Effect of pompage on pain, disability and craniocervical position of female teachers Randomized clinical trial

Introduction: Education professionals are one of the most important occupational groups and represents one of the main parts of the economy of modern society. The vocal demands most mentioned by the teachers are talking while standing up, talking a lot and in a closed environment, which corresponds to the most frequent situations encountered in teaching. In addition, remaining in the standing position for a prolonged period may have repercussions on other systems and generate postural deviations, pain and reduced functionality. Objective: To verify changes in pressure pain threshold, in disability index and in craniocervical posture of female teachers with vocal and musculoskeletal complaints, and with normal larynx, after myofascial release - pompage. Methods: This study was a controlled and randomized clinical trial. The following procedures were performed: anamnesis, videolaryngoscopy, hearing screening, clinical and photogrammetric postural assessment using the SAPo® protocol, completion of the neck pain self-assessment protocol Neck Disability Index, and pain threshold in the cervical muscles using the Pain Pressure Threshold. Myofascial therapy with pompage had a total of 24 sessions of 40 min each, three times a week, in 28 teachers assigned to the study group (SG), and 28 to the control group (CG). Afterwards, the groups were reassessed. Results: The SG presented a significant improvement in the pain threshold of all the muscles evaluated, in the posture of most of the body segments evaluated, and in the cervical disability. In the CG there was a significant improvement in angle A2 after therapy. Conclusion: After myofascial release therapy with pompage, the subjects presented a reduction in cervical pain and in functional disability, an increase in pain threshold, and posture improvement.


Introduction
The group of education professionals is one of the most important occupational groups and represents one of the main parts of the economy of modern society.
In addition, it has important roles in the political and cultural scene. 1,2 Teachers have an intense voice demand in activities that require muscular effort, adequate respiratory and postural control (static and dynamic) for several hours. [3][4][5] The biomechanical complexity of body posture is the result of the functional integration of multiple systems.
Any alteration in this balance generates a change in postural control that affects different body areas, which can generate chronic nonspecific craniocervical pain.
This affects joint position, motor control of the head, postural stability, and the intensity and chronicity of pain. 5,6 The vocal demands most mentioned by the teachers are talking while standing up, talking a lot and in a closed environment, which corresponds to the most frequent situations encountered in teaching. 4 In addition, remaining in the standing position for a prolonged period may have repercussions on other systems and generate postural deviations, pain and reduced functionality.
In this sense, the literature presents evidence of the importance of proper posture for good professional performance and maintenance of vocal health. 3,5,7 The ideal, during the vocal production process, is to keep the torso erect, the head aligned to it, with the chin slightly lowered and the shoulders relaxed. The supra and infrahyoid muscle groups, involved in the phonation process, must be in balance regarding the lengthtension relationship, so that the larynx can remain in an appropriate vertical position. 3 For the synchronicity between vocal production, adequate body posture, especially in the craniocervical and scapular region, and efficient breathing at phonation, it is necessary that the structures and their functions interrelate in a cohesive and balanced way. 8,9 Among the structures that act on postural control and the phonatory apparatus, muscles influence each other continuously, integrating the entire body through the fascia -myofascia -grouped nature, inseparable from the muscle tissue (myo) and its connective tissue web (fascia). 8,10 All body muscles are surrounded by the fascia, that also involve viscera, arteries and veins, presented as a network connected from the skull to the soles of the feet. 9 The musculoskeletal manipulation via pompage is a technique that acts on the connective tissue. It is a myotensive work with mobilization added to the sliding of the fasciae. Its objective is muscle relaxation, improvement in circulatory nutrition of soft tissues and joints, dissolution of contractures, shortening, retraction, restoration of the normal shape or length of myotendinous structures, and pain reduction. 9,11 The muscular fascia has stood out in the physiotherapeutic treatment, as it is the mechanical element of force transmission. 9,11,12  Ninety teachers volunteered for this investigation.
Of these, two dropped out after the first evaluations and 32 were excluded: two were part of the physiotherapy course; one reported rheumatic disease; two reported being amateur singers; one underwent physiotherapeutic treatment; three reported a benign thyroid gland nodule; three reported gastroesophageal reflux; two underwent speech therapy for the voice; two reported surgery and/or face trauma; two were smokers; one was not a teacher; one was pregnant; one was older than the age limit defined by the inclusion criteria; two were away from the classrooms; two did not respond to contacts; three did not remain interested in participating in the research, and four teachers had laryngeal disease. 13 Procedures and instruments for data collection and analysis All SG and CG participants underwent the assessments described below, before and after therapy.
The CG did not receive any treatment during the SG intervention period, but was reassessed at the same time as the SG, that is, two months after the start of the intervention.
The assessments were performed on the same day and the first therapy session was started no later than three days after the assessment. Reassessments were performed immediately after the last day of therapy.
The occurrence of chronic cervical pain or chronic neck pain was verified through the Neck Disability Index (NDI). 21 This pain is located in the cervical region and/or is associated with symptoms of the upper limbs lasting three months or more. 8,21,22 The NDI is a selfadministered questionnaire used to measure disability associated with cervical pain condition. 8  After the two-month therapy period of the SG and the reassessments of all teachers, the CG teachers, who did not receive the intervention, were invited to receive the pompage.
In the statistical analysis of the data, the program

Control group Study group
Number of volunteers 28 28 Minimum age (years) 21 28 Maximum age (years) 60 57 Average age (years) 38.6 41.4 Minimum weekly workload of professional voice use (hours) 14 12 Maximum weekly workload of professional voice use (hours) 27 26 Average weekly workload of professional voice use (hours) 15.4 22.4 Minimum working time as a teacher (years) 5 8 Maximum working time as a teacher (years) 18 18 Average working time as a teacher (years) 9.1 14.8  of the body segments of the SG after therapy. Table 5 shows the results of craniocervical biophotogrammetry, with a post-therapy decrease of A2 in the CG.  compared the results with a control group. We believe that deviations in these measurements can negatively interfere with voice production.   Deviations from laryngeal posture occur due to muscle adaptations, 7 and dysphonic women have more pronounced craniocervical dysfunction. 6,7 In our study, the clinical postural assessment showed significant changes after intervention in the SG regarding the following aspects: head with anterior/posterior tilt, head in rotation, shoulder, total spine and back curvature.
In the intergroup analysis, there were significant postintervention improvements in the SG regarding the aspects: head with anterior/posterior tilt, head with lateral tilt, head in rotation, total spine and back curvature (Table 4). In the objective postural assessment, there were no significant results after therapy, except for the improvement of A2 in the CG ( The SG had a  (Table 3).
This result is in line with studies with women who found an association between reduced PPT values in the craniocervical region and pain characteristics, such as frequency, duration or intensity. 18,33,37,38 Pain may be responsible for higher rates of musculoskeletal complaints, even with low-level static efforts. 19 Both exclusively manual therapy and that associated with kinesiotherapy are effective in the treatment of cervical myofascial pain. Myofascial release therapy is a superior therapy for reducing algiogenic processes and muscle hypertension. 19,33,37,38 Myofascial release is believed to promote benefits through automatic muscle redefinition, which defines the duration and intensity of pain in the affected muscles.
Myofascial therapy promotes an increase in sarcomeres (units of actin and myosin that are repeated along the myofibril) in the area where there is contraction. PPT and local pain intensity improve after the application of this therapy, possibly also due to the manual contact component of the treatment and the stimulation of muscle fibers, a process that can lead to pain block, 19 endorsing our results.
In the CG (Table 3), the right scalene muscle showed significant improvement. This result, despite being lower than the values found in the SG, agrees with a study that also found improvement without intervention. 34 The hypothesis for such a result would be the reduction of A research with global postural correction method in adult women used biophotogrammetry with subsequent analysis by SAPo®. 43 There was a reduction in pain and increased flexibility, but there were no changes in posture, disagreeing with our results regarding the reduction of hyperextension of the head, which showed improvement (Table 4) In our study, postural improvement was significant (Table   4), which may have repercussions on both vocal and musculoskeletal complaints.
Myofascial release involves the application of low tension load -and longer duration -to the myofascial complex, in order to restore the ideal length, decrease pain and improve function. A systematic review of clinical trials points out myofascial release as a strategy with a solid evidence base and excellent therapeutic potential. 12 As a limitation of this work, we highlight the nonblinding of both SG and CG groups and the non-followup of the teachers after the end of the intervention, in order to verify whether the effects were maintained over time. We believe that future research should contemplate double-blinding and proof of long-term results.

Conclusion
In the group of teachers with vocal and musculoskeletal complaints that received musculoskeletal manipulations of the myofascial release type through the use of pompage, there was a reduction in cervical pain and functional disability, an increase in pain threshold, and postural improvement. This shows the effectiveness of the physiotherapy protocol proposed, under the evaluated aspects.