INTRODUCTION
Natural spine alignment is one of the important factors for a healthy life because it decreases the load on the body joints and prevents deformation of one’s posture. A modified spinal alignment leads to abnormal morphological changes in the musculoskeletal system induced by the range of motion (ROM) reduction and muscle imbalance, which causes functional restriction of physical activity with pain (Nussbaumer et al., 2010).
ROM is influenced by muscle tightness resulting from an increase in active tension. It has been well known that limitations of ROM in human joints for an extended period may induce a variety of physical problems including illness, injury, poor posture, and muscle imbalances. In the field of sports medicine, many researchers have recommended and emphasized the importance of flexibility and muscle strength to treat a body imbalance (Rubini et al., 2007). In particular, Gleim and McHugh (1997) suggested that flexibility might be a mediator to prevent limitation of ROM in target joints through increase of muscle elasticity as well as Paolucci et al. (2018) and Berglund et al. (2018) reported that increase in muscle strength could maintain the body’s alignment by preventing mechanical deformation of the spine. With these results mentioned by previous studies, an active stretching program with flexibility and muscle strength may improve the quality of life for patients suffering from pain induced by ROM restriction.
Based on these theories, Janda (1983, 1986) developed a stretching and strength exercise program for musculoskeletal pain relief such as protecting the pained tissues and recovering proper body alignment, which named Janda approach. And then Page (2012), a disciple of Janda, redefined the concrete exercise method and the effectiveness of the Janda approach. After re-establishment, Yuktasir and Kaya (2009) reported that isometric exercise with static stretching for 6 weeks further improved ROM of patients with functional limitation of joints compared to those in static stretching group. Also Page (2011) confirmed that a stretching program based on the Janda approach decreased the pain caused by subacromial impingement of athletes who were involved in overhead sports such as baseball and swimming.
However, previous studies focused on pain relief in young patients and athletes with medical diagnosis. There are few studies on the effect of the Janda approach when applied to middle-aged women with self-report muscular skeletal symptoms. Therefore, the purpose of this study was to investigate the effect of a stretching program based on the Janda approach in regards to the ROM, muscular strength and pain in middle-aged women with self-report muscular skeletal symptoms.
MATERIALS AND METHODS
Participants
The participants in this study were 16 middle-aged women with self-reported muscular skeletal symptoms, whose limitations of ROM and moderate pain in the neck and shoulder were indicated. Specifically, all participants were classified between grade 3 and grade 1 in the evaluation criteria of the manual muscle test reported by Kelly et al. (1996). But five of the participants were excluded by revealing their intention to give up during the experiment. As shown in Table 1, all participants were randomly allocated to the traditional static stretching group (TSSG, n = 5) and the Janda approach stretching group (SJAG, n = 6). Before beginning the study, all participants had a detailed explanation of this study and submitted their written informed consent to researchers. This research was conducted ethically according to international guidelines.
Therapeutic stretching program
Janda’s approach is one of the therapeutic strategies that have received attention in the field of chronic pain management. We performed a modified stretching program, according to a previously described method (Mine et al., 2017). As shown in Table 2, the static stretching program in both TSSG and SJAG consisted of 14 types of exercise and strength program in SJAG was comprised of 5 isometric contractions. All programs were done 3 times per week for 6 weeks. Static stretching in two groups was performed holding the stretch for at least 15 sec (Page, 2012) and isometric exercise was conducted three times in a maximum contraction mode for 3 sec under the supervision of a certified expert.
ROM assessment
ROM was measured by goniometer (Orthopedic Equipment Co., Bourbon, IN, USA) that is reliable and extensively used in the field of anthropometry. All examiners were experienced professionals with a rehabilitation therapist license. Passive neck extension, rotation and lateral bending were analyzed with standard goniometry in sitting position (Nussbaumer et al., 2010).
Manual muscle test
Manual muscle test is a popular test method that has high validity and reliability to confirm muscle strength in patients with musculoskeletal problems (Cuthbert and Goodheart, 2007). ROM and functional problems of each joint of the participants with pain were confirmed and all assessments are based on the evaluation criteria of the manual muscle test suggested by Gleim and McHugh (1997).
Numeric rating scale
In the clinical setting, numeric rating scale (NRS) is an evaluation tool for patients with pain in the musculoskeletal system, which is simple and easy to apply (Krebs et al., 2007; Mannion et al., 2007). Examiner measures the pain level through the subject’s interview and the pain range is a 0 to 10 scores. A score of ‘0’ indicates no pain and ‘10’ means severe pain (Hawker et al., 2011).
Statistical analysis
PASW Statistics ver. 18.0 (SPSS Inc., Chicago, IL, USA) was used to determine the effect of a stretching program based on the Janda approach. To confirm the main effect, we used a two-way repeated analysis of variance. If there was a significant interaction effect, an independent t-test between groups or a paired t-test between times was applied. All values are expressed as mean ± standard deviation. P<0.05 was considered significant.
RESULTS
Change in ROM of each joint with pain
Changes of ROM of each joint with pain before and after a stretching program based on the Janda approach are shown in Table 3. ROM of the left neck rotation and right neck rotation in SJAG were significantly increased over time compared to TSSG, and ROM of right shoulder external rotation showed significant difference only in TSSG. Although ROM of left neck rotation (F = 1.858, P = 0.045) showed interaction between two groups, ROM of neck extension (F = 0.872, P = 0.375), the right neck rotation (F = 0.001, P = 1.000), the left neck lateral bending (F = 0.905, P = 0.366), the right neck lateral bending (F = 0.459, P = 0.515), the left shoulder internal rotation (F = 0.120, P = 0.737), the right shoulder internal rotation (F = 1.488, P = 0.254), the left shoulder external rotation (F = 0.722, P = 0.417), and the right shoulder external rotation (F = 0.010, P = 0.921) showed no relative effects between groups or over time.
Change in muscle strength
Changes in muscle strength before and after a stretching program based on the Janda approach are shown in Table 4. Strength of the left neck rotator, right neck rotator and right shoulder external rotator were significantly increased over time compared to TSSG, and the left neck lateral bending muscle strength showed significant difference in both SJAG and TSSG. Although strength of the left neck rotator (F = 6.890, P = 0.028) showed interaction between two groups, strength of the neck extensor (F = 3.593, P = 0.091), the right neck rotator (F = 2.267 P = 0.166), the left neck lateral bending muscle (F = 4.909, P = 0.054), the right neck lateral bending muscle (F = 0.211, P = 0.657), the left shoulder internal rotator (F = 0.495, P = 0.500), the right shoulder internal rotator (F = 0.628, P = 0.449), the left shoulder external rotator (F = 3.273, P = 0.104), and the right shoulder external rotator (F = 0.144, P = 0.713) showed no relative effects between groups or over time.
Change in the pain NRS
To examine the pain NRS, we performed the interview before and after stretching program based on Janda approach. As shown in Table 5, NRS score (F = 20.928, P = 0.001) showed interaction between two groups and SJAG had a significant decrease over time compared to those in TSSG.
DISCUSSION
The Janda approach to stretching exercise is one of the therapeutic tools for improvement of musculoskeletal dysfunction, consisting of static stretching and isometric contraction exercises. To performing Janda approach stretching exercises, flexibility and muscle strength are very important factors.
Most previous studies suggested that muscle stretching and strengthening exercises such as pilates provided benefits in improvement of ROM in the joints and muscle strength (Aladro-Gonzalvo et al., 2012; Curnow et al., 2009). Not only Ahearn et al. (2018) identified that flexibility exercise increased muscle strength and body alignment in gymnasts but also Watson et al. (2017) reported the effect of regular stretching and strength exercises on improvement of ROM, pelvic-lumbar stability, and muscle functions in normal adults.
Muscular strength exercise is a critical regulator that improves shortening the muscle-tendon length and stabilizes the posture alignment of the human body. And stretching exercise increases flexibility with improving ROM of each joint. Yuktasir and Kaya (2009) reported that static stretching exercise with isometric exercise 4 times a week for 6 weeks significantly increased ROM of the joint compared to only static stretching exercise. Also a previous study on effectiveness of stretching and strengthening exercise emphasized that these types of stretching exercises are beneficial in increasing strength of abdominals and gluteals, and enhancing flexibility of rectus femoris, iliopsoas and erector spinae (Hrysomallis and Goodman, 2001). A present study confirmed similar results that Janda-approach stretching exercise further improved ROM of the left neck rotation and right neck rotation in SJAG over time, and ROM of left neck rotation showed interaction between two groups rather than those in TSSG. We think that these positive alterations of stretching and strength exercise are due to the contraction of the antagonistic muscle leading to isometric contraction of the agonistic muscle.
Pain is a common cause of ROM limitation and decreased muscle contraction, which leads to muscle weakness. Graven-Nielsen et al. (2002) reported a close relationship between ROM and muscle strength in patients with chronic pain. This study examined whether pain was significantly different between the treatment period and the group, and there were also interactions with the group and the treatment period. In previous studies, sensorimotor training similar to Janda approach stretching exercises has been proven to improve proprioceptive sensory function, muscular strength, and skeletal alignment in ankle instability (Freeman et al., 1965), knee instability (Ihara and Nakayama, 1986), and after anterior cruciate ligament surgery (Nyland et al., 2017). It is thus considered a relevant therapeutic method to decrease pain and increase muscle strength for patients with self-report muscular skeletal symptoms.
Taken together, self-reported muscular skeletal symptoms are a medical condition that adversely affects daily life and lowers the quality of life. And Janda approach stretching exercises, consisting of stretching and isometric exercise, for 6 weeks increased ROM of the joint and muscular strength as well as decreased pain. Therefore our findings provide important evidence that Janda approach stretching exercise may be effective tools to improve body composition, the ROM, muscular strength and pain in middle-aged women with self-report musculoskeletal symptoms.
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