Skip to main content
Download PDF

Effects of scapular treatment on chronic neck pain: a systematic review and meta-analysis of randomized controlled trials

BMC Musculoskeletal Disorders volume 25, Article number: 252 (2024) Cite this article

Abstract

Background

Chronic neck pain (CNP) is a common public health problem that affects daily living activities and quality of life. There is biomechanical interdependence between the neck and scapula. Studies have shown that shoulder blade function might be related to chronic neck pain. We therefore evaluated the effects of scapular targeted therapy on neck pain and function in patients with CNP.

Methods

Databases, including MEDLINE (via PubMed), EMBASE (via Ovid), Ovid, Web of Science, and Scopus, were systematically searched for randomized controlled trials published in English investigating treatment of the scapula for CNP before July 16, 2023.

Results

A total of 313 participants were included from 8 RCTs. Compared with those in the control group, the intervention in the scapular treatment group exhibited greater improvement in pain intensity (standardized mean difference (SMD) = 2.55; 95% CI = 0.97 to 4.13; P = 0.002), with moderate evidence. Subgroup analysis for pain intensity revealed a significant difference between the sexes, with only the female population (SMD = 6.23, 95% CI = 4.80 to 7.65) showing better outcomes than those with both sexes (SMD = 1.07, 95% CI = 0.57 to 1.56) (p < 0.00001). However, moderate evidence demonstrated no improvement in neck disability after scapular treatment (SMD of 0.24[-0.14, 0.62] of Neck Disability Index or Northwick Park Neck Pain Questionnaire). No effect of scapular treatment was shown on the pressure pain threshold (PPT). The cervical range of motion (CROM) and electromyographic activity of neck muscles could not be conclusively evaluated due to limited support in the articles, and further study was needed. However, the patient’s head forward posture appeared to be corrected after scapular treatment.

Conclusion

Scapular therapy was beneficial for relieving pain intensity in patients with CNP, especially in women. Head forward posture might also be corrected with scapular therapy. However, scapular therapy may have no effect on the PPT or neck disability. However, whether scapular therapy could improve CROM and cervical muscle activation in patients with CNPs had not been determined and needed further study.

Peer Review reports

Introduction

Neck pain ranks as the second most common skeletal-muscular disease [1], with an age-standardized prevalence rate of 3551.1/100,000 people [2]. Neck pain that lasts for more than three months can be defined as chronic neck pain (CNP) [3]. Compared with people without neck pain, people with neck pain have a reduced ability to perform activities of daily living, poorer quality of life and health, and increased disability as the duration and intensity of pain increase [4,5,6].

The current view is that neck pain is not only a problem of the cervical spine itself but also a broader area, such as the shoulder blade [7]. An abnormal scapular position and kinematics can lead to functional dynamic chain breaks, increasing the risk of injury to the connected region [8, 9]. From a structural point of view, scapular dysfunction may be associated with neck pain and dysfunction because multiple muscles, such as the levator scapularis and superior trapezius, are attached to both the scapula and the cervical spine. An imbalance of coordination or increased tension in the muscles of the scapular region may directly increase small joint loading in the neck through the common muscles [10]. Compared with healthy people, patients with neck pain tend to exhibit muscle stiffness, fatigue and atrophy in the scapular region [11, 12], leading to abnormal scapular positioning and motor dysfunction [13]. Therefore, subsequent abnormal scapular position or function can in turn increase tissue mechanical sensitivity and neck pressure pain sensitivity [14,15,16]. Compared to healthy people, people with abnormal scapular positioning exhibit prolonged and repetitive nerve compression and greater neck neural tissue mechanosensitivity, resulting in neck pain [14]. The interaction between neck pain and the abnormal function of the scapula may be the mechanism for the occurrence, maintenance and even aggravation of chronic neck pain [17, 18]. Consequently, focusing on the scapular region in patients with CNP is highly necessary.

Although scapular therapies are recommended for chronic neck pain treatment [19], the effect of scapular therapy on neck pain is still controversial. Several studies have shown that scapular therapy can effectively ameliorate neck pain and neck dysfunction [20,21,22]. Another study provided "fair" to "good" evidence that treatment targeting scapular kinematics and stability could reduce neck pain severity [23]. However, some studies have shown that this effect is not significant for improving pain intensity [24] or neck function [25]. To our knowledge, a systematic review [26] summarizing the effect of scapular stabilization exercise on CNP has been published, but no effective conclusions have been drawn due to the insufficient quantity and low quality of the literature. A comprehensive meta-analysis to rigorously evaluate the effect of scapular treatment on CNP incidence is lacking; therefore, we aimed to conduct a meta-analysis of randomized controlled trials (RCTs) through multiple literature searches to investigate the potential effects of scapular therapy in reducing pain and neck function in patients with CNP.

Method

Protocol and registration

This systematic review and meta-analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines [27]. The study was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (ID: CRD42023303203).

Selection criteria

The selection criteria followed the PICOS principle. Populations: Patients older than 18 years with chronic neck pain (duration ≥ 3 months) were included. Patients with abnormal posture, position and dyskinesia in the cervical spine and scapula were allowed. Patients with neck pain caused by any of the following disorders were excluded: cervical infection, fracture or tumor, spinal trauma, whiplash injury, radicular pain, disc disease, or neurologic disorders such as stroke. Interventions: Scapular treatment, such as postural correctional exercises (SCE) and scapular stabilization exercise (SSE) or scapulothoracic mobilization (STM), should be implemented. Outcomes: Any study that assessed neck pain and function using relevant scales or instruments could be included. Comparison: The blank control was used as the blank control group. When the experimental group received only scapular therapy, the control group did not receive any intervention. When the control group received other treatments, scapula treatment was added only to the experimental group. Study design: Included studies were clinical randomized controlled trials.

Study selection

Two authors (KN and CY) separately searched the following electronic databases for articles published before July 16, 2023: MEDLINE (via PubMed), EMBASE, Ovid, Web of Science, and Scopus. The search strategy is provided in the Supplementary material. All the papers were imported into EndNote20 for further screening. After duplicates were removed, two researchers separately assessed the eligibility of the studies. The initial screening was based on the title, abstract or reference type of the articles. Articles not written in English, nonrandomized studies, animal studies, reviews, letters and literature unrelated to the intended topic were excluded. Then, a full-text screening was performed to identify the final inclusion criteria. Disagreements were resolved by a third researcher.

Outcome measures

This review analysed neck pain intensity utilizing the visual analog scale (VAS) and numerical rating scale (NRS) and cervical disability evaluated by the Neck Disability Index (NDI) or Northwick Park Neck Pain Questionnaire (NPQ) as primary outcomes. The pressure pain threshold (PPT) of the neck muscles, cervical range of motion (CROM), electromyographic activity of the neck muscles, and head forward posture measured by the craniovertebral angle (CVA) were analysed as secondary outcomes.

Data extraction

Two reviewers (TW and JH) independently extracted the following data: authors and years of the literature; population characteristics; interventions, including type of therapy; duration, frequency and timing of follow-up assessment; and outcomes. The mean changes from baseline to the end of intervention or follow-up were expressed using the means and SDs (the average and standard deviation) directly extracted from the articles or calculated by measurement results before and after treatment using the following formula with r = 0.5, according to the Cochrane Handbook for Systematic Reviews of Interventions [28]. \(SD=\sqrt{{{SD}_{final}}^{2}+{{SD}_{baseline}}^{2}-{2\times r\times SD}_{final}\times {SD}_{baseline}}\) When medians were reported, they were transferred into means and standard deviations (SDs) [29, 30]. When the data were fuzzy or presented as pictures, we emailed the author to ask for data or used a web-based digitizer (WebPlotDigitizer 4.6) to extrapolate the data from the data pictures.

Risk of bias and methodological quality assessment

The two reviewers mentioned above also assessed the risk of bias for each of the included RCTs using the Cochrane risk-of-bias 2.0 tool [28], which judges articles according to random sequence generation, allocation concealment, blinding of participants and outcome assessment, incomplete outcome data, and selective reporting and classifies each domain as low risk, high risk, or unclear risk. A graphical representation of the risk of bias assessment was generated by RevMan (version 5.4). The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) assessment [31] was applied to rate the quality of evidence considering five aspects: the risk of bias, inconsistency, indirectness, imprecision, publication bias, and other factors, classifying the evidence into high, medium, low, and very low.

Statistical analysis

Statistical analyses were performed using RevMan 5.4. Source heterogeneity was analysed using the I2 statistical test. When P < 0.05 or I2 > 50%, indicating significant heterogeneity between studies, a random effects model was used. Otherwise, a fixed-effect model was used. When heterogeneity was detected, sensitivity and subgroup analyses were performed by removing one study iteratively to evaluate the robustness of the results.

Results

Study selection

The PRISMA flowchart shows our process for the inclusion of literature (Fig. 1). A total of 1411 records were retrieved from the database. Duplicate options, nonclinical research articles such as reviews and conference abstracts and irrelevant studies were removed first. Finally, 8 studies [21, 24, 25, 32,33,34,35,36] were selected for further evaluation after eliminating articles that did not meet the inclusion criteria of our study. Due to the lack of detailed data in Yildiz's study [36], only 7 studies were included in the quantitative synthesis.

Fig. 1
figure 1

Flow diagram of the study selection process

Full size image

Study and patient characteristics

All 8 RCTs [21, 24, 25, 32,33,34,35,36] published in English between 2016 and 2023 were included in the meta-analysis. These studies were conducted in Asia (the Kingdom of Saudi Arabia [24], Korea [32] and Iran [21, 25, 33, 35]) and Europe (Turkey [34, 36]). A total of 313 participants were enrolled, and the sample sizes of these studies ranged from 15 to 87. All the studies [21, 24, 25, 32,33,34,35,36] included patients with CNP that persisted for 3–6 months in the neck region. Some of the neck pain patients in these included studies also had problems with abnormal shoulder and neck posture [21, 25, 32] or scapular movement [24, 34,35,36]. The included patients were younger than 50 years old, considering the need to minimize the impact of degenerative changes on neck function. All the articles included both men and women, except for two studies [25, 35] that included only females. The detailed characteristics of the eligible studies are shown in Table 1 (at the end of this text).

Table 1 Characteristics of the included studies
Full size table

Interventions

The scapular treatment in the included studies included active exercises, such as scapular correctional exercises [21] and stability exercises[25, 32,33,34, 36], as well as passive exercises, such as scapulothoracic mobilization [24, 35]. In the control group of the 6 articles [24, 33,34,35,36], certain treatment measures were adopted, such as cervical stability exercises, postural correction training, elastic band therapy or normal physical therapy, while treatment of the scapula was added to the experimental group on the basis of the control group. The other 3 studies [21, 25, 32] set blank controls as control groups for scapular treatment.

Risk assessment

The risk assessment is shown in Fig. 2. As 3 studies [25, 32, 34] did not describe the process of randomization and 2 studies [32, 34] did not describe the allocation process, they were considered to have unclear risk. Alshami AM’s study [24] used alternate randomization, which was the wrong method, leading to a high risk of randomization and allocation. All the studies [21, 24, 25, 32,33,34,35,36] were high risk for participant blinding, as none of the included studies met the criteria for participant blinding. Whether evaluators knew the allocations of patients was not clear in 4 studies [24, 25, 32, 34], which were believed to have an unclear risk. None of the included studies had follow-up data, so all of them were of unclear risk [21, 24, 25, 32,33,34,35,36]. Three studies [32, 35, 36] were considered high risk because of unclear or insufficient baseline information and outcomes.

Fig. 2
figure 2

(A) Risk of bias graph and (B) risk of bias summary

Full size image

Effects of interventions

Pain intensity (VAS or NRS)

Eight studies [21, 24, 25, 32,33,34,35,36] measured pain intensity before and after inventions using the VAS or NRS, but one study [36] did not report available data. Six studies [24, 25, 32,33,34,35] were included in the meta-analysis; six studies were assessed at rest, and one study [21] was at the end range of maximum active cervical rotation. The results showed that the standardized mean difference (SMD) was 2.55 (95% CI, 0.97 to 4.13; P = 0.002), with high heterogeneity (Chi2 = 138.43, P < 0.00001; I2 = 96%) (Fig. 3) in patients with neck pain in the intervention group vs. the control group. The aggregated results did not change after excluding studies with high heterogeneity iteratively (Table 2).

Fig. 3
figure 3

Forest plots of pain intensity (VAS or NRS) in the intervention and control groups

Full size image
Table 2 Results of sensitivity analyses after removing one study iteratively
Full size table

To analyse the heterogeneity, a subgroup meta-analysis was conducted on disease characteristics, sex, and scapular interventions. The subgroup analysis of CNP patients with abnormal posture and STM showed no significant differences (SMD = 3.36 (-0.07, 6.78); SMD = 3.33 (-0.76, 7.43); Table 3). According to the guidelines for interpreting subgroup analysis [37], we concluded that the treatment effect was very similar among the subgroups given that the confidence intervals of the subgroup analyses completely overlapped each other. Therefore, no differences in disease characteristics or interventions were found within groups (p = 0.69, 0.31). Female-only studies performed better effectiveness than did studies that included men and women (p < 0.00001; Table 3).

Table 3 Subgroup analysis of pain intensity (VAS or NRS)
Full size table

Yildiz’s research [36], which did not provide specific data, suggested that adding extra scapular treatment could significantly improve pain intensity but was not different from what was observed in the group receiving neck-focused exercise and scapular stabilization training.

Neck disability status (NDI or NPQ)

Five studies [24, 32, 34,35,36] evaluated the outcome of neck function with multiple scales, 3 studies used the NDI [24, 32, 35], and 1 study used the NPQ[34]. The results of the quantitative synthesis did not reveal a significant effect on neck function, with an SMD of 0.24 (95% CI, -0.14 to 0.62; P = 0.22) and significant heterogeneity (Chi2 = 5.68, P = 0.13; I2 = 47%). Figure 4).

Fig. 4
figure 4

Forest plots of neck function (NDI or NPQ) in patients with neck pain in the intervention and control groups

Full size image

PPT

Two studies [21, 24] reported no significant effect of scapular treatment on the PPT. We did not merge the articles because of the limitations of the number of articles and the different positions of the ppt measurements (one measured in the UT [21] and the other used the average PPT of the cervical spine, trapezius and levator scapulae muscles [24]).

CROM

CROM was presented in 3 studies [21, 24, 33], all of which had different results. According to the findings of Javdaneh N's study [33], the scapular treatment group exhibited greater improvements in the CROM at cervical flexion (p = 0.024) and extension (p = 0.025) than did the control group. Shizadi Z et al. [21] found that scapular treatment significantly improved the CROM of neck rotation (p = 0.006, 0.016), while the control group did not significantly differ before or after treatment. However, Alshami AM [24] reported no difference (p > 0.05) in the CROM of any cervical spine movements, including flexion, extension, left rotation, right rotation, or left and right flexion, between the intervention and control groups.

Electromyographic activity of neck muscles

Im B et al. [32] suggested that the activation of the upper trapezius muscle decreased (P < 0.05) and that the activity of the serratus anterior muscle increased (P < 0.05). There was no significant improvement in the control group. Shravi [25] reported that neither the test group nor the control group showed improvement in the electromyographic activity of the trapezius and serratus anterior muscles (P > 0.05).

Head forward posture

Both Im B et al. [32] and Javdaneh’s study [24] showed that CVA was greatly improved in the experimental group, while the control group did not show improvement.

GRADE analysis of the evidence

Moderate and low quality evidence was found for pain intensity, neck function, CROM, electromyographic activity of neck muscles and CVA (a detailed GRADE evaluation of evidence grades of pain intensity and neck disability is provided in the Supplementary material).

Discussion

This was the first systematic review and meta-analysis of RCTs analysing the effect of scapular treatment on improving CNP incidence. There was moderate-quality evidence that scapular treatment alone could reduce subjective pain intensity in patients with CNP. The outcome of our study was persuasive, as the experimental groups in the included articles only received scapular therapy in combination with the control group. Excess activation and decreased control or weakness of scapulothoracic muscles, such as the trapezius and serratus anterior, may lead to neck pain [38]; thus, the mechanism by which scapular therapy improves neck pain may stem from changes in muscle activity in the neck [39]. Scapular treatment, including stability exercises, corrective exercises and scapulothoracic mobilization, could reduce the tension of cervicoscapular muscles [10], strengthen the neck muscle strength [40], and restore the normal biomechanical structure of the neck [41], thus decreasing abnormal loading in the neck region and reducing neck pain. Subgroup analysis indicated that postural abnormalities or scapular dyskinesia did not influence the effectiveness of scapular treatment for pain intensity in patients with CNP, revealing the general applicability of scapular therapy for people with CNP. In addition, SEE, SCE and STM had the same ability to relieve pain in the CNP population, which demonstrated the effectiveness of different scapular treatment methods. Notably, females with CNP seemed to be better treated with scapular treatment, which was a valuable finding, as females have shown a trend toward a greater incidence of CNP than males in recent years [42].

As there was a high degree of heterogeneity in this study, sensitivity analyses were performed, revealing no changes in the results. Subsequent subgroup analysis of patient characteristics and intervention methods did not reveal reduced heterogeneity, whereas reduced heterogeneity was found for the gender subgroups, which revealed that the source of heterogeneity might be the sex composition of the included patients. In addition, we did not analyse specific interventions, such as exercise posture, frequency, or treatment cycle, which might also be responsible for the heterogeneity.

Two studies [21, 24] showed no effect of scapular therapy on PPT improvement in CNP patients, which was inconsistent with the findings of previous studies [16, 20, 38]. The reasons might be associated with differences in PPT measurement tools and locations, as well as with interventions [24]. Therefore, the effect of scapular therapy on improving cervical tissue mechanical sensitivity needs further study.

Our results showed that scapular therapy alone did not seem to improve cervical disability. In addition, no definitive conclusions could be drawn about whether scapular therapy improved cervical muscle activation or CROM because the amount of literature was limited and because the conclusions of these studies were not uniform. Therefore, we believe that scapular therapy alone has little or no efficacy in improving neck function.

Scapular exercise therapy has now been added to head forward posture training as level 1b evidence [43]. Our study also reconfirmed that scapular therapy could change head forward posture through the limited available literature. Although our study did not find that patients with CNP with scapular dysfunction could benefit better from scapular therapy, it is undisputed that scapular training is necessary to improve scapular positional abnormalities and dyskinesia [44]. Therefore, we prefer to recommend the inclusion of scapular therapy for patients with CNP associated with scapular abnormalities.

According to an international survey, physiotherapists most often use exercise therapy and manipulation therapy for neck pain; therefore, we conclude that the use of scapular exercise and mobilization therapy for the treatment of CNP is readily acceptable and achievable for clinical application [45]. The main purpose of this study was to investigate the effectiveness of scapular therapy alone; therefore, articles combining scapular treatment with other therapies were not included or analysed. However, some studies have reported the effects of scapular therapy in combination with upper limb proprioceptive training [40], thoracic extension exercises [46], and cognitive functional therapy [47] for the treatment of CNP. The results showed that, compared to normal neck exercise, scapular treatment combined with other treatments could improve pain and neck function. We believed that the effects of the combination of scapular treatment and other treatments might be the direction and focus of further research.

There were several limitations of the present study. 1) None of the included studies had a follow-up period, so the long-term effect of interventions on the scapula could not be evaluated. 2) There was a lack of evidence for the effects of scapular therapy on cervical muscle strength and quality of life in patients with CNP. 3) All the participants were younger, with an average age ranging from 25.11 to 39.82 years; therefore, the effects of scapular treatment on older populations could not be determined.

Conclusion

There was moderate-quality evidence that scapular therapy was highly beneficial for improving pain intensity in CNP patients, especially in female patients. The head forward posture also appeared to benefit from scapular treatment. However, the PPT did not improve, and moderate-quality evidence suggested that neck disability assessed using the NDI or NPQ did not improve after scapular treatment. The improvement in CROM and cervical muscles activation in patients with CNP from scapular therapy was uncertain.

Availability of data and materials

The datasets supporting the conclusion of this article are included within the article.

Abbreviations

CNP:

Chronic neck pain

RCTs:

Randomized controlled trials

SCE:

Postural correctional exercises

SSE:

Scapular stabilization exercise

STM:

Scapulothoracic mobilization

VAS:

Visual analog scale

NRS:

Numerical rating scale

NDI:

Neck Disability Index

NPQ:

Northwick Park Neck Pain Questionnaire

PPT:

Pressure pain threshold

CROM:

Cervical range of motion

CVA:

Craniovertebral angle

SD:

Standard deviation

GRADE:

Grading of Recommendations, Assessment, Development and Evaluations

SMD:

Standardized mean difference

References

  1. Cieza A, Causey K, Kamenov K, Hanson SW, Chatterji S, Vos T. Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2021;396(10267):2006–17.

    Article  PubMed  Google Scholar 

  2. Safiri S, Kolahi AA, Hoy D, Buchbinder R, Mansournia MA, Bettampadi D, Ashrafi-Asgarabad A, Almasi-Hashiani A, Smith E, Sepidarkish M, et al. Global, regional, and national burden of neck pain in the general population, 1990–2017: systematic analysis of the Global Burden of Disease Study 2017. BMJ. 2020;368:m791.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Treede RD, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R, Cohen M, Evers S, Finnerup NB, First MB, et al. Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11). Pain. 2019;160(1):19–27.

    Article  PubMed  Google Scholar 

  4. Hey HWD, Lim JXY, Ong JZ, Luo N. Epidemiology of Neck Pain and Its Impact on Quality-of-Life-A Population-Based, Cross Sectional Study in Singapore. Spine (Phila Pa 1976). 2021;46(22):1572–80.

    Article  PubMed  Google Scholar 

  5. Nolet PS, Côté P, Kristman VL, Rezai M, Carroll LJ, Cassidy JD. Is neck pain associated with worse health-related quality of life 6 months later? A population-based cohort study. Spine J. 2015;15(4):675–84.

    Article  PubMed  Google Scholar 

  6. Machino M, Ando K, Kobayashi K, Nakashima H, Morozumi M, Kanbara S, Ito S, Inoue T, Koshimizu H, Seki T, et al. Impact of Neck and Shoulder Pain on Health-Related Quality of Life in a Middle-Aged Community-Living Population. Biomed Res Int. 2021;2021:6674264.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Cagnie B, Struyf F, Cools A, Castelein B, Danneels L, O’Leary S. The relevance of scapular dysfunction in neck pain: a brief commentary. J Orthop Sports Phys Ther. 2014;44(6):435–9.

    Article  PubMed  Google Scholar 

  8. Cools AM, Struyf F, De Mey K, Maenhout A, Castelein B, Cagnie B. Rehabilitation of scapular dyskinesis: from the office worker to the elite overhead athlete. Br J Sports Med. 2014;48(8):692–7.

    Article  PubMed  Google Scholar 

  9. Kim SR, Kang MH, Bahng SY, An JK, Lee JY, Park SY, Kim SG. Correlation among scapular asymmetry, neck pain, and neck disability index (NDI) in young women with slight neck pain. J Phys Ther Sci. 2016;28(5):1508–10.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Van Dillen LR, McDonnell MK, Susco TM, Sahrmann SA. The immediate effect of passive scapular elevation on symptoms with active neck rotation in patients with neck pain. Clin J Pain. 2007;23(8):641–7.

    Article  PubMed  Google Scholar 

  11. Uthaikhup S, Pensri C, Kawsoiy K. Decreased thickness of the lower trapezius muscle in patients with unilateral neck pain. Muscle Nerve. 2016;54(3):439–43.

    Article  PubMed  Google Scholar 

  12. Ishikawa H, Muraki T, Morise S, Sekiguchi Y, Yamamoto N, Itoi E, Izumi SI. Changes in stiffness of the dorsal scapular muscles before and after computer work: a comparison between individuals with and without neck and shoulder complaints. Eur J Appl Physiol. 2017;117(1):179–87.

    Article  PubMed  Google Scholar 

  13. Yildiz TI, Cools A, Duzgun I. Alterations in the 3-dimensional scapular orientation in patients with non-specific neck pain. Clin Biomech. 2019;70:97–106.

    Article  Google Scholar 

  14. Martínez-Merinero P, Lluch E, Gallezo-Izquierdo T, Pecos-Martín D, Plaza-Manzano G, Nuñez-Nagy S, Falla D. The influence of a depressed scapular alignment on upper limb neural tissue mechanosensitivity and local pressure pain sensitivity. Musculoskelet Sci Pract. 2017;29:60–5.

    Article  PubMed  Google Scholar 

  15. Azevedo DC, de Lima PT, de Souza AF, McDonnell MK. Influence of scapular position on the pressure pain threshold of the upper trapezius muscle region. Eur J Pain. 2008;12(2):226–32.

    Article  PubMed  Google Scholar 

  16. Lluch E, Arguisuelas MD, Quesada OC, Noguera EM, Puchades MP, Perez Rodriguez JA, Falla D. Immediate effects of active versus passive scapular correction on pain and pressure pain threshold in patients with chronic neck pain. J Manipulative Physiol Ther. 2014;37(9):660–6.

    Article  PubMed  Google Scholar 

  17. Helgadottir H, Kristjansson E, Mottram S, Karduna A, Jonsson H Jr. Altered alignment of the shoulder girdle and cervical spine in patients with insidious onset neck pain and whiplash-associated disorder. J Appl Biomech. 2011;27(3):181–91.

    Article  PubMed  Google Scholar 

  18. Helgadottir H, Kristjansson E, Mottram S, Karduna AR, Jonsson H Jr. Altered scapular orientation during arm elevation in patients with insidious onset neck pain and whiplash-associated disorder. J Orthop Sports Phys Ther. 2010;40(12):784–91.

    Article  PubMed  Google Scholar 

  19. Blanpied PR, Gross AR, Elliott JM, Devaney LL, Clewley D, Walton DM, Sparks C, Robertson EK. Neck Pain: Revision 2017. J Orthop Sports Phys Ther. 2017;47(7):A1-a83.

    Article  PubMed  Google Scholar 

  20. Abd El-Azeim AS, Mahmoud AG, Mohamed MT, El-Khateeb YS. Impact of adding scapular stabilization to postural correctional exercises on symptomatic forward head posture: a randomized controlled trial. Eur J Phys Rehabil Med. 2022;58(5):757–66.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Srikrajang S, Kanlayanaphotporn R. Effects of active scapular correction on cervical range of motion, pain, and pressure pain threshold in patients with chronic neck pain and depressed scapula: a randomized controlled trial. Man Manip Ther. 2023;31(1):24–31.

    Article  Google Scholar 

  22. Park SH, Lee MM. Effects of lower trapezius strengthening exercises on pain, dysfunction, posture alignment, muscle thickness and contraction rate in patients with neck pain; randomized controlled trial. Med Sci Monit. 2020;26:e920208.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Edwards CM. Exercise Programs Targeting Scapular Kinematics and Stability Are Effective in Decreasing Neck Pain: A Critically Appraised Topic. J Sport Rehabil. 2021;30(6):952–5.

    Article  PubMed  Google Scholar 

  24. Alshami AM, AlSadiq AI. Outcomes of scapulothoracic mobilisation in patients with neck pain and scapular dyskinesis: A randomised clinical trial. J Taibah Univ Med Sci. 2021;16(4):540–9.

    PubMed  PubMed Central  Google Scholar 

  25. Shiravi S, Letafatkar A, Bertozzi L, Pillastrini P, Khaleghi Tazji M. Efficacy of Abdominal Control Feedback and Scapula Stabilization Exercises in Participants With Forward Head, Round Shoulder Postures and Neck Movement Impairment. Sports health. 2019;11(3):272–9.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Seo YG, Park WH, Lee CS, Kang KC, Min KB, Lee SM, Yoo JC. Is Scapular Stabilization Exercise Effective for Managing Nonspecific Chronic Neck Pain?: A Systematic Review. Asian Spine J. 2020;14(1):122–9.

    Article  PubMed  Google Scholar 

  27. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009;339:b2700.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Cumpston M, Li T, Page MJ, Chandler J, Welch VA, Higgins JP, Thomas J. Updated guidance for trusted systematic reviews: a new edition of the Cochrane Handbook for Systematic Reviews of Interventions. Cochrane Database Syst Rev. 2019;10:Ed000142.

    PubMed  Google Scholar 

  29. Luo D, Wan X, Liu J, Tong T. Optimally estimating the sample mean from the sample size, median, mid-range, and/or mid-quartile range. Stat Methods Med Res. 2018;27(6):1785–805.

    Article  PubMed  Google Scholar 

  30. Wan X, Wang W, Liu J, Tong T. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol. 2014;14:135.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Goldet G, Howick J. Understanding GRADE: an introduction. J Evid Based Med. 2013;6(1):50–4.

    Article  PubMed  Google Scholar 

  32. Im B, Kim Y, Chung Y, Hwang S. Effects of scapular stabilization exercise on neck posture and muscle activation in individuals with neck pain and forward head posture. J Phys Ther Sci. 2016;28(3):951–5.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Javdaneh N, Ambrozy T, Barati AH, Mozafaripour E, Rydzik L. Focus on the scapular region in the rehabilitation of chronic neck pain is effective in improving the symptoms: A randomized controlled trial. J Clin Med. 2021;10(16):3495.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Ozdemir F, Toy S, Kizilay F, Avci ZT, Altay Z, Colak C. Effects of scapular stabilization exercises in patients of chronic neck pain with scapular dyskinesis: A quasi-experimental study. Turk J Phys Med Rehabil. 2021;67(1):77–83.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Shirzadi Z, Rojhani-Shirazi Z, Hemmati L. A Comparison Between the Effects of Scapulothoracic Mobilization Plus Physical Therapy With Physical Therapy Alone in Patients With Mechanical Neck Pain: A Randomized Clinical Trial. J Chiropr Med. 2018;17(4):237–43.

    Article  PubMed  Google Scholar 

  36. Yildiz TI, Turgut E, Duzgun I. Neck and Scapula-Focused Exercise Training on Patients With Nonspecific Neck Pain: A Randomized Controlled Trial. J Sport Rehabil. 2018;27(5):403–12.

    Article  PubMed  Google Scholar 

  37. Sun X, Ioannidis JP, Agoritsas T, Alba AC, Guyatt G. How to use a subgroup analysis: users’ guide to the medical literature. JAMA. 2014;311(4):405–11.

    Article  CAS  PubMed  Google Scholar 

  38. Andersen CH, Andersen LL, Zebis MK, Sjøgaard G. Effect of scapular function training on chronic pain in the neck/shoulder region: a randomized controlled trial. J Occup Rehabil. 2014;24(2):316–24.

    Article  PubMed  Google Scholar 

  39. Wegner S, Jull G, O’Leary S, Johnston V. The effect of a scapular postural correction strategy on trapezius activity in patients with neck pain. Man Ther. 2010;15(6):562–6.

    Article  PubMed  Google Scholar 

  40. Fatima A, Veqar Z, Zaidi S, Tanwar T. Effects of scapular stabilization and upper limb proprioception as an adjunct to cervical stabilization in chronic neck pain patients: A randomized controlled trial. J Bodyw Mov Ther. 2022;29:291–301.

    Article  PubMed  Google Scholar 

  41. Kang JI, Choi HH, Jeong DK, Choi H, Moon YJ, Park JS. Effect of scapular stabilization exercise on neck alignment and muscle activity in patients with forward head posture. J Phys Ther Sci. 2018;30(6):804–8.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Safiri SA-O, Kolahi AA, Hoy D, Buchbinder R, Mansournia MA, Bettampadi D, Ashrafi-Asgarabad A, Almasi-Hashiani A, Smith E, Sepidarkish M et al: Global, regional, and national burden of neck pain in the general population, 1990–2017: systematic analysis of the Global Burden of Disease Study 2017. 2020(1756–1833 (Electronic)).

  43. Titcomb DA, Melton BF, Miyashita T, Bland HW. Evidence-Based Corrective Exercise Intervention for Forward Head Posture in Adolescents and Young Adults Without Musculoskeletal Pathology: A Critically Appraised Topic. J Sport Rehabil. 2022;31(5):640–4.

    Article  PubMed  Google Scholar 

  44. Micoogullari M, Uygur SF, Yosmaoglu HB. Effect of Scapular Stabilizer Muscles Strength on Scapular Position. Sports Health. 2023;15(3):349–56.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Carlesso LC, Macdermid JC, Gross AR, Walton DM, Santaguida PL. Treatment preferences amongst physical therapists and chiropractors for the management of neck pain: results of an international survey. Chiropr Man Therap. 2014;22(1):11.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Kang NY, Im SC, Kim K. Effects of a combination of scapular stabilization and thoracic extension exercises for office workers with forward head posture on the craniovertebral angle, respiration, pain, and disability: A randomized-controlled trial. Turk J Phys Med Rehabil. 2021;67(3):291–9.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Javdaneh N, Letafatkar A, Shojaedin S, Hadadnezhad M. Scapular exercise combined with cognitive functional therapy is more effective at reducing chronic neck pain and kinesiophobia than scapular exercise alone: a randomized controlled trial. Clin Rehabil. 2020;34(12):1485–96.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

Not applicable.

Funding

The research reported in this publication was supported by the Project of the Science & Technology Department of Sichuan Province (2021YJ0184), the Scientific Research Project of the Health Commission of Sichuan Province (20PJ035) and Research on the Application of Mind Mapping in Clinical Practice Teaching of Rehabilitation Medicine (GSSCU2021152).

Author information

Authors and Affiliations

  1. Department of Rehabilitation Medicine, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan, China, #37, Guo Xue Lane

    Yin Chen, Chunlan Yang, Kailu Nie, Jiapeng Huang, Yun Qu & Tingting Wang

  2. College of Rehabilitation Medicine, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan, China

    Yin Chen, Chunlan Yang, Kailu Nie, Jiapeng Huang, Yun Qu & Tingting Wang

  3. Sichuan Provincial Key Laboratory of Rehabilitation Medicine, Sichuan University, Chengdu, 610041, Sichuan, China

    Yin Chen, Chunlan Yang, Kailu Nie, Jiapeng Huang, Yun Qu & Tingting Wang

Authors
  1. Yin Chen
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Chunlan Yang
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Kailu Nie
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jiapeng Huang
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Yun Qu
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Tingting Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

YC and TW conceived and designed the study. YC and CY developed the search strategy. KN and CY screened abstracts and full-text reports. TW and JH extracted outcomes. YQ interpretation of the data. YC and KN wrote the manuscript. All authors contributed to the article and approved the submitted version.

Corresponding author

Correspondence to Tingting Wang.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Chen, Y., Yang, C., Nie, K. et al. Effects of scapular treatment on chronic neck pain: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskelet Disord 25, 252 (2024). https://0-doi-org.brum.beds.ac.uk/10.1186/s12891-024-07220-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://0-doi-org.brum.beds.ac.uk/10.1186/s12891-024-07220-8

Keywords

BMC Musculoskeletal Disorders

ISSN: 1471-2474

Contact us