective, highly scalable option that promotes patient self-efficacy.
• 2.5. JOB STRESS AND QUALITY OF LIFE

Neck pain is not merely a mechanical dysfunction; it represents a condition with clear biopsychosocial dimensions.

• **Job Stress:** *Karasek's Job Demand-Control Model* and *Siegrist's Effort-Reward Imbalance Model* explain how occupational stressors trigger musculoskeletal symptoms. Increased sympathetic neuroendocrine discharge maintains chronically elevated muscle tone, predisposing tissues to intramuscular ischemia and heightened nociceptive input.
• **Health-Related Quality of Life:** Chronic pain and functional limitation lower both physical component scores (mobility, energy) and mental component scores (emotional state, social functioning). Exercise interventions aim not only to reduce nociception and pain intensity, but also to enhance overall well-being and build individual capacity (self-efficacy) to manage workplace stress.

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Inclusion criteria

• Men and women aged 25 to 60 years
• Currently employed as office workers with continuous computer usage
• Ability to participate in and adhere to the intervention protocol
• Diagnosis of chronic non-specific neck pain lasting for more than 3 months

Exclusion criteria

• Previous history of physical therapy or rehabilitation for neck pain
• History of cervical spine surgery
• Cervical joint instability
• Diagnosis of migraine or other severe headache disorders
• Spasmodic torticollis
• Inflammatory rheumatic diseases (e.g., rheumatoid arthritis, ankylosing spondylitis)
• Peripheral nerve entrapment syndromes (e.g., cervical radiculopathy, carpal tunnel syndrome)
• Presence of severe psychiatric disorders