Effects of Connective Tissue Massage and Physical Modalities Combined With Stabilization Exercises in Chronic Neck Pain

To assess disability in neck pain, only the Neck Disability Index (NDI), which evaluates current pain and disability, was used. The NDI consists of 10 items grouped into 6 subdomains. Each item is scored on a scale from 0 to 5, with higher scores indicating greater levels of disability.

To evaluate deep neck flexor muscle endurance, the Deep Cervical Flexor Test was used. This test assesses the maximal contraction capacity of the deep cervical flexor muscles. It is performed in the supine position, with the participant lifting the head approximately 2.5 cm off the surface while maintaining chin retraction. The examiner places a hand under the participant's occiput. The test is terminated when cervical flexion is lost or the participant's head touches the examiner's hand, and the duration is recorded in seconds.

Cervical range of motion was assessed using a universal goniometer. The participant was seated in an upright position, and measurements were taken for cervical flexion, extension, right and left rotation, and right and left lateral flexion. For flexion and extension, the acromion was accepted as the pivot point, with the stationary arm held parallel to the ground and the movable arm aligned with the ear line. For rotation, a straight rod was placed between the participant's teeth, the midline of the head was accepted as the pivot point, the stationary arm was kept parallel to the ground, and the movable arm was aligned with the rod. For lateral flexion, the spinous process of C7 was accepted as the pivot point, the stationary arm was positioned parallel to the ground, and the movable arm was aligned with the spinous processes of the cervical vertebrae. Care was taken to ensure that the head was not rotated during the measurements.

For pain assessment, the Bournemouth Neck Questionnaire, which focuses on the participant's current symptoms over the past week, was used. The questionnaire evaluates aspects such as onset, localization, duration, type and characteristics of pain, aggravating and relieving factors, history of previous treatments, and accompanying symptoms. The Bournemouth Neck Questionnaire consists of 7 items, each scored on a scale from 0 to 10. The maximum score is 70, with higher scores indicating greater disability.

The World Health Organization Quality of Life Instrument, Short Form (WHOQOL-BREF) was used to assess the quality of life of the participants. The WHOQOL-BREF was developed by the World Health Organization and consists of six domains. Since each domain independently reflects the quality of life within its own scope, domain scores are calculated on a scale ranging from 4 to 20. Higher scores indicate better quality of life.

The Lateral Scapular Slide Test (LSST) is a clinical assessment used to evaluate scapular positioning and detect scapular dyskinesis by measuring the distance between the inferior angle of the scapula and the spinous process at various arm positions.

In the Scapular Dyskinesis Test, a load of 2.3 kg is used for individuals weighing 68.1 kg or more, and a load of 1.4 kg is used for those weighing less than 68.1 kg. Participants are instructed to hold the weights with the thumbs pointing upward, elbows extended, and shoulders in a neutral position, and to actively perform bilateral shoulder flexion and abduction. Each movement is repeated five times, during which scapular motion is observed. The presence of scapular winging or dysrhythmia during the movements is recorded as either "dyskinesis present" or "dyskinesis absent".

The Scapular Retraction Test is used to grade the strength of the supraspinatus muscle. The test begins with the traditional Empty Can Test, in which the patient's shoulder is placed in internal rotation, 90 degrees of flexion, and the scapular plane position ("scaption"). The examiner applies a downward force to the patient's arm while the patient resists. The test is then repeated with the examiner manually stabilizing the scapula in a retracted position. To achieve this, the examiner's fingers firmly grasp the patient's anterior shoulder over the clavicle, while the forearm is positioned along the medial border of the scapula. The test is considered positive if rotator cuff strength is restored, as indicated by the patient's improved ability to resist the examiner's downward force compared with the traditional Empty Can Test.