Research Report

Effectiveness of Global Postural

P. Pillastrini, PT, MSc, Occupa-
tional Medicine Unit, Department
of Biomedical and Neurological
Re-education in Patients With
Sciences, University of Bologna,
via P. Palagi 9-40138 Bologna, Chronic Nonspecific Neck Pain:
Italy. Address all correspondence
to Professor Pillastrini at: Randomized Controlled Trial
paolo.pillastrini@unibo.it.
Paolo Pillastrini, Fernanda de Lima e Sa Resende, Federico Banchelli, Anna Burioli,
F. de Lima e Sa Resende, PT, PhD,
Occupational Medicine Unit, Emanuele Di Ciaccio, Andrew A. Guccione, Jorge Hugo Villafane, Carla Vanti
Department of Biomedical and
Neurological Sciences, University
of Bologna. Background. Global postural re-education (GPR) has shown positive results for patients
with musculoskeletal disorders, but no previous randomized controlled trial (RCT) has inves-
F. Banchelli, PhD, Department of
Statistical Sciences Paolo Fortu- tigated its effectiveness as the sole procedure for adult patients with chronic nonspecific neck
nati, University of Bologna. pain (NP).

A. Burioli, PT, Occupational Med-

icine Unit, Department of Biomed-
Objective. The purpose of this study was to evaluate the effectiveness of applying GPR
ical and Neurological Sciences, compared with a manual therapy (MT) intervention to patients with chronic nonspecific NP.
University of Bologna.
Design. An RCT was conducted.
E. Di Ciaccio, PT, Occupational
Medicine Unit, Department of
Biomedical and Neurological Sci- Patients. Ninety-four patients with chronic nonspecific NP (72 women and 22 men;
ences, University of Bologna. average age47.5 years, SD11.3) were randomly assigned to receive either a GPR interven-
tion or an MT intervention.
A.A. Guccione, PT, DPT, PhD,
FAPTA, Department of Rehabilita-
tion Science, College of Health Outcome Measures. Pain intensity (visual analog scale), disability (Neck Disability
and Human Services, George Index), cervical range of motion, and kinesiophobia (Tampa Scale of Kinesiophobia) were
Mason University, Fairfax, assessed.
Virginia.

J.H. Villafane, PT, PhD, IRCCS Don Methods. The experimental group received GPR, and the reference group received MT.
Gnocchi Foundation, Milan, Italy. Both groups received nine 60-minute-long sessions with one-to-one supervision from physical
C. Vanti, PT, MSc, Occupational therapists as the care providers. All participants were asked to follow ergonomic advice and to
Medicine Unit, Department of perform home exercises. Measures were assessed before treatment, following treatment, and
Biomedical and Neurological Sci- at a 6-month follow-up.
ences, University of Bologna.

[Pillastrini P, de Lima e Sa Resende Results. No important baseline differences were found between groups. The experimental
F, Banchelli F, et al. Effectiveness group exhibited a statistically significant reduction in pain following treatment and in disability
of global postural re-education in 6 months after the intervention compared with the reference group.
patients with chronic nonspecific
neck pain: randomized controlled Limitations. Randomization did not lead to completely homogeneous groups. It also was
trial. Phys Ther. 2016;96:1408
noted that the time spent integrating the movements practiced during the session into daily
1416.]
routines at the end of each session was requested only of participants in the GPR group and
2016 American Physical Therapy may have had an impact on patient adherence that contributed to a better outcome.
Association

Published Ahead of Print: Conclusions. The results suggest that GPR was more effective than MT for reducing pain
March 24, 2016 after treatment and for reducing disability at 6-month follow-up in patients with chronic
Accepted: March 10, 2016 nonspecific NP.
Submitted: September 9, 2015

Post a Rapid Response to

this article at:
ptjournal.apta.org

1408 f Physical Therapy Volume 96 Number 9 September 2016

 Effectiveness of Global Postural Re-education

N eck pain (NP) is a very common

clinical condition, whose associ-
ated social and economic costs
related to disability and days off work are
about to equal those for lumbar pain.1
retractions associated with lower
back pain or NP.19 Global postural
re-education aims to stretch and elongate
these muscles, which are in a shortened
state, by using prolonged active postures
postural configurations noted above as
indicated by the patients clinical presen-
tation) compared with an MT approach
that includes stretching, cervical passive
mobilization, and active neck exercises
Changes in muscle control, such as and by enhancing contraction of the in patients with nonspecific chronic NP
increased activity of superficial muscles,2 antagonist muscles to promote improved (ie, NP lasting for more than 12 weeks).
increased coactivation of the superficial muscle balance and postural symmetry.20 The purpose of this superiority trial was
muscles of the cervical spine and the to examine the effectiveness of the appli-
upper trapezius muscle during isometric The GPR intervention comprises 8 dis- cation of GPR compared with an MT
contractions, and delayed feed-forward tinct postural configurations, divided intervention in adult patients with
activation of superficial and deep mus- into 2 groups. Hip flexion postures chronic nonspecific NP, focusing atten-
cles,3 have been reported in individuals emphasize the posterior chain: (1) lying tion primarily on pain and disability and
with NP. Although the exact relationship on back with the legs flexed and the secondarily on fear of movement and
between posture and NP is unresolved, upper limbs adducted, (2) lying on back cervical ROM.
posture of the cervical spine appears to with the legs flexed and the upper limbs
influence dorsal neck muscle activity at abducted, (3) sitting with legs extended, Method
rest and when lifting.4 Furthermore, the and (4) standing with the body leaning We conducted an RCT. Informed con-
forward head posture associated with forward. Hip extension postures empha- sent was obtained from all participants,
thoracic kyphosis indirectly affects cervi- size the anterior chain: (1) lying on back and procedures were conducted accord-
cal flexion and rotational range of with the legs extended and the upper ing to the Declaration of Helsinki.
motion (ROM),5 and sustained computer limbs adducted, (2) lying on back with
work, often in positions that encourage a the legs extended and the upper limbs Participants
functional kyphosis, appears to alter abducted, (3) standing with the back From September 2013 to April 2014, all
neck posture, as well as scapular posi- against the wall, and (4) standing with- outpatients (N108) diagnosed with
tioning and upper trapezius muscle activ- out any back support.21 chronic nonspecific NP at S. Orsola-
ity.6 Ergonomic interventions,7 including
Malpighi University Hospital were eligi-
adjustments of the workplace station and Patients receive a global assessment in ble to participate. According to inclusion
postural correction, have been demon- which different body segments are and exclusion criteria, 94 patients from
strated to be effective in reducing NP observed by the physical therapist in urban and rural areas were enrolled in
with some work conditions. order to identify dysfunctional muscle this study by the principal investigator
chains. Appropriate postures are (P.P.).
Among conservative treatments for pain- then selected to correct the identified
ful musculoskeletal conditions, various muscle imbalances.22 All muscles of the Participants of both sexes were included
manual approaches to mobilize soft tis- same chain are simultaneously stretched if they fulfilled the following criteria:
sues and restore joint mechanics are fre- during a posture, avoiding any chronic nonspecific NP lasting for at
quently combined with supervised compensation.23 least 3 months, aged 18 to 80 years, and
active exercises, education, and home able to read and speak Italian. Exclusion
programs including self-treatment.8 11 Some studies support GPRs clinical criteria were acute or subacute NP, spe-
Manual therapy (MT) may decrease pain effectiveness in treating patients with dif- cific cause of NP (eg, systemic, rheu-
and muscle spasm and provide some ferent musculoskeletal disorders and matic, neuromuscular diseases), central
degree of short-term NP relief.12 Manual impairments.19,20,24,25 To our knowl- or peripheral neurological signs, cogni-
therapy includes stretching techniques edge, only one randomized controlled tive impairment, spinal surgery, or phys-
for superficial cervical muscles,13 passive trial (RCT) using GPR for rehabilitation ical therapy treatments in the 6 months
mobilization through physiological and of NP has been conducted.26 This study prior to baseline assessment. Neither
accessory movements,14 and massage compared the effectiveness of conven- inclusion nor exclusion criteria were
and fascial manipulation or release.15,16 tional static stretching and muscle chain changed during the trial. All eligible par-
stretching in women with chronic NP ticipants underwent a medical examina-
An alternative conservative treatment for and drew the conclusion that both meth- tion by an occupational health physician,
NP is global postural re-education (GPR), ods were equally effective in relieving who excluded specific causes of NP and
a therapeutic strategy developed by pain and improving ROM and quality of cognitive impairments, according to the
Souchard.17 It is based on a central con- life. Nevertheless, both groups also Italian low back pain guidelines.27
cept that postural muscles are organized received MT. Thus, the separate effects
to act in concert with each other as of the 2 different techniques could be The dimension of the sample was calcu-
muscle chains located anterior and identified. No previous RCT, to our lated to be at least equal to 88 patients
posterior to the spine.18 It has been knowledge, has investigated the effec- (44 per group) on the basis of a .95
hypothesized that specific clinical pre- tiveness of GPR delivered as the sole pro- confidence level, a 0.8 statistical power,
sentations are caused by muscle chain cedure (ie, using one or more of the 8 and a 0.6 Cohen d effect size coefficient.

September 2016 Volume 96 Number 9 Physical Therapy f 1409

Effectiveness of Global Postural Re-education

This last calculation was approximated designed according to the CONSORT

based on group differences and standard publishing guidelines.29
deviations at long-term follow-up re-
ported by Bonetti et al20 and Monticone Interventions
and coworkers28 for Neck Pain and Dis- Both GPR and MT interventions lasted 9
ability Scale (NPDS), numeric rating scale sessions, 1 hour each, with one-to-one
(NRS), and visual analog scale (VAS) out- supervision, once or twice a week
comes (NPDS statistics were rescaled to according to the participants needs.
a 0 50 range in order to be compared Three physical therapists with expertise
with Neck Disability Index [NDI] statis- in GPR provided the GPR treatment, and
tics). Effect sizes were 1.0 for the NPDS, 5 experts in NP treatment carried out the
0.6 for the NRS, and 0.7 for the VAS. MT program. Before starting this study,
Aiming to enroll more than 88 patients in some practice sessions were organized
order to balance potential dropouts, the to standardize the procedures among the
current sample size of 94 was finally physical therapists, including agreement
determined by the availability of among different examiners on how the
resources with respect to study budget cervical ROM measurement would be
and physical therapists able to imple- calculated. All participants in both
ment the intervention. The stopping groups received advice to follow written
rules included adverse events and per- ergonomic suggestions (eAppendix 1,
sonal or health problems; furthermore, available at ptjournal.apta.org) and to
we had agreed to stop the study if there repeat the exercises taught in the first
was evidence of the superiority of one physical therapy session at home twice a
treatment over the other when prelimi- week for 15 minutes. Each group had a
nary analyses were performed immedi- home exercise program, which differed
ately postintervention (time 1). according to the type of treatment
received. Participants in the GPR group Figure 1.
Randomization executed one posture routine (A) Supine posture with leg extension pro-
Randomization was performed in 2 (eAppendix 2, available at ptjournal. gression: anterior muscle chain stretching.
steps. Using a progressive list of num- apta.org), and those in the MT group Starting position. (B) Supine posture with leg
bers, each number was randomly executed stretching and active ROM extension progression: anterior muscle chain
assigned to a type of treatment (GPR or exercises (eAppendix 3, available at stretching. Final position.
MT) by a software procedure. The GPR ptjournal.apta.org). During the course of
or MT intervention was then assigned to this study, 2 expert physical therapists
each of the participants on the basis of (P.P., C.V.) supervised the fidelity of limbs and adduction of the upper limbs.
their recruiting order, following the ran- treating therapists to the protocols on a The second posture started in lying with
domized sequence of treatments estab- monthly basis through meetings and con- hip flexed, and progression consisted of
lished by the first step of the randomiza- ference calls. The GPR and MT treat- increasing hip flexion, knee extension,
tion process. Randomization followed a ments were strictly performed according and dorsiflexion of the ankle.
fixed-size design with a concealed alloca- to the initial rules.
tion ratio of 1:1. Thus, 47 participants During GPR treatment, manual traction
were assigned to the MT intervention, GPR. In this study, only 2 lying pos- was applied both to lumbar and cervical
and 47 participants were assigned to the tures were used from the 8 different ther- areas, and isometric contractions of the
GPR program. All of the randomization apeutic postures of GPR method17: the stiff muscles were requested to induce
procedures were concealed and con- supine posture with leg extension, post-isometric relaxation.30 Physical
ducted by the study statistician. which progressively stretches the ante- therapists used verbal commands and
rior muscle chain (Figs. 1A and 1B), and manual contact to maintain the postural
Basic demographic data (age, sex, and the supine posture with hip flexion, alignment. The manual contact also was
body mass index [BMI]) and information which stretches the posterior muscle important to optimize stretching and
on smoking habits, physical activities, chain (Figs. 2A and 2B). The first posture discourage compensatory movements
marital status, and referred pain were started with the hips flexed, abducted, while achieving the desired postures.
collected at baseline. All outcome mea- and laterally rotated, with foot soles Each posture was held for about 20 min-
sures were captured at baseline, at time touching each other. The participant utes. At the end of each session, partici-
1, and at 6 months postintervention was instructed to spread his or her hips pants were requested to correct their
(time 2) by an assessor blinded to group from the initial position, maintaining the standing posture and to perform simple
assignment. The sequence of testing for soles of the feet together in alignment cervical movements while maintaining
the outcome measures was randomized with the body axis. The progression was the corrected posture for a total of 10
among participants. The trial was in the direction of extension of the lower minutes. The correct posture was related
not only to the neck region (eg, straight-

1410 f Physical Therapy Volume 96 Number 9 September 2016

 Effectiveness of Global Postural Re-education

tain normal breathing during all of these nets held anteriorly and posteriorly was
therapeutic procedures. provided to reduce the influence of tho-
racic rotation.41 The CROM has demon-
Outcome data collection. Outcome strated good concurrent validity for
measurements were collected by 3 active ROM.42 According to the system-
researchers who were blinded to treat- atic review by Chen et al,42 the mean
ment at baseline and at 2 follow-up normative values of cervical ROM were
examinations: at the end of the treatment determined to be: 52 degrees for flexion,
and after 6 months. 71 degrees for extension, 72 degrees for
rotation, and 43 degrees for lateral
Outcome Measures flexion. Documentation of cervical
The primary outcome measures of this ROM was rendered in the form of full
study were pain and disability. Mean range (ie, a total value for the sagittal,
rates of perceived pain during the last 24 frontal, or transverse plane, yielding 3
hours were measured with a 0 100 measurements).43
VAS,34 and cervical disability was rated
using the Italian version of the Neck Dis- Before starting the study, we calculated
ability Index (NDI-I).35 The NDI is the the internal consistency of ROM assess-
most commonly used questionnaire for ment. Thirty measurements were taken
measuring neck disability; its reliability by 3 different examiners for a total num-
and validity have been demonstrated in ber of 90 measurements. Cronbach alpha
different languages.36 The secondary out- was .93, .96, and .93 for flexion and
Figure 2. come measures were: kinesiophobia, extension, lateral flexion, and rotation
(A) Supine posture with leg flexion progres- perceived effect of the intervention, measurements, respectively, so the inter-
sion: posterior muscle chain stretching. patient satisfaction, and cervical ROM. examiner reliability of the cervical ROM
Starting position. (B) Supine posture with leg Kinesiophobia was assessed with the measure was satisfactory.
flexion progression: posterior muscle chain
13-item Italian version of the Tampa
stretching. Final position.
Scale of Kinesiophobia (TSK),37 which Data Analysis
provides a measure of fear of movement Descriptive statistics of the recorded
or injury.38 The Italian version of the TSK characteristics and the outcome mea-
ening a forward head posture) but also to
comprises 2 subscales: the activity avoid- sures at baseline were calculated. Con-
the entire spine and the pelvis (eg,
ance subscale (TSK-1) and the harm sub- tinuous variables were expressed as
correcting lumbar lordosis or pelvic
scale (TSK-2).37 The perceived effect of mean (SD), and categorical variables
tilt). The final parts of each session aimed
the intervention was assessed with the were expressed as absolute and percent-
to facilitate the integration of the pos-
Global Perceived Effect Questionnaire age frequencies. In order to assess base-
tural correction into daily functional
(GPE), a 5-point Likert-type scale used to line homogeneity of the 2 groups,
activities.20
evaluate self-reported improvement or 2-tailed Student t tests for continuous
deterioration after the intervention. Use variables and chi-square tests for categor-
MT. The MT program included a com- of the GPE is widely reported in the phys- ical variables were performed.
bination of different therapeutic tech- ical therapy literature.39 Patient satisfac-
niques. Axial cervical general traction tion was assessed with the Italian version Repeated-measures mixed models con-
and mobilization of muscle fascia (sca- of the Physical Therapy Patient Satisfac- sidering outcome scores at different
lene, levator scapulae, upper trapezius, tion Questionnaire (PTPSQ-I[15]),19,40 times as the dependent variable, with
sternocleidomastoid, and pectoralis which demonstrated good psychometric time as the within-subject factor and
minor muscles)31 were performed for at properties and a 2-factor structure, group as the between-subjects factor,
least 30 minutes. Then, passive mobiliza- related to perceived overall experience were used to determine treatment effect
tion was applied to the cervical spine and professional impression. on outcomes at each measurement. The
using Maitlands technique for posterior
main hypothesis of interest was group
to anterior accessory movements by
Finally, cervical ROM was measured in a time interaction. The baseline score also
applying the physical therapists thumbs
sitting posture with an inclinometer was included in the calculations to con-
to the spinous process with a rhythmic
(CROM Deluxe model, Performance trol for its potential confounder over the
gentle pressure.32,33 Only slow, grade II
Attainment Associates, Lindstrom, Min- treatment effect. The between-groups
movements were performed from
nesota). The CROM consists of 2 gravity- differences were the estimated mean dif-
C0 C1 to C7T1 for approximately 1
dependent goniometers, one compass ferences in scores (with 95% confidence
minute for each cervical level. Therapeu-
dial, and a head-mounted frame allowing interval) at the 3 measurement times
tic massage was applied to the neck and
measurement of ROM in 3 planes (flex- between the 2 groups. Both unadjusted
shoulder areas as a final technique for
ion/extension, lateral flexion, rotation). and baseline-adjusted between-groups
approximately 15 minutes using almond
A magnetic yoke consisting of 2 bar mag- differences were reported, with the lat-
oil. Participants were instructed to main-

September 2016 Volume 96 Number 9 Physical Therapy f 1411

Effectiveness of Global Postural Re-education

North Carolina) at the .05 significance

level.

Results
Ninety-four patients were enrolled in the
study and randomized to a treatment
group. One patient assigned to the GPR
group dropped out before the first visit,
leaving 93 participants in our initial sam-
ple (46 in the GPR group and 47 in the
MT group; mean age47.5 years,
SD11.3; 23.7% male). Outcome mea-
surements were completed on 89 partic-
ipants (44 in the GPR group and 45 in the
MT group) at time 1, and 87 participants
(43 in the GPR group and 44 in the MT
group) were examined at time 2. No
important adverse events or side effects
happened in either intervention group.
Furthermore, according to the prelimi-
nary analyses performed at the end of
time 1, we found no evidence for the
superiority of one treatment over the
other.

Figure 3 provides a flow diagram of

participant recruitment and retention
through the study. The baseline charac-
teristics were similar between groups;
there was no evidence of a statistically
significant difference between the inter-
vention and reference groups, except for
Figure 3. TSK-2 (Tab. 1). Both groups showed
Flowchart of participants through the study. reduced cervical ROM in relation to the
normative values at baseline.

ter being our main indicator. The Best-case scenario: average ob- The between-groups effect sizes for the
between-groups effect sizes were calcu- served improvement from baseline unadjusted difference from baseline,
lated using the Cohen d statistic. An was assigned to GPR group drop- according to Cohen d values, were mod-
effect size greater than 0.8 was consid- outs, and average observed worsen- erate or large for VAS at time 1, for NDI
ered large, approximately 0.5 was con- ing was assigned to MT group and TSK at time 2 and for TSK-2, and for
sidered moderate, and less than 0.2 was dropouts. ROM flexion and extension and ROM lat-
considered small. eral flexion at both time 1 and time 2. All
Intention-to-treat analysis results were
reported as baseline-adjusted mean dif- of the remaining between-groups effect
An intention-to-treat analysis was con- sizes were less than moderate (Tab. 2).
ferences in scores (with 95% confidence
ducted to assess the effect of dropouts
interval) at each time between the 2
on the results of the baseline-adjusted
groups, according to the 2 scenarios. Time group interaction factors in
mixed models considering VAS and NDI-I baseline-adjusted mixed models were
outcomes as dependent variables. Two significant for VAS, NDI-I, TSK-2, ROM
Mean (SD) values were reported for the
scenarios were defined, based on differ- flexion and extension, and ROM lateral
PTPSQ-I, and absolute and percentage
ent imputing techniques for the missing flexion (P.0043, P.0113, P.0448,
frequencies were reported for GPR out-
scores at time 1 and time 2: P.0109, and P.0120, respectively),
comes. Differences in GPE scores were
Worst-case scenario: average ob- tested with the Fisher exact test, and according to the associated F tests. In
served improvement from baseline differences in PTPSQ-I scores were particular, baseline-adjusted differences
was assigned to MT group drop- tested with the 2-tailed Student t test. All between groups were significant for VAS
outs, and average observed worsen- analyses were performed with SAS/STAT at time 1 and for NDI-I, TSK-2, ROM flex-
ing was assigned to GPR group 9.3 software (SAS Institute Inc, Cary, ion and extension, and ROM lateral flex-
dropouts. ion at time 2 (Tab. 2). All time factors,

1412 f Physical Therapy Volume 96 Number 9 September 2016

 Effectiveness of Global Postural Re-education

Table 1. Cervical spine ROM showed very differ-

Characteristics of Participants at Baselinea ent results between groups. This finding
may be interpreted in light of other stud-
GPR Group MT Group
Characteristic (n46) (n47) P
ies regarding changes in muscular activa-
tion pattern following cervical pain.
Age (y), X (SD) 47.5 (7.9) 47.4 (13.9) .9528
Increased activity of the superficial mus-
BMI (kg/m2), X (SD) 24.9 (4.3) 24.3 (4.0) .4870 cles and decreased activity of the deep
Male sex, n (%) 11 (23.9) 11 (23.4) .9540 muscles have been observed in individu-
als with NP.40,41 Furthermore, coactiva-
Married, n (%) 32 (69.6) 27 (57.5) .2250
tion of agonists and antagonists has been
Current smoker, n (%) 14 (30.4) 17 (36.2) .5575 observed.42 We can hypothesize that
Physical activity, 23 (50.0) 24 (51.0) .9183 GPR sessions may promote a pattern of
sportsperson, n (%) muscle activation that has positive con-
Referred pain, n (%) 35 (76.1) 29 (61.7) .1343 sequences on cervical ROM43 and may
Outcomes, X (SD)
enhance the recruitment of the deep cer-
vical flexor muscles.44
VAS 47.1 (24.1) 42.0 (21.0) .2782

NDI-I 15.9 (7.0) 14.6 (5.9) .3451 Our results also may be discussed in a
TSK 30.7 (7.1) 27.8 (7.9) .0711 broader context that takes into consider-
TSK-1 12.1 (3.5) 12.0 (3.9) .8233
ation some psychosocial components of
the chronic pain. Global postural
TSK-2 18.5 (4.4) 15.8 (4.6) .0051*
re-education may be a gentle option to
ROM flexion and 84.2 (22.5) 90.7 (25.9) .1987 propose movement without pain,
extension enhance relaxation via respiratory
ROM lateral flexion 57.7 (18.1) 64.7 (19.9) .0815 rhythm, and offer a positive experience
ROM rotation 106.7 (16.9) 106.0 (17.8) .8469 of body posture modification. This
a
approach to a clinical encounter can
GPRglobal postural re-education, MTmanual therapy, BMIbody mass index, VASvisual analog
scale, NDI-INeck Disability Index (Italian version), TSKTampa Scale of Kinesiophobia, TSK-1TSK
influence not only the posture but also
activity avoidance subscale, TSK-2TSK harm subscale, ROMrange of motion. *Significantly different. the negative feelings and beliefs that are
frequently associated with chronic pain.

From a clinical point of view, GPR may

except for TSK-1 (P.0527), were statis- for both groups (eTable, available at be an interesting option to manage
tically significant (all, P.01), and all ptjournal.apta.org). No relevant differ- chronic spinal pain. This noninvasive
baseline score factors also were statisti- ences in perceived effect and satisfaction procedure is safe and can be easily inte-
cally significant (all, P.0001), accord- were found for the GPR group compared grated with home exercises. This study
ing to F tests. Nonsignificant baseline- with the MT group. showed better results on pain and dis-
adjusted between-groups differences ability following GPR procedures; never-
were found for all outcomes except VAS Discussion theless, in the absence of a control
at time 1 and for VAS, TSK, TSK-1, and The results of this study showed that group, we cannot comment about the
ROM rotation at time 2 (Tab. 2). GPR was more effective than MT for difference between any type of treat-
reducing pain and disability at 6-month ment and the natural course of NP. Epi-
In our intention-to-treat analysis, in the follow-up. Moreover, according to an demiological studies showed that close
worst-case scenario, the baseline- intention-to-treat analysis, our previous to 50% of patients will continue to have
adjusted between-groups differences in results were quite robust with respect to pain or recurrences for several months
scores were significant for VAS at time 1 missing data. A potential explanation for after the first episode44 and that treat-
(P.0260) but not for NDI-I at time 2 the better results produced by GPR is ment appears to have little effect on per-
(P.0784), whereas in best-case sce- that this procedure takes the whole sistence of NP.45 Our groups improved
nario, all between-groups effects were kinetic chain into account, whereas MT not only in the short term but also at
significant (all, P.05) (Tab. 3). More- applies only regional treatment to the mid-term follow-up, even if a decrease in
over, the range of the estimates across upper quadrant. Therefore, clinicians the magnitude of clinical improvement
the 2 scenarios and the complete-case should potentially consider postural cor- was demonstrated. Nine physical ther-
analysis were quite narrow (Tabs. 2 and rection of the entire spine and pelvis apy sessions may not have been enough
3). With respect to the subjective per- during the examination and management for management of chronic NP, and this
ception of improvement measured by of chronic NP in order to achieve the may have been the underlying reason for
the GPE questionnaire and satisfaction desired outcome with respect to pain the diminution of initial response at the
with physical therapy treatment mea- and disability. 6-month follow-up.
sured by the PTPSQ-I at time 1, satisfac-
tion, in general, appeared to be very high

September 2016 Volume 96 Number 9 Physical Therapy f 1413

1414
f
Table 2.
Mean (SD) for Outcome Measures at All Study Visits for Each Group, Mean (95% CI) Difference Between Groups, and Mean (95% CI) Difference Between Groups Adjusted for

Physical Therapy
Baseline Scorea

Effect Size for Difference Between

Difference Between Groups Adjusted for
Groups Difference Between Groups Groups Baseline Score

Volume 96
T1 Minus T2 Minus
Baseline T1 T2
T1 Minus T2 Minus T1 Minus T2 Minus Baseline/ Baseline/
Outcome GPR MT GPR MT GPR MT Baseline/GPR Baseline/GPR Baseline, Baseline, GPR Minus GPR Minus
Measure (n46) (n47) (n44) (n45) (n43) (n44) Minus MT Minus MT Cohen d Cohen d MT MT

Number 9
VAS 47.0 (24.1) 42.0 (21.0) 13.5 (13.2) 24.2 (20.6) 35.2 (23.8) 41.1 (24.7) 15.7* 11.0* 0.7 0.4 12.2* 7.5
(26.3, 5.1) (21.7, 0.3) (20.6, 3.9) (15.9, 0.9)
Effectiveness of Global Postural Re-education

NDI-I 15.9 (7.0) 14.6 (5.9) 7.8 (6.4) 9.0 (5.7) 12.9 (7.0) 15.0 (6.0) 2.4 3.3* 0.4 0.6 1.8 2.7*
(4.8, 0.1) (5.7, 0.8) (4.0, 0.3) (4.9, 0.6)

TSK 30.7 (7.1) 27.8 (7.9) 26.5 (7.4) 26.3 (5.8) 28.4 (7.6) 29.3 (6.9) 2.8 3.7* 0.4 0.5 1.3 2.3
(5.6, 0.0) (6.6, 0.9) (3.7, 1.0) (4.8, 0.0)

TSK-1 12.1 (3.5) 12.0 (3.9) 10.6 (3.6) 10.9 (3.0) 12.0 (3.9) 12.7 (3.6) 0.4 0.6 0.1 0.2 0.3 0.6
(1.9, 1.1) (2.1, 0.8) (1.6, 0.6) (1.9, 0.9)

TSK-2 18.5 (4.4) 15.8 (4.6) 15.8 (4.3) 15.3 (3.3) 16.4 (4.2) 16.7 (3.9) 2.3* 3.1* 0.6 0.8 0.9 1.6*
(4.0, 0.7) (4.8, 1.4) (2.3, 0.5) (3.0, 0.2)

ROM flexion 84.2 (22.5) 90.7 (25.9) 105.3 (22.2) 105.0 (21.1) 95 (23.1) 91.6 (24.5) 7.8* 11.6* 0.5 0.6 5.3 8.9*
and (0.5, 15.2) (4.2, 19.1) (1.2, 11.9) (2.2, 15.6)
extension

ROM lateral 57.7 (18.1) 64.7 (19.9) 72.0 (20.8) 74.0 (17.8) 63.6 (17.1) 62.4 (17.1) 6.1* 8.7* 0.5 0.7 4.0 6.8*
flexion (0.8, 11.5) (3.3, 14.2) (1.0, 9.0) (1.7, 11.8)

ROM 106.7 (16.9) 106.0 (17.8) 123.7 (18.0) 121.9 (18.1) 110.5 (18.5) 111.3 (17.0) 1.1 2.1 0.1 0.1 1.3 1.7
rotation (4.5, 6.7) (7.8, 3.6) (4.0, 6.6) (7.0, 3.6)
a
GPRglobal postural re-education, MTmanual therapy, T1time 1 (immediately postintervention), T2time 2 (6 months postintervention), CIconfidence interval, VASvisual analog scale, NDI-I
Neck Disability Index (Italian version), TSKTampa Scale of Kinesiophobia, TSK-1TSK activity avoidance subscale, TSK-2TSK harm subscale, ROMrange of motion, *Significantly different between
groups (adjusting for baseline score): P.05 (95% CI).

September 2016
 Effectiveness of Global Postural Re-education

Table 3.
Mean (95% CI), at Each Study Visit, of Principal Outcomes Difference Between Groups Adjusted for Baseline Score, According to Best-
Case and Worst-Case Scenariosa

Difference Between Groups Adjusted for Baseline Score

Best-Case Scenario Worst-Case Scenario

Outcome T1 Minus Baseline/ T2 Minus Baseline/ T1 Minus Baseline/ T2 Minus Baseline/

Measure GPR Minus MT GPR Minus MT GPR Minus MT GPR Minus MT

VAS 13.5* (22.1, 5.0) 10.3* (18.9, 1.7) 9.8* (18.4, 1.2) 4.4 (12.9, 4.2)

NDI-I 2.2* (4.4, 0.1) 3.2* (5.3, 1.1) 1.2 (3.3, 0.9) 1.9 (4.1, 0.2)
a
GPRglobal postural re-education group, MTmanual therapy group, T1time 1 (immediately postintervention), T2time 2 (6 months postintervention),
CIconfidence interval, VASvisual analog scale, NDI-INeck Disability Index (Italian version), *Significantly different between groups (adjusting for baseline
score): P.05 (95% CI).

A potential bias in this study is the fact day clinical practice, and less experi- The study was approved by the Independent
that randomization did not lead to com- enced therapists might not produce Ethics Committee in Clinical Research of the
pletely homogeneous groups; the GPR results as strong as ours. University of Bologna (53/2013/U/Sper).
group was characterized by higher level The study protocol was registered in the
of pain, disability, and kinesiophobia and The results of this study are easily gener- Clinical Trials Registry of the National Insti-
lower cervical ROM. However, even alizable in common clinical practice due tutes of Health (ClinicalTrials.gov Identifier:
after adjusting for baseline scores in the to the inexpensive interventions, equip- NCT01947231).
between-groups statistical analysis, this ment, and setting involved. Moreover, DOI: 10.2522/ptj.20150501
inequality between groups did not affect the characteristics of the participants are
our results. We also note that a critical similar to those of individuals who are
component of the GPR intervention is normally seen for physical therapy man- References
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