in their lifetimes , without accounting for special cases of major incidents , most people 
 will experience a traumatic event that threatens their life or to cause physical harm . among 
 the general population of the us
, 5090% will experience some form of traumatic event at 
 least once in their lifetimes1 .
post - traumatic stress disorder ( ptsd ) is a general anxiety disorder that occurs after 
 exposure to a traumatic event .
it was first introduced in the diagnostic and statistical 
 manual of mental disorders ( dsm ) of the american psychiatric association2 .
studies on ptsd using computed tomography 
 have reported that most ptsd patients frontal and temporal lobes , which control emotions , 
 fear , and problem solving skills , are severely damaged .
the positive effects of exercise as a form of physical therapy on symptoms of ptsd are 
 currently being studied .
diaz and motta3 
 showed that in 91% of child subjects , the symptoms of ptsd decreased significantly after a 
 walking exercise .
manger et al.4 found 
 that aerobic exercise reduced ptsd symptoms in a group of adults , while newman et al.5 showed that after 8 weeks of aerobic 
 exercise , children with ptsd showed a significant decrease in ptsd symptoms , depression , and 
 anxiety after exercise , despite little decrease in symptoms in the early days of the 
 intervention .
kim et al.6 reported that 
 after 8 weeks of meditation and respiration exercise , ptsd checklist scores decreased 
 significantly while cortisol levels increased .
the treatment of ptsd has so far been limited to drug therapy and psychotherapy ( e.g. , 
 cognitive behavioral therapy ) .
the physical symptoms are treated by respiration , meditation , 
 and relaxation exercises . however , among studies on the psychological and social problems 
 associated with ptsd , such as depression and anxiety , studies on problems of the neck  which 
 is the most common musculoskeletal problem in people with ptsd  is lacking . direct contact 
 with a person who has experienced traumatic events
has its limits and can cause subjects to 
 feel external pressure or resistance . to compensate for these disadvantages , in this study , 
 we present a treatment that relies on the sling system .
this study aimed to investigate the impact of six weeks of a neck exercise intervention on 
 neck pain levels , upper trapezius pressure threshold , and depression in patients with ptsd 
 and neck pain .
this study targeted 31 patients living in g city who had neck pain and a diagnosis of ptsd . 

patients who understood our description of the study and could answer the questionnaire were 
 selected . to participate
, subjects had to give their written consent to participate in the 
 study with their own hand .
this study was approved by the center , and all the participants 
 provided their written informed consent . the specific criteria for selecting subjects are as 
 follows .
first , according to the diagnostic criteria of the dsm - iv , subjects had to have 
 more than a certain number of the three major symptoms of ptsd  re - experiencing , avoidance , 
 and arousal  lasting for at least a month .
second , subjects had to have neck pain for more 
 than 3 months and a neck dysfunction index of lower than 15 .
the study was performed using a 
 pre - posttest control group design . in the t center located in g city , 31 subjects who met 
 the selection and exclusion criteria for neck pain among patients diagnosed with ptsd ( n = 
 58 ) were selected . using a coin toss ,
subjects were divided randomly into the neck exercise 
 group ( experimental group ) and neck self - exercise group ( control group ) .
neck exercise 
 training using a sling system was used for the experimental group whereas a neck movement 
 self - exercise ( specifically , a modification of the mckenzie exercise ) was used for the 
 control group .
we checked in with both groups weekly to determine whether they had performed 
 the exercises .
both groups performed their exercise for 35 minutes at a time , 3 times per 
 week .
the total intervention period was 6 weeks . to compare the effects of the exercises , 

the threshold of neck tenderness and depression were measured before and after the 
 intervention and at a follow - up .
the neck exercise of the experimental group involved the sling system presented by 
 kirkesola7 .
the warm - up before the 
 exercise for the experimental group was 10 minutes of treadmill running and stretching 
 ( stretching was also performed after the exercise as a cool - down ) .
first , in the main 
 exercise , subjects , while supine , actively move to the left and right while an inelastic 
 band holds their heads in a neutral position .
second , subjects performed a 
 curvature - extension of the neck : while supine , they hold their head in a neutral position 
 and slowly extend it using the elastic band until they are bent into a lying down position . 

third , subjects performed an extensional movement : while supine , they hook the sling to the 
 back of the skull using the inelastic band and pull the jaw , holding this for 30 seconds . 

fourth was a neck stabilization exercise : with the elastic band , subjects hook the sling to 
 the pelvis and shoulders from the knee - high , and with the inelastic band , they hook the 
 sling to their occipital bones and pull the jaw forwards , after which they hold this 
 position .
the first movement was performed for 5 to 10 minutes and the second movement was 
 performed repeatedly 15 times in 3 sets ( each set involved holding the position for 30 
 seconds and resting for 10 seconds ) .
the third and fourth movements were performed in 3 sets 
 ( each set involved holding the position for 30 seconds and resting for 10 seconds ) .
all of 
 the interventions were performed 3 times per week for a total of 6 weeks .
the control group 
 was educated on neck self - exercise using mckenzie exercise therapy8 . during the education , verbal explanations and 
 demonstrations by the therapist
were provided along with handouts . in this study , to evaluate the threshold of upper trapezius pressure and joint working 
 range , we used an algometer . to evaluate the degree of depression
each measurement and evaluation was performed a total of three 
 times : before the intervention , just after the intervention ( 6 weeks from the start ) , and 12 
 weeks of the intervention .
to compare the changes in neck pain between two groups over the measurement period , we 
 compared the pain threshold of each group .
the pain threshold of the left trapezius showed a significant difference between two groups 
 at the three measurement points .
it increased by 19.7% in the experimental group after the 
 intervention compared to before the intervention . at follow - up , it had increased by 20.0% in 
 the experimental group ( p < 0.05 ) compared to before the intervention . in the control 
 group , it increased by 6.59% after the intervention compared to before it , while at 
 follow - up , it had increased by 6.5% compared to before .
accordingly , the interaction between 
 group and measurement time was significant ( f = 4.1 , p < 0.01 ) .
the pain threshold of the 
 right trapezius showed significant differences across the three measurements between the 
 groups . in the experimental group , the pain threshold increased by 18.35%
after the 
 intervention compared to before it , and at follow - up , it had increased by 15.9% ( p < 
 0.05 ) compared to before the intervention . in the control group , pain threshold increased by 
 2.6% after the intervention compared to before it , while at follow - up , it had only increased 
 by 1.74% .
accordingly , the interaction between group and measurement time was significant ( f 
 = 7.1 , p < 0.01 ) . to compare the changes in depression level over the measurement period between two groups , 
 we compared the hopkins symptom checklist scores between the groups across the measurement 
 period .
it decreased by 18.0% after the intervention compared to before it , and 
 decreased by 15.2% at follow - up compared to before the intervention . in the control group , 
 depression level
decreased by 2.3% after the intervention compared to before it , and at 
 follow - up , it increased by 3.0% compared to before the intervention .
accordingly , the 
 interaction between group and measurement time in depression level was significant ( f = 
 23.5 , p < 0.01 ) ( table 1table 1.changes in the pressure threshold of the trapezius muscle and depression between 
 the experimental and control groups before and after intervention and at 
 follow - upexperimental groupcontrol grouppressure threshold ( kg / cm)depression(score)pressure threshold ( kg / cm)depression(score)leftrightleftrightbefore3.0  0.4 3.2  0.252.1  4.83.1  0.43.3  0.253.3  8.1after3.6  0.43.7  0.542.8  7.53.2  0.63.4  0.352.0  8.5follow - up3.6  0.3**3.7  0.744.3  6.8**3.2  0.63.4  0.351.6  7.7rate of change 119.7  12.618.3  13.618.0  9.96.5  23.62.6  8.02.3  5.5rate of change 220.0  12.215.9  22.215.2  8.26.3  23.71.7
 4.53.0  5.5neck exercise training group , self - exercise training group , 
 mean  standard deviation .
there is a significant difference between the 
 three times : * p < 0.05 , * * p < 0.01 .
there is a significant difference between 
 the two groups , p < 0.05 , p < 0.01 . rate of change 1 : 
 the rate of change between before and after the intervention . rate of change 2 : the 
 rate of change between before the intervention and follow - up . ) . neck exercise training group , self - exercise training group , 
 mean  standard deviation .
there is a significant difference between the 
 three times : * p < 0.05 , * * p < 0.01 .
there is a significant difference between 
 the two groups , p < 0.05 , p < 0.01 . rate of change 1 : 
 the rate of change between before and after the intervention . rate of change 2 : the 
 rate of change between before the intervention and follow - up .
this study was performed to investigate the impact of a neck musculoskeletal intervention 
 on the neck pain and depression levels of patients with ptsd and to identify the utility of 
 this intervention for clinical practice .
the results indicated significant differences in pain threshold on both sides of the upper 
 trapezius muscle and in depression level across the measurement period for subjects with 
 ptsd who had undergone an exercise intervention with the sling system .
it has been reported that people who have neck pain have poor neck strength and 
 endurance10 .
for these people , use of a 
 neck exercise therapy has been reported to increase neck strength and decrease pain11 .
lee et al.13 investigated the measurement of the 
 threshold of the upper trapezius muscle between a trapezius asymmetric group and a symmetric 
 group .
the results indicated that the asymmetric group s right and left trapezius threshold 
 values were 3.27  0.8  kg / cm and 2.90  1.1  kg / cm , respectively . in 
 contrast , the symmetric group s right and left thresholds were 4.68  1.3  kg / cm 
 and 4.41  1.2  kg / cm , respectively ; these latter numbers are similar to what was 
 found in the present study . the subjects of this study differed from people with neck pain alone , as they had neck pain 
 with psychological problems .
ptsd is caused by traumatic events and can damage the same 
 muscles treated in physical therapy for whiplash injury .
ursano et al.14 compared the incidence of chronic and acute ptsd between a 
 group severely injured by car accidents and a group injured by other traumatic events on the 
 basis of disability for 3 months .
the results indicated that ptsd incidence increases in 
 subjects with a history of the disorder .
mishaels et al.15 performed psychological evaluations on 35 people hospitalized due 
 to a car accident both one month and 5 months after the accident . in less than a month ,
34% 
 of subjects had been diagnosed with acute ptsd ; after 5 months , 38% had been diagnosed with 
 chronic ptsd .
it has been reported that subjects who have suffered a trauma experience 
 symptoms related to depression such as fear , anxiety , depressed mood , lethargy , 
 hopelessness , and feelings of self - deprecation16 .
sabin et al.17 
 reported that for at least 46 months after a trauma , 11% of the 30% of the sample who 
 showed ptsd symptoms had high levels of depressive symptoms
. additionally , in agaibi and 
 wilson s study18 , higher levels of ptsd 
 after a trauma were associated with more severe symptoms of depression .
however , in the 
 study by bryant et al.19 , there was no 
 relationship between level of impairment and depression .
ptsd and anxiety symptoms , however , 
 were reported to be associated . among those who had experienced trauma and who had been 
 diagnosed with ptsd ,
higher percentages of neck pain have been reported among 
 people with psychological problems22 . 

people who have neck pain can experience discomfort and restrictions in daily life and 
 develop further psychological problems8 .
this study has important implications for therapeutic strategies , given that it describes 
 an intervention that can improve symptoms of neck pain in subjects who have psychological 
 problems such as ptsd .
furthermore , it provides preliminary results for a specific 
 intervention for psychological problems and musculoskeletal pain , which has recently been 
 studied .
 [ purpose ] to identify the effects of a neck intervention on neck pain and depression in 
 patients with post - traumatic stress disorder ( ptsd ) . 
 [ subjects ] thirty - one patients with 
 neck pain and a diagnosis of ptsd were enrolled . [ methods ] 
 neck exercise training was 
 performed with the experimental group and neck self - exercise ( using a modification of the 
 mckenzie exercise ) was used with the control group . 
 both groups performed their exercises 
 for 30 minutes at a time , three times per week . to compare the effects of the 
 interventions , 
 the threshold of neck tenderness and depression levels were measured at 
 each period . [ results ] 
 the pain threshold of both sides of the trapezius showed a 
 significant difference between the two groups at the three measurement periods . in the 
 experimental group , 
 the threshold increased by 19.7% on the left and 18.3% on the right 
 after the intervention compared to before . 
 depression levels significantly differed in the 
 experimental group between the three measurements . 
 [ conclusion ] this study has important 
 implications for therapeutic strategies , as it provides strong evidence for a method of 
 improving symptoms of neck pain ; furthermore , it is effective for subjects with 
 psychological problems such as ptsd . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION