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 Table of Contents  
Year : 2023  |  Volume : 15  |  Issue : 1  |  Page : 29-33

Effect of neck rehabilitation exercise and breathing exercise on visual complaints in individuals with idiopathic chronic neck pain

Department of Physiotherapy, SRM College of Physiotherapy, SRM Institute of Science and Technology, Kattankulathur, Tamil Nadu, India

Date of Submission17-Oct-2022
Date of Decision26-Dec-2022
Date of Acceptance11-Jan-2023
Date of Web Publication31-Mar-2023

Correspondence Address:
D Vincent Jeyaraj
Assistant Professor, SRM College of Physiotherapy, SRM Institute of Science and Technology, Kattankulathur - 603 203, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ajprhc.ajprhc_91_22

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Background: Neck pain is one of the most common musculoskeletal disorders and a leading cause of disability. Chronic neck pain causes hyperalgesia in soft tissues around the neck, and in severe cases, it leads to restriction of daily life activities. The excessive stress caused by the chronic pain leads to cervico-ocular gain, leading to a mismatch of reflexes that determine the gaze and vision. Chronic neck pain also alters the cervicothoracic kinematic change and length-tension changes in neck muscles and leads to decreased thoracic cage mobility. This leads to respiratory insufficiency in patients with chronic neck pain, which is similar to the changes that occur in cases of a neuromuscular disorder. Objective: The objective of this study was to find the effect of neck rehabilitation exercises and breathing exercises on visual complaints in individuals with idiopathic chronic neck pain. Materials and Methods: Thirty individuals with idiopathic chronic neck pain of both sexes ranging from 20 to 35 years were included according to the selection criteria and divided into two groups. Group A (n = 15) received the intervention for neck pain, whereas Group B (n = 15) did not receive any interventions. Outcome Measures: Neck disability Index, Visual Complain Index and NPRS are used as outcome measures. Results: Statistical analysis was done using SBM SPSS software version 20, which showed that there was a significant improvement in NDI in the experimental group (P < 0.05). Conclusion: This study concludes that there is a significant effect of neck rehabilitation exercises and breathing exercises on visual complaints in individuals with idiopathic chronic neck pain.

Keywords: Breathing exercise, cervico-ocular reflex, chronic neck pain, idiopathic neck pain, neck exercise, visual complaints

How to cite this article:
Abishek J R, Jeyaraj D V. Effect of neck rehabilitation exercise and breathing exercise on visual complaints in individuals with idiopathic chronic neck pain. Asian J Pharm Res Health Care 2023;15:29-33

How to cite this URL:
Abishek J R, Jeyaraj D V. Effect of neck rehabilitation exercise and breathing exercise on visual complaints in individuals with idiopathic chronic neck pain. Asian J Pharm Res Health Care [serial online] 2023 [cited 2023 Jun 8];15:29-33. Available from: http://www.ajprhc.com/text.asp?2023/15/1/29/373381

  Introduction Top

Neck pain is the most prevalent musculoskeletal discomfort that people report with, to physiotherapists. As of the study conducted in 2010, neck pain was ranked as 4th leading cause of disability.[1]

The International Association for the Study of Pain has defined chronic neck pain as a widespread increased pain sensitivity over the soft-tissue structures which is felt more prominently on palpation and in movements of the neck and shoulder area irrespective of the movement being active or passive and it lasts for a minimum period of 12 weeks.[2]

The Australian Acute Musculoskeletal Pain Guidelines state that neck pain that do not have any known etiology or any underlying pathology may be termed idiopathic neck pain.[2]

Specific features of chronic cervical spinal pain include weakness of neck muscles and restriction of activities of daily living.[3],[4]

Neck muscles have abundant mechanoreceptors that provide neuromuscular control to the spine of the neck. This control is provided through the afferent impulses from the cervical mechanoreceptors to the visual and vestibular systems. The visual system is maintained by two reflexes, namely the cervicocollic reflex and cervico-ocular reflex (COR), while the tonic neck reflex influences head and postural stability.[5],[6]

Gaze and vision depend upon the optokinetic reflex (OKR). OKR works in coordination with the vestibulo-ocular reflex (VOR) and COR.[7] Chronic neck pain leads to COR gain and mismatch between the COR and VOR. This makes the person with chronic neck pain to often present with visual disturbances, altered head-eye movement control, and postural instability.[5],[6],[7],[8]

In the case of chronic pain, there is an altered control in the kinetic chain and adaptive musculoskeletal change along with length tension discrepancy of the neck muscles which also act as inspiratory muscles along with arthrogenous joint de-efferentation, dynamic instability, and finally, results in arthrogenous muscle atrophy. Therefore, the muscle activity is reduced and the thoracic cage dynamics are altered.[9],[10], [11]

The unstabilized thoracic and cervical spines during respiration lead to the alteration of rib movements. All these factors predispose to respiratory insufficiency in cases of individuals with chronic neck pain.[9]

These plastic adaptations of the neck and thoracic muscles will result in permanent respiratory dysfunction with reduced respiratory muscle strength and deterioration of minute ventilation volume.[11],[12]

The studies to conclude the effect of neck rehabilitation exercise and breathing exercise on visual complaints in individuals with idiopathic chronic neck pain is sparse. Neck pain being a leading cause of disability, a multimodal approach is needed to assess as well as to treat neck pain. Visual discomforts caused due to chronic neck pain are potent in reducing the health-related quality of life. Thereby, it becomes important to address both visual and neck complaints. This study aims to find out the effect of neck rehabilitation exercises and breathing exercises on visual complaints in individuals with idiopathic chronic neck pain.

  Materials and Methods Top

A quasi-experimental study was conducted among 30 individuals of both sexes between the ages 20 and 35 who had idiopathic neck pain for more than 3 months and a Neck Disability Index (NDI) score of 20 and above with mild or moderate severity on the Numerical Pain Rating Scale (NPRS).

While individuals who were previously diagnosed with neurological disorders, trigeminal neuralgia, cardiovascular disorder, migraine, or any cervical pathology were excluded from the study.

Before the study, the participants were clearly explained about the study, its advantages and needs were explained to the participants, and a consent form was obtained from them.

A pretest was performed on all the participants using a self-administered questionnaire. The neck pain of the individuals was assessed using NDI, and the pain intensity was measured using the NPRS.

Visual complaints of the individuals were graded using the Visual Complaint Index which consisted of 16 items related to vision. Each item had a maximum score of 12 which is obtained by multiplying the frequency and intensity of the complaint. The maximum score that can be scored is 192.

Individuals with an NDI score of 20 and above were selected and were divided into two groups that consists of 15 individuals in each group.

Group A was experimental and Group B was the control group. Participants of Group A were instructed to perform diaphragmatic breathing exercises, followed by active neck stretching and neck isometric exercises, whereas Group B received did not receive any intervention.

Diaphragmatic breathing exercise was taught to the individual in a semi-recumbent position. They were instructed to breath-in for 3 s, breath hold for 2 s, and exhale for 6 s.

Neck stretching was done for all groups of neck muscles including flexors, extensors, side flexors, and rotators. They were asked to maintain the stretch for 30 s and repeat it thrice. Isometrics of the neck were done with self-resistance and were asked to maintain for 6 s and repeat 5 repetitions. All these exercises were done once in a day for 5 days per week for 4 weeks.

At the end of 4 weeks, participants of both groups were asked to fill out the Visual Complaint Index and NDI and rate their pain severity on NPRS.

Statistical analysis

The collected data were tabulated and analyzed using IBM SPSS version 20, USA. Demographic data and questionnaire data of the participants of both groups were analyzed by descriptive statistics. Pretest and posttest values of NPRS, NDI, and visual complaint index of both control and experimental groups were compared separately using paired sample t-test. An independent sample t-test was used to compare the posttest values of NPRS, NDI, and Visual Complaint Index of the experimental and control group.

  Results Top

[Table 1] shows the demographics and questionnaire data and its mean and standard deviation (SD) obtained from both groups.
Table 1: Demographics and questionnaire data

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[Table 2] shows the mean pretest and posttest values of the experimental group. The mean difference of NPRS was 2.80 (SD = 1.47), NDI was 21.56 (SD = 9.18), and vascular cognitive impairment (VCI) was 17.67 (SD = 5.90). The improvement was statistically significant with a significance level of 0.000. This shows that the pain intensity and disability caused due to neck pain have significantly reduced on NPRS and NDI. There is also a significant improvement in visual discomfort in the experimental group.
Table 2: Comparison of mean values of pre- and posttest values of the experimental group

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[Table 3] shows the mean values of pre- and posttest scores of the control group. The mean value of NPRS was –0.40 (SD = 0.463) with P < 0.05 and had significant improvement. The mean value of NDI was –1.01 (SD = 2.76) with P > 0.05 and the mean value of VCI was – 1.93 (SD = 7.19) with P > 0.05. This indicates that there is no significant improvement in neck pain, neck pain-related disability, and visual discomfort in the control group.
Table 3: Comparison between the mean values of pre. and posttests of Numerical Pain Rating Scale, Visual Complaint Index, and Neck Disability Index of the control group

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[Table 4] shows the comparison between the mean values of the posttest scores of the experimental and control groups. There is a significant difference between the posttest values in NPRS, NDI, and VCI of the experimental and control groups with P = 0.000. This indicates that the experimental group shows a significant improvement in neck pain, visual discomfort, and neck pain-related disability when compared to the control group.
Table 4: Comparison between the mean values of posttest scores of the experimental and control group

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[Table 1] depicts the mean age of participants of the experimental and control group were 24.27 and 25.80 years, respectively.

The experimental group shows a mean of 17.06 months of neck pain while that of the control group was 16.87 months.

The mean values of NPRS, NDI, and VCI of the experimental group were 5.13, 30.64, and 23.07, respectively, whereas the mean values of NPRS, NDI, and VCI of the control group were 5.47, 28.48, and 36.93, respectively.

According to [Table 2], there is a statistically significant improvement in mean values of NPRS, NDI, and VCI in the experimental group with a significant value of P < 0.05.

According to [Table 3], there is a statistically significant improvement in the mean value of NPRS with a significance of 0.028 (P < 0.05). However, there is no statistically significant improvement in the mean values of NDI and VCI with significance values of 0.177 and 0.315, respectively (P > 0.05).

[Table 4] shows that there is a statistically significant difference in the posttest mean values of the NPRS, NDI, and VCI between the experimental and control group. Experiment group showed a statistically significant improvement when compared to the control with a significance value of P < 0.05 in NPRS, NDI, and VCI (P < 0.05).

  Discussion Top

The current study aimed at reducing the visual discomforts of the participants by reducing their neck pain by implementing neck isometrics, active neck stretching, and diaphragmatic breathing exercise.

This study is the first of its kind which aimed at reducing visual discomforts by targeting neck pain and disability and no such studies were reported previously.

It included 30 participants of which 14 were male and 16 were female between the age group of 20 and 35 years. They were divided into two groups experimental and control groups. Group A (experimental group) has 15 participants who received interventions including breathing exercises, neck isometrics, and active neck stretching.

The chronic cervical spinal pain, pain-related disability, and visual discomforts were notably reduced in the experimental group while there was no significant difference observed in the control group. Thus, these results imply that the protocol involving active neck stretches, isometrics, and diaphragmatic exercises performed for 5 days in 4 weeks is effective in reducing neck pain, thereby reducing the visual complaints of the individual.

As explained by Phil Page, the significant reduction in pain intensity was attributed to the increased stretch tolerance of the muscles. A static stretch of hold duration between 10 and 30 s is sufficient to obtain the desired results.[13]

The reduced pain intensity in NPRS responds to the study conducted by Tariq et al., where they selected only female workers and showed a significant improvement in NPRS and neck disability with neck isometrics. In our study, both boys and girls were included and they had a significant improvement in pain intensity.[14]

The results of our study also support the previous comparative study conducted in idiopathic neck pain conducted by Hassan et al., wherein they found isometrics and stretching exercises when given together effectively reduce the pain and it also improves the range of motion.[15] While the study conducted by Khan et al. revealed that isometric exercises of the neck aided in reducing chronic neck pain because of the strengthening effects, and also provided a stable base of support for the wide range of cervical kinematics.[3]

The results of the study are in accordance with the study proposed by Häkkinen et al., where they described that actively done exercises proved to be effective and had long-lasting effects on pain which were chronic in nature.[16]

Isometric contraction exercises prove to be efficient in reducing muscle pain as discussed by Khosrojerdi et al., the sustained isometric exercise on one side will act as an analgesic for the contralateral side.[17]

As explained by Mohan et al., the significant effect yielded by neck rehabilitation and breathing exercise on chronic pain was due to the improved function of respiratory muscles such as the trapezius, sternocleidomastoid, and scalene. These muscles not only aid inspiration but are also responsible for cervical movement.[18]

As described by Lee et al., home-based respiratory exercises have better effects on increasing respiratory muscle strength and endurance. It also helps in improving the oxygenation of tissues and thereby improves the quality of life. As discussed earlier, the improved strength of respiratory muscles which also acts as cervical mobilizers and stabilizers helps in reducing the pain.[19]

The reduced pain intensity of the cervical region in the experimental group supports the study of Rio et al., wherein they explained that cortical inhibition, supra-spinal inhibition, and the pooling of motor neurons induced by the isometric exercises were the major cause for reduced pain intensity.[20]

From the obtained results, it is evident that as the neck pain reduces the visual discomforts of an individual also reduce significantly.

This might be due to the effect of the neck exercises and breathing exercises which help in reducing the excessive stress in the neck muscles and the excessive stress on the cervical mechanoreceptors in the muscle spindles.

As the stress over the cervical spinal muscle reduces, the increased cervico-ocular reflex also reduces, thereby reducing the imbalance between the reflexes that integrate the vision.

Limitations of the study are that the sample size was limited and only a particular age group was included in the study. There were no specific investigations or examinations were employed in this study to rule out idiopathic neck pain and it was purely based on the history given by the participants. Further studies should consider employing a larger sample and involving whiplash injury, pathological and traumatic neck pain, and comparing the results obtained among different groups.

  Conclusion Top

From the results obtained from the study, it can be concluded that neck rehabilitation exercises and breathing exercises have a significant effect on visual complaints in individuals with idiopathic chronic neck pain.


The authors extend heartfelt gratitude to all the participants for extending their support to complete this study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, et al. The global burden of low back pain: Estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis 2014;73:968-74.  Back to cited text no. 1
Misailidou V, Malliou P, Beneka A, Karagiannidis A, Godolias G. Assessment of patients with neck pain: A review of definitions, selection criteria, and measurement tools. J Chiropr Med 2010;9:49-59.  Back to cited text no. 2
Khan M, Soomro RR, Ali SS. The effectiveness of isometric exercises as compared to general exercises in the management of chronic non-specific neck pain. Pak J Pharm Sci 2014;27:1719-22.  Back to cited text no. 3
Ylinen JJ, Häkkinen AH, Takala EP, Nykänen MJ, Kautiainen HJ, Mälkiä EA, et al. Effects of neck muscle training in women with chronic neck pain: One-year follow-up study. J Strength Cond Res 2006;20:6-13.  Back to cited text no. 4
Kristjansson E, Treleaven J. Sensorimotor function and dizziness in neck pain: Implications for assessment and management. J Orthop Sports Phys Ther 2009;39:364-77.  Back to cited text no. 5
Treleaven J. Sensorimotor disturbances in neck disorders affecting postural stability, head and eye movement control. Man Ther 2008;13:2-11.  Back to cited text no. 6
Treleaven J. Dizziness, unsteadiness, visual disturbances, and sensorimotor control in traumatic neck pain. J Orthop Sports Phys Ther 2017;47:492-502.  Back to cited text no. 7
Treleaven J, Takasaki H. Characteristics of visual disturbances reported by subjects with neck pain. Man Ther 2014;19:203-7.  Back to cited text no. 8
Kapreli E, Vourazanis E, Strimpakos N. Neck pain causes respiratory dysfunction. Med Hypotheses 2008;70:1009-13.  Back to cited text no. 9
Dimitriadis Z, Kapreli E, Strimpakos N, Oldham J. Respiratory weakness in patients with chronic neck pain. Man Ther 2013;18:248-53.  Back to cited text no. 10
Kapreli E, Vourazanis E, Billis E, Oldham JA, Strimpakos N. Respiratory dysfunction in chronic neck pain patients. A pilot study. Cephalalgia 2009;29:701-10.  Back to cited text no. 11
Dimitriadis Z, Kapreli E, Strimpakos N, Oldham J. Pulmonary function of patients with chronic neck pain: A spirometry study. Respir Care 2014;59:543-9.  Back to cited text no. 12
Page P. Current concepts in muscle stretching for exercise and rehabilitation. Int J Sports Phys Ther 2012;7:109-19.  Back to cited text no. 13
Tariq M, Sarfraz N, Gilani H. Comparative efficacy of isometric exercises and active range of motion exercises in mechanical neck pain of female sewing machine operators. Isra Med J 2018. p. 301-5.  Back to cited text no. 14
Hassan W, Malik S, Gondal J, Akhtar M, Akhtar SK, Zafar A, et al. Comparison of effectiveness of isometric exercises with and without stretching exercises in non specific cervical pain. Int J Physiotherapy 2016;3:371-5.  Back to cited text no. 15
Häkkinen A, Salo P, Tarvainen U, Wirén K, Ylinen J. Effect of manual therapy and stretching on neck muscle strength and mobility in chronic neck pain. J Rehabil Med 2007;39:575-9.  Back to cited text no. 16
Khosrojerdi H, Tajabadi A, Amadani M, Akrami R, Tadayonfar M. The effect of isometric exercise on pain severity and muscle strength of patients with lower limb fractures: A randomized clinical trial study. Med Surg Nurs J 2018;7:e68104.  Back to cited text no. 17
Mohan V, Ahmad NB, Tambi NB. Effect of respiratory exercises on neck pain patients: A pilot study. Pol Ann Med 2016;23:15-20.  Back to cited text no. 18
Lee HY, Cheon SH, Yong MS. Effect of diaphragm breathing exercise applied on the basis of overload principle. J Phys Ther Sci 2017;29:1054-6.  Back to cited text no. 19
Rio E, Kidgell D, Purdam C, Gaida J, Moseley GL, Pearce AJ, et al. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Br J Sports Med 2015;49:1277-83.  Back to cited text no. 20


  [Table 1], [Table 2], [Table 3], [Table 4]


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