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Bodywork & Movement Therapies (2017) 21 , 11 e 18 Available online at www.sciencedirect.com ScienceDirect

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ScienceDirect journal homepage: www.elsevier.com/jbmt REPEATED MEASUREMENTS STUDY Effect of exams period on
ScienceDirect journal homepage: www.elsevier.com/jbmt REPEATED MEASUREMENTS STUDY Effect of exams period on

REPEATED MEASUREMENTS STUDY

Effect of exams period on prevalence of Myofascial Trigger points and head posture in undergraduate students: Repeated measurements study

Leonid Kalichman, PT, PhD* , Natalie Bulanov, BPT, Aryeh Friedman, BPT

PT, PhD * , Natalie Bulanov, BPT, Aryeh Friedman, BPT Physical Therapy Department, Recanati School for

Physical Therapy Department, Recanati School for Community Health Professions, Faculty of Health Sciences at Ben-Gurion University of the Negev, Beer Sheva, Israel

Received 23 November 2015; received in revised form 14 March 2016; accepted 21 March 2016

KEYWORDS

Myofascial trigger

points;

Forward head

position;

Exams

Summary Background: Myofascial Trigger points (MTrPs) may be caused or aggravated by many factors, such as mental stress associated with exams and impaired posture. Aim: To compare the prevalence and sensitivity of MTrPs, and forward head position (FHP) dur- ing exam period vs. mid-semester among physical therapy students. Methods: 39 physical therapy students were palpated for MTrPs in neck and shoulder muscles and were photographed laterally for FHP measurement during the academic semester and dur- ing the academic examination period. Results: The subjects showed higher prevalence of active MTrPs in the right Trapezius and Le- vator Scapula muscles, and higher prevalence of latent MTrPs in the left Sternocleidomastoi- deus and Levator Scapula muscles during exams, as well as a higher rate of tenderness in suboccipital musculature. Conclusions: Physical therapy students show greater prevalence of MTrPs during exams. The authors recommend implementing preventative programs towards the examination period. ª 2016 Elsevier Ltd. All rights reserved.

* Corresponding author. Department of Physical Therapy, Recanati School for Community Health Professions, Faculty of Health Sciences, Ben-Gurion University of the Negev, POB 653, Beer Sheva, 84105, Israel. Tel.: þ972 52 2767050; fax: þ972 8 6477683. E-mail addresses: kalichman@hotmail.com, kleonid@bgu.ac.il (L. Kalichman).

1360-8592/ª 2016 Elsevier Ltd. All rights reserved.

12

L. Kalichman et al.

Background

Myofascial trigger points (MTrPs) are a widely prevalent phenomenon that has been studied extensively in recent years (Tali et al., 2014 ). Travell and Simons (1983 e 1992) defined MTrPs as ‘a hyperirritable spot, usually within a taut band of skeletal muscle or in the muscle’s fascia, that is painful on compression and that can give rise to char- acteristic referred pain, tenderness and autonomic phe- nomena’ (the hyperirritable spot is often within a palpable nodule) (Travell & Simons, 1983 e 1992 ). The pathophysi- ology of MTrPs is not completely understood. A common agreement is that muscle overload or direct trauma to the muscle might lead to the development of MTrPs ( Bron and Dommerholt, 2012 ). The most hypothesized theory today is that the MTrPs are areas of sensitized low-threshold nociceptors (free nerve endings) combined with motor endplate dysfunction and possibly an increased leakage of acetylcholine (Huguenin, 2004; Kuan et al., 2007; Hong and Simons, 1998 ). Electrophysiological studies have demon- strated abnormal electrical activity near MTrPs, which is described in literature as endplate noise, and is associated with an increased amount of acetylcholine. This amount is not sufficient to create a muscle contraction, but might explain the taut band and the nodule in the muscle (Huguenin, 2004 ). MTrPs are divided into two major sub-categories: active and latent. Active MTrPs are associated with spontaneous local and referred pain. They may also be associated with other symptoms such as weakness, paresthesia, or tem- perature changes, whereas latent MTrPs only evoke local or referred pain when palpated and direct pressure is applied to them (Travell & Simons, 1983 e 1992 ). Latent MTrPs may become activated by a variety of stimuli, including poor posture, overuse, or muscle imbalance (Travell & Simons, 1983 e 1992, Huguenin, 2004 ). However, both active and latent MTrPs cause loss of range of motion and weakness, which can result in limited function ( Travell & Simons, 1983 e 1992 ). Shah et al. (2005) and Bron and Dommerholt (2012) showed that there are differences in the biochem- ical concentration in the areas near active MTrPs compared to latent MTrPs. Biochemicals associated with pain and inflammation such as bradykinin, substance P, interleukins, norepinephrine and more, were significantly higher near active MTrPs and the pH levels found near active MTrPs were significantly lower. Studies have shown that MTrPs are often the cause of symptoms among patients whose primary complaint is pain. One study found that 30% of general internal medicine patients suffering from undiagnosed pain suffered from active MTrPs ( Skootsky et al., 1989 ), while another study found MTrPs to be the cause of head and neck pain in 55.4% of the patients examined ( Fricton et al., 1985 ). According to Gerwin et al. (1997) , there are a variety of clinical characteristics that indicate the presence of a MTrP, the most prominent being: ‘a tender point in a taut band of muscle, a local twitch response (LTR) to mechani- cal stimulation, a pain referral pattern characteristic of MTrPs of specific areas in each muscle, and the reproduc- tion of the patient’s usual pain’ (Gerwin et al., 1997 ). Myburgh et al. (2011) suggested the diagnosis should be a

global assessment-either the MTrP is present, or it is not. He based this idea on Brunse et al. (2010) diagnosis of musculoskeletal chest pain. In order to positively diagnose an MTrP, at least two of the four aforementioned criteria must be present, with the presence of a taut band neces- sary for a positive diagnosis (Myburgh et al., 2011 ). Studies suggest that myofascial pain may be triggered, among other causes, by mental stress. It is also assumed that stress and anxiety influence pain. In a study conducted by Vedolin et al. (2009) , the stress and anxiety levels were shown to be higher as the academic exam period approached, both in healthy subjects and in patients with chronic temporomandibular joint pain, though the tempo- romandibular joint patients reported higher stress levels than the healthy subjects. When pressure pain threshold (PPT) was measured, PPT values were lower in both groups during the examination period. A different study showed similar results: The PPTs of the masticatory muscles and the Achilles tendon were significantly lower in stressed stu- dents, on the exam day and the adjacent days ( Michelotti et al., 2000 ). Treaster et al. (2006) investigated the development of MTrPs during computer work, and concluded that the visual stress caused during computer work increases the formation of MTrPs, especially in the trapezius muscles. In Moraska’s (Moraska and Chandler, 2009 ) work, an as- sociation between stress and MTrPs is presented through a massage therapy aimed for MTrPs, which resulted in reduced levels of anxiety, depression and overall stress levels. Many studies have established an association between MTrPs and headaches such as Tension Type Headaches (TTH) and Migraine Headaches (Davidoff, 1998 ). A connec- tion has also been shown between the presence of active MTrPs and a greater intensity and longer duration of headache episode ( Fernandez-de-Las-Penas et al., 2006a, b ). The research group of Fernandez de las Penas ( Fernandez-de-Las-Penas et al., 2006a, b, c, d; Fernandez- de-Las-Penas et al., 2007; Fernandez-de-Las-Penas et al., 2010 ) has conducted numerous studies regarding MTrPs in cervical muscles and different types of headaches. In one study, authors demonstrated that both active MTrPs in the suboccipital muscles and forward head position (FHP) correlate with chronic TTH ( Fernandez-de-las-Penas et al., 2006b ). In another study, he established a correspondence between active MTrPs and migraine headaches (Fernandez- de-Las-Penas et al., 2006d ). In both studies the majority of MTrPs among the study groups were active, and all subjects in the study group without active MTrPs presented latent MTrPs ( Fernandez-de-las-Penas et al., 2006b, d ). FHP is a common postural disorder, in which the cra- niovertebral angle indicates the head on trunk positioning. A small angle often appears with shortening of the cervical extensors as well as the sternocleidomastoid (SCM) ( Grimmer-Somers et al., 2008; Fernandez-de-las-Penas et al., 2006b ). In Fernandez-de-las-Penas et al. (2006b) study regarding FHP and TTH, the craniovertebral angle was compared between a group of chronic TTH patients and matched controls. Within the chronic TTH group, the cra- niovertebral angle was smaller, and headache frequency and duration was significantly higher (Fernandez-de-las- Penas et al., 2006b ). In a cross-sectional study of 62

Effect of exams on prevalence of trigger points and head posture

13

subjects with neck pain and 52 healthy subjects, a signifi- cantly smaller craniovertebral angle was found in the neck pain group. Moreover, the subjects with smaller cranio- vertebral angle scored higher in Northwick Park Neck Pain Questionnaire and Numeric Pain Rating Scale. These results demonstrate that the severity of the FHP correlates with functional disabilities and neck pain ( Yip et al., 2008 ). Another study showed that as the FHP severity increases, a decrease in cervical joint position sense was found, implying a connection between FHP and proprioception ( Lee et al., 2014 ). University students preparing for exams are exposed to a wide variety of predisposing factors for MTrPs, mainly prolonged sitting, prolonged use of computers, mental concentration, reading papers, and psychological stress which can result in FHP and MTrPs (Treaster et al., 2006; Hoyle et al., 2011 ). Shahidi et al. (2013) demonstrated that circumstances that require high mental concentration correlate with high stress levels and high trapezius muscle activity. The same study also showed that the FHP became worse during mental concentration ( Shahidi et al., 2013 ). The aim of the study was to compare the prevalence and sensitivity of MTrPs and forward head position (FHP) during exam period vs. mid-semester in physical therapy students.

Methods

Design

Repeated measurements study with no intervention.

Setting

Department of Physical Therapy, Recanati School for Community Health Professions, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel.

Sample

41 students were recruited for the study, of which 39 stu- dents participated in both measurements and two only in the first measurement. Participation was voluntary and students were not compensated for their time.

Inclusion criteria

physical therapy students, males and females, 20e 30 years old.

Exclusion criteria

significant neck or head injury in the past three years; active neurological disorder; mental disorders; significant scoliosis or kyphosis.

Data collection

Basic demographic data were collected using a self- administered questionnaire and include age, sex, self- reported weight and height (from which Body Mass Index

(BMI) was calculated as weight in kg divided by height in meters squared) and smoking.

Measurements

Each subject was examined twice: once during the semes- ter, then again during the exams period, or vice versa. About alf of the sample (N Z 20) was evaluated first time during the semester and second time during the exams period, another half (N Z 19) were evaluated in an oposit order. Examiners during the second evaluation were blin- ded to the results of the first examination. Before each measurement the subjects filled in a subjective numeric rating scale (NRS) evaluating stress level, head and neck pain, as well as a widely used 14 item Perceived Stress Scale (PSS) questionnaire. The Alpha Cronbach reliability of the Hebrew version is 79 ( Cohen et al., 1983 ). The examination included assessment of MTrPs in the cervical musculature and tenderness of the suboccipital muscles, while testing the PPT in the MTrPs discovered.

Outcome measures

FHP evaluation FHP is defined by the angle between the line connecting the two markers and a horizontal line drawn from the cervical marker. A computer program (“MB Ruler”) was used to calculate the angle. This is the most common method for sagittal plane posture assessment today, and it has also been suggested that due to the natural postural sway it is more reliable to measure the angle while sitting, rather than upright ( Grimmer-Somers et al., 2008 ). FHP was examined through a lateral photograph, with one marker placed on the tragus of the left ear and one on the spinous process of C7 vertebra ( Grimmer-Somers et al., 2008 ).

MTrP evaluation MTrP diagnosis relies mainly on manual evaluation due to lack of established reliable imaging or laboratory tech- niques. There is no gold standard for diagnosis of MTrPs to which manual palpation can be compared ( Bron et al., 2007; Huguenin, 2004 ). Wytra˛ zek_ et al. (2015) study aimed to correlate palpatory findings with algometric measurements and surface electromyography (sEMG) re- cordings in neck and shoulder girdle muscles. Seventy vol- unteers were palpated bilaterally in four different shoulder muscles, and were examined by sEMG. The study showed that palpation findings correspond with sEMG recordings and algometry measurements, which lead to a conclusion that palpation may be regarded as an objective instru- mental method. Before the beginning of the current study, both exam- iners (senior year physical therapy students A.F. and N.B.) underwent training in finding MTrPs, led by an experienced instructor in myofascial pain evaluation and treatment (L.K.). During the training, they practiced palpation skills, rehearsed the surface anatomy of relevant areas, discussed technique, amount of pressure and subjects’ position and prepared a detailed protocol of MTrPs evaluation. The Upper Trapezius, Levator Scapula, and SCM muscles were examined bilaterally for MTrPs. Two examiners who

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L. Kalichman et al.

classified the results as active MTrP, latent MTrP, tight band, or no MTrP performed the examination separately. To define an MTrP, the examiners palpated the muscles in search of a taut band in the muscle, within which they looked for a nodule. If a nodule was located, the examiner pressed the nodule for few seconds and asked the subject whether it evoked pain. If the subject responded nega- tively, the findings were described as a taut band. If the subject responded positively, he/she was asked to show where pain was felt and whether the pain is familiar. A referred and familiar pain was considered an active MTrP, while local or referred but unfamiliar pain was considered a latent MTrP. For Upper Trapezius and SCM muscles the examiners used a pincer palpation technique, as suggested by Travell and Simons (1983 e1992) , to find a hyperirritable spot or nodule and press it against the muscle fibers. For the Le- vator Scapula examiners used a flat palpation technique at the muscle’s insertion to find a hyperirritable spot and press it toward the underlying bone (Travell & Simons, 1983 e 1992 ). Only consistent diagnoses between exam- iners were regarded as MTrPs. Once a positive diagnosis was achieved, the MTrP sensitivity was tested by one of the examiners by measuring the PPT with an algometer. If multiple MTrPs were found in the same muscle, the examiner asked the subject to indi- cate the most irritable spot. The examiner instructed the subject as following: ‘I am going to apply pressure, tell me when you feel a minimal amount of pain’ (in Hebrew), then applied pressure to the MTrP with the algometer, at a rate of approximately 1 kg/cm 2 /second. This method has been shown to have high interrater and intra-rater reliability by Reeves et al. (1986).

Suboccipital muscle tenderness The suboccipital muscles were palpated by both examiners and the subjects were requested to report pain if it was evoked. This criteria was measured dichotomously-pain was either present or absent.

Ethical considerations Participation in the study was voluntary. Each subject received an explanation as to the aims of the study and methods of data and signed an informed consent form. The study was approved by the Ethics Committee of the Reca- nati School for Community Health Professions.

Statistical analysis All statistical computations were performed using the SPSS 17.0 for Windows (SPSS, Chicago, IL, USA). Statistical ana- lyses were conducted at a 95% confidence level. A p-value <0.05 was considered significant. Descriptive statistics were used to characterize the sample. To compare continuous variables (FHP, NRS stress level and PSS, NRS headache and neck pain, and PPTs of all studied muscles) measured during the semester vs. ones measured during the exams period we used paired T-test. To compare (semester vs. exams) suboccipital muscles tenderness, as well as prevalence of latent and active MTrPs (dichotomous variables) Wilcoxon Signed Ranks Test was used. We also conducted the same test separately in two sub-samples, those that evaluated first during the

semester and those evaluated first during the exams period. In addition, the results of the muscles palpation findings were ranked as ordinal variables (0-no findings, 1-tight band, 2-latent MTrP and 3-active MTrP). These findings were compared (semester vs. exams) using Wilcoxon Signed Ranks Test.

Results

In this study 39 students from the physical therapy department were analyzed ( Table 1). Average age:

25.33 1.94, 30 (76.9%) of which were female. Students were recruited from three different classes: 11 (28.2%) first year students, 8 (20.5%) second year, and 20 (51.3%) third year students. BMI was calculated based on self-reported height and weight. Mean BMI (kg/m 2 ): 22.80 3.07 (17.80 e 30.86). Regular physical activity was reported by 35 (89.7%) students, with a mean duration (hours/week)

4.24 2.60 (0 e10).

Subjective self-reported NRS stress level was signifi- cantly higher during exams, scored6.21 2.20, compared to 3.72 2.61 during the semester (p < 0.001). This is

consistent with the PSS scores, which are also significantly higher during the exams: 2.21 0.42, compared to

1.99 0.37 during the semester (t Z 3.174, p Z 0.003).

FHP showed no significant difference between the se- mester and the exams period. The mean CV angle measured during semester was 48.82 5.30, and examination period mean angle was 49.58 6.35. In all studied muscles the PPT was higher during exam- ination ( Table 2 ). However, only three muscles had statis-

tically significant differences: Right SCM, Left SCM and Right Levator Scapula. Subjective headache and neck pain NRS was also significantly higher during examination period:

Headache NRS during the semester: 1.62 2.42, during exams: 2.87 2.82 (t Z 2.698, p Z 0.01). Neck pain NRS during the semester: 1.90 2.30, during exams:

3.05 2.47 (t Z 3.283, p Z 0.002).

Active MTrPs in the Right Trapzius and Right Levator scapula muscles were significantly more prevalent during the exams (p Z 0.035 and 0.014, correspondingly), as well

Table 1 Characteristics of subjects (n Z 39).

Characteristics

n (%)

Mean SD (minemax)

Age (years)

25.33 1.94 (22 e30)

Gender (females)

30 (76.9)

BMI (kg/m2)

22.80 3.07 (17.80 e30.86)

Year at university

1st

11 (28.2)

2nd

8 (20.5)

3rd

20 (51.3)

Leisure physical activity Participation Duration (hours/week) Smoking Handedness (right)

35 (89.7)

 

4.24 2.60 (0e10)

5 (12.8)

35 (89.7)

BMI e body mass index; SD e standard deviation.

 

Effect of exams on prevalence of trigger points and head posture

15

Table 2 The comparison between continuous measurements done during the semester and ones during exams.

 

Variables

During semester

During exams

Comparison

Mean

SD

Mean

SD

t

Sig. (2-tailed)

FHP NRS stress level PSS NRS headache NRS neck pain PPT Right Trapezius PPT Left Trapezius PPT Right SCM PPT Left SCM PPT Right Levator Scapula PPT Left Levator Scapula

48.82

5.30

49.58

6.35

1.266

0.213

3.72

2.61

6.21

2.20

5.787

0.000

1.99

0.37

2.21

0.42

3.174

0.003

1.62

2.42

2.87

2.82

2.698

0.010

1.90

2.30

3.05

2.47

3.283

0.002

1.55

0.78

1.56

0.64

0.092

0.927

1.76

0.73

1.84

0.91

0.443

0.660

0.29

0.51

0.63

0.59

2.982

0.006

0.19

0.44

0.52

0.62

2.553

0.016

1.28

1.13

1.77

0.98

2.379

0.023

1.09

0.99

1.48

0.96

1.878

0.068

FHP e forward head posture; SD e standard deviation; Sig. e significance; NRS e numeric rating scale; PPT e pressure pain threshold; SCM e sternocleidomastoid muscle.

Statistically significant differences (p < 0.05) marked bold.

 
   

as latent MTrPs in the Left SCM and Left Levator Scapula muscles (p Z 0.007 and 0.029, correspondingly). Sub- occipital muscle tenderness was also significantly more prevalent during the exams (p Z 0.011). In the other muscles examined, no significant results were demon- strated ( Table 3). The total prevalance of MTrPs, both active and latent, during the exam period was higher compared to the semester. When treated as a ordinal variables, myofascial findings showed significantly higher prevalence of MTrPs in the right Trapezius and right SCM muscles during exams ( Table 4). We calculated the power (probability) to reject the null hypothesis that this response difference between semester and exam period is zero for the following parameters:

N Z 39, type I probability Z 0.05. For all parametric tests the power was < 0.8, meaning that our sample size was sufficient to test our hypotheses.

Discussion

The results of this study showed a greater prevalance of MTrPs during the exam period, in correlation with the study’s thesis. Many studies have established a connection between mental load and muscle activity, as Roman-Liu et al. (2013) discuss in depth in the introduction to their study. The results of their study confirm that muscle ten- sion increases during sustained attention and vigilance tests, especially in the shoulder girdle and, less signifi- cantly, in the forearm (Roman-Liu et al., 2013 ). The re- searchers attempted to isolate the mental load from posture by having the study and control groups remain in the same supported posture throughout the test, thus minimizing the biomechanical load on the shoulder girdle. Shahidi et al. (2013) study also showed an increase in muscle EMG activity during high stress condition in

Table 3 The comparison between measurements done during the semester and ones during exams.

 

Variables

During semester

During exams

Comparison

Yes

No

Yes

No

Z a

Sig. (2-tailed)

Suboccipital muscles tenderness Active MTrPs Right Trapezius Active MTrPs Left Trapezius Active MTrPs Right SCM Active MTrPs Left SCM Active MTrPs Right Levator Scapula Active MTrPs Left Levator Scapula Latent MTrPs Right Trapezius Latent MTrPs Left Trapezius Latent MTrPs Right SCM Latent MTrPs Left SCM Latent MTrPs Right Levator Scapula Latent MTrPs Left Levator Scapula

27

14

33

6

2.530

0.011

11

30

17

22

2.111

0.035

7

34

9

30

1.000

0.317

3

38

4

35

0.447

0.655

3

38

2

37

1.000

0.317

2

39

7

32

2.449

0.014

5

36

2

37

1.342

0.180

28

13

21

18

1.508

0.132

34

7

29

10

1.342

0.180

6

35

13

26

1.941

0.052

2

39

11

28

2.714

0.007

25

15

24

15

0.277

0.782

21

20

29

10

2.183

0.029

Statistically significant differences (p < 0.05) marked bold.

 

a Result of the Wilcoxon Signed Ranks Test; Sig. e significance; SCM e sternocleidomastoid muscle.

 
   

16

L. Kalichman et al.

Table 4 Comparison between muscles palpation findings done during the semester and ones during exams (MTrPs findings

treated as ordinal variable).

Variables

MTrPs evaluation

 

Comparison

No

Tight band

Latent MTrPs

Active MTrPs

Z a

Sig. (2-tailed)

Right Trapezius

Semester

1

1

28

11

2.111

0.035

Exams

1

0

21

17

Right SCM

Semester

25

7

6

3

1.975

0.048

Exams

18

4

13

4

Right Levator Scapula

Semester

13

0

26

2

1.811

0.070

Exams

8

0

24

7

Left Trapezius

Semester

0

0

34

7

0.000

1.000

Exams

1

0

29

9

Left SCM

Semester

31

4

3

3

1.762

0.078

Exams

21

5

11

2

Left Levator Scapula

Semester

15

0

21

5

1.232

0.218

Exams

8

0

29

1

Statistically significant differences (p < 0.05) marked bold.

 

a Result of the Wilcoxon Signed Ranks Test; Sig. e significance; SCM e sternocleidomastoid muscle.

 
   

comparison to low stress, in the Upper Trapezius muscle, both in dominant and non-dominant sides. In Linton (2000) review of 11 studies discussing stress

and anxiety, a significant relation was found between these parameters and neck or back pain. This is consistent with

the current study’s results, in which the NRS of neck pain

was significantly higher during the exam period.

The hypothesis that FHP will be more pronounced during

the exam period was repudiated. The FHP was slightly lesser

during the semester with the mean angle measuring a mere 0.76 degrees less than the mean angle during the exam period. This could be explained by Shahidi et al. (2013) study, in which subjects had to complete a computer task in low stress and in high stress conditions. the CV angle measured during the task was smaller compared to baseline measurements, but there was no difference between the

lower and the higher stress conditions. In other words, the

CV angle decreases during task performance and mental

concentration but is not necessarily influenced by stress

levels. Based on these findings, it is possible that because students require mental concentration during the semester as well as during exams, the FHP results are similar during

the two time periods, despite the difference in stress levels.

The PPT values in the current study were consistently higher during examinations than during the semester, con- trary to the researchers’ hypothesis and to other studies: In one study, the researchers asserted that fear and anxiety affect the pain threshold inversely: While fear decreases pain and increases PPT values, anxiety decreases the PPT and increases pain sensitivity (Rhudy and Meagher, 2000 ). According to their definition of anxiety, ‘future-oriented emotion characterized by negative affect and apprehensive anticipation of potential threats’ ( Rhudy and Meagher, 2000 ). It would seem that students during exams fall into that category, yet their results differ from the results of the current study. Vedolin et al. (2009) and Michelotti et al. (2000) also conducted studies with results that disagree with the findings of the current study. Both studies found the academic examination to be a natural stressor, and investigated the influence of stress and anxiety on the PPT.

The findings of these studies were a drop in the PPT values, suggesting the stress condition increases the pain sensi- tivity. However, in Michelotti et al. (2000) study it is stated that the spearman correlation between changes in PPT and stress, on the day of exam and a month later, were generally low. It is possible that the current study is less reliable than contradicting studies, as the PPT was measured only once at each location in the current study, whereas most other studies involved multiple measurements with a mean or maximal result (Michelotti et al., 2000; Walton et al., 2014; Chesterton et al., 2003; Vedolin et al., 2009 ). On the other hand, the consistent increase in PPT during exams (in both sub-samples, those that evaluated first during the semester and those evaluated first during the exams period) and the statistically significant values of the current study suggest low risk of bias in PPT evaluations. In the current study, suboccipital tenderness was examined as an indication of possible MTrPs in the sub- occipital muscles. Travell and Simons (1983 e 1992) wrote that actual diagnosis of MTrPs in these muscles is very difficult, given the layers of muscles superficial to them. Fernandez-de-las-Penas et al. (2006b) devised an inter- esting method which defined modified criteria for diag- nosis: the suboccipital muscles are to be palpated and compressed for 10 s with the neck in neutral position while the subject is supine. If the aforementioned palpation elicits pain, the subject should be instructed to extend his upper cervical spine by tilting his head back. If this exam- ination elicits familiar pain, the MTrP is defined as active. If the elicited pain is unfamiliar, The MTrP is be defined as inactive (Fernandez-de-las-Penas et al., 2006b ). Regret- tably, this method has not been validated and was there- fore deemed irrelevant to the current study. If this method will be validated, it could be a valuable diagnostic tool.

Limitations

The first limitation of this study is the relative lack of experience of the examiners. The researchers tried to

Effect of exams on prevalence of trigger points and head posture

17

minimize the possible bias by specific training, strict pro- tocol and double (by both examiners, blinded to results of each other) evaluation of MTrPs. Only consensus results were recorded. Another limitation is that the examiners were not blin- ded as to whether the student was in the exam period or the semester, which may cause a bias. The results of the current study pertain to 22 e 30 years old university students. It is possible that individuals of different age or education backgrounds would react differently in a similar situation.

Conclusions

The results of this study showed a greater number of MTrPs in cervical and shoulder girdle musculature and a higher neck pain NRS score during the exam period. However, no difference in FHP between two periods was established. It is still unclear whether the stressful nature of academic examinations, a relevant threat for students, is the main cause for these findings, or the prolonged mental demand of preparing for the exams. This question should be further investigated. The authors suggest that a preventative pro- gram should be considered for students during their exams, in order to minimize musculoskeletal disorders and dis- abilities in the future.

Conflict of interest statement

There were no funding or financial benefits to the authors. This paper has not been presented in the past in any form. No conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.

Financial support

None.

Acknowledgments

We would like to thank all subjects for participating in this study.

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L. Kalichman et al.