RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
KARNATAKA, BANGALORE
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1) NAME AND ADDRESS OF THE SANJEEV KUMAR NAYAK
CANDIDATE : Department of Physiotherapy
M.S Ramaiah Medical College
M.S.R.I.T Post, Bangalore-54
2) NAME OF THE INSTITUTION: Department of physiotherapy
M.S Ramaiah Medical College
3) COURSE OF STUDY AND Master of physiotherapy
SUBJECT: (Musculoskeletal and
Sports Disorders)
4) DATE OF ADMISSION TO
COURSE: 2nd July 2012
5) TITLE OF THE STUDY: “COMBINED EFFECT OF
MYOFASCIAL RELEASE AND
MUSCLE ENERGY TECHNIQUE
ON UPPER TRAPEZIUS TRIGGER
POINT IN SUBJECTS WITH
MECHANICAL NECK PAIN”
6. BRIEF RESUME OF INTENDED WORK
6.1. NEED FOR THE STUDY
Mechanical Neck pain (MNP) is one among the commonest problems seen in the musculoskeletal practice. MNP has a lifetime incidence of 37% in general world population. Pathophysiology of MNP is attributed to myofascial disorder and cervical joint dysfunction.1
Trigger points are defined as hyperirritable spots within taut bands of skeletal muscle fibers. They exhibit a local twitch response (muscle fasciculation) or jump sign (whole body movement) in response to pressure applied by therapist’s thumb or dry needling. The spots are painful on compression and can produce referred pain, referred tenderness, motor dysfunction and autonomic phenomena.2
Trigger points can be categorized as either active or latent. An active myofascial trigger point is defined as “A Myofascial trigger point that causes pain and is always tender, prevents full lengthening of the muscle, weakens the muscle, patient recognizes pain on direct compression, mediates a local twitch response of the muscle fibers when adequately stimulated and when compressed within the patients pain tolerance produces referred motor phenomena and often autonomic phenomena generally in its pain reference zone and causes tenderness in the pain reference zone”.
The term ‘Myo’ means “Relating to muscle”. Fascia is a sheet or band of fibrous connective tissue separating or binding together muscles and organs. Myofascial release (MFR) is promoted to restore flexibility and relieve pain. Poor posture, injury, illness or stress can negatively affect the body’s alignment and cause fascia to become restricted. This restriction leads to pain and impaired movement .Myofascial release practitioner uses variety of technique like “Cross-Hand” stretches, focused stretches, Skin rolling, wind-mill or J-stretches, fascial glide. This helps to align fascia layers in their direction of ease and causes a tender point release. Myofascial release consists of gentle form of stretching and manual compression to connective tissue and releasing bond between fascia and the muscle. This is usually done by applying shear, compression or tension in various directions or by skin rolling.3
Muscle energy technique is an established osteopathic manipulative intervention often used to treat somatic dysfunctions of the spine. It is a revolution in manipulative therapy involving a movement away from high velocity low amplitude thrusts. This approach is a soft tissue primarily; it also makes a major contribution towards joint mobilisation.4, 5
Many treatment approaches can be used to treat myofascial pain syndrome, often a combination is necessary to obtain pain relief and full functional recovery. Commonly used treatment techniques are stretch and spray, trigger point injections, massage therapy, exercise, electrical muscle stimulation (EMS) using interferential current (IFC), electrical nerve stimulation (ENS) or high frequency transcutaneous electrical nerve stimulation (TENS), Ultrasound and EMG biofeedback.6
There is evidence to prove that muscle energy technique (MET) over upper trapezius muscle is effective in relieving myofascial pain and improving functional ability of neck in patients with myofascial pain syndrome7 and cervical mobilization is also effective. MET alone is effective on upper trapezius trigger point in relieving pain and MFR along with conventional therapy is effective in upper trapezius trigger point.8
Since, there is lack of evidence as the effect of MFR alone on upper trapezius trigger point and combined effect of MFR and MET on upper trapezius trigger point. Therefore, this study is undertaken to find out effect of MFR alone and combined effect of MFR and MET on upper trapezius trigger point in relieving pain and improving range of motion in individuals with mechanical neck pain.
NULL HYPOTHESIS:
There will be no difference between combination of MFR and MET and MFR alone on pain and range of motion in upper trapezius trigger point in individual with mechanical neck pain.
RESEARCH HYPOTHESIS:
There will be a difference between combination of MFR and MET and MFR alone on pain and range of motion in upper trapezius trigger point in individual with mechanical neck pain.
6.2 REVIEW OF LITERATURE
A study conducted by Amit V Nagrale et al on the efficacy of an integrated neuromuscular inhibition technique (INIT) on upper trapezius trigger points in subjects with non-specific neck pain. They compared the effects of MET and INIT on individuals having myofascial pain syndrome over upper trapezius. It was concluded that the integrated neuromuscular inhibition technique had better effect than muscle energy technique.9
A clinical literature reviewed by Simons DG concerning prevalence; diagnostic criteria and treatment of myofascial trigger point (MTrPs). The findings of the study is , prevalence of myofascial trigger points in patients complaining of pain ranged from 30%- 93%, among this 55% were with craniofascial pain. The study identified two differing hypothesis for the basis of trigger point 1.Dysfunctional muscle spindle. 2. Dysfunctional extrafusal neuromuscular junction. The study also concluded from the review of electrophysiological investigations that dysfunctional extrafusal motor end plates to play a key role in pathophysiology trigger points.10
Chaitow L.et al advocates MET as a useful means of treatment for trigger points. He pointed out that Post Isometric Relaxation Technique (PIR) have fairly, conclusively demonstrated the efficiency & state that Post Isometric Relaxation Technique abolished trigger point in muscle, increased the length of shortened muscles, relieved tenderness and pain.11
Chuen -Ru Hou et al investigated the immediate effects of physical therapeutic modalities on myofascial pain in upper trapezius muscle by Randomized Controlled Trial, they concluded that Spray and Stretch technique with active ROM plus hot packs was effective for easing MTrPs pain and increasing cervical ROM.12
An experimental study conducted by Lewit. K, et al on 70 patients with myofascial pain syndrome .The purpose of the study was to find out the effectiveness of muscle energy technique on myofascial pain syndrome. The result of the study showed significant reduction of pain in myofascial pain syndrome following the application of muscle energy technique.13
Lewit K & Simons.D.G studied the effects of PIR, they observed 244 subjects on immediate pain relief and lasting pain relief and the result showed significant improvement in pain scores. They stated that PIR is useful in addition to or in place of local anaesthetic injection or dry needling. They confirmed the other observation that increased tension of the affected muscles and the resulting pain and dysfunction are both relieved by restoring the full stretch length of muscle.14
A study conducted by Viswas Rajadurai to assess the effectiveness of muscle energy technique on temporomandibular joint dysfunction. The study included 40 patients between 20-30 years diagnosed with temporomandibular dysfunction of less than 3 months duration. Participants were treated with MET, which included post isometric relaxation and reciprocal inhibition given on alternate days for 5 weeks. The subjects were evaluated for pain and maximal mouth opening. The study concluded that MET is effective in reducing pain and improving maximal mouth opening in patients with temporomandibular joint dysfunction.15
An experimental study conducted by Herald Brodin, et. al on 41 subjects with myofascial pain syndrome. The purpose of the study was to find out the effectiveness of muscle energy technique in patients with myofascial pain syndrome over periscapular muscles. The treatment duration was 3 weeks. There was a significant reduction in pain and improvement of range of motion of cervical spine.16
6.3 OBJECTIVES OF THE STUDY:
· To determine the effect of MFR in reducing pain and improving cervical range of motion in upper trapezius trigger point in individual with mechanical neck pain.
· To determine the combined effect of MFR and MET in reducing pain and improving cervical range of motion in upper trapezius trigger point in individual with mechanical neck pain.
· To compare the combined effects of MET and MFR with MFR alone in upper trapezius trigger point in individual with mechanical neck pain
7. MATERIALS AND METHOD
7.1 SOURCES OF COLLECTION OF DATA: Physiotherapy Out Patient Department, M.S.Ramaiah Hospitals, Bangalore
7.2 METHODS OF COLLECTION OF DATA
Methods of Sampling : Purposive sampling
Type of the Study : Interventional study
Proposed Sample Size : 62 (31 in each group)
PROCEDURE OF DATA COLLECTION:
An ethical clearance will be obtained from the ethical committee of M.S. Ramaiah Medical college. The Purpose of the study will be explained and an informed consent will be obtained from the subjects. A total of 62 subjects diagnosed with mechanical neck pain over upper trapezius muscle will be selected based on inclusion and exclusion criteria. They will be randomly allocated to 2 groups as group A and group B, each consists of 31 subjects.
Evaluation of pain intensity with visual analogue scale and pain pressure threshold and cervical range of motion using gravity inclinometer will be taken on the subjects.
Subjects in group A will be subjected to myofascial release over upper trapezius muscle. Patient will be sitting on a chair with back support, forearm supported on the arm rest of chair and feet touching the ground. A Longitudinal stretch is applied along the sufficient stretch to hold the tissue at its end range for at least 40-50 seconds and will be repeated for 3 times.
Subjects in group B will be subjected to myofascial release with muscle energy technique over upper trapezius. Myofascial release will be applied on the patient (procedure same as above) .Ten minutes after application of myofascial release, the muscle energy technique will be applied. The patient will be positioned in supine lying with head flexed, rotated towards and laterally flexed away from the stretch. The patient’s head will be stabilised with one hand and the other hand will be placed on the patients shoulder. Patient will be instructed to elevate the shoulder towards the ear at the same time therapist will give equal and opposite resistance on the same side of elevation and hold it for 10 seconds. Patient will be asked to relax. Following that, patient’s head will be moved to the new resistance barrier. This will be repeated for 4-5 times.
Visual analogue scale, pain pressure threshold and cervical range of motion will be taken post-treatment and the results will be compared to that of pre treatment.
INCLUSION CRITERIA:
1. Individuals of age group between 18-45 years
2. Mechanical neck pain diagnosed as per Schalkwyk and Smith diagnostic criteria.
3. Individual diagnosed to have active upper trapezius trigger point under Simon’s diagnostic criteria.
4. Minimum pain of 4 on VAS.
5. Pain pressure threshold less than 3 kg/cm2
EXCLUSION CRITERIA:
1. Symptoms of fibromyalgia syndrome.
2. History of whiplash injury.
3. History of cervical spine surgery.
4. Diagnosis of cervical radiculopathy/myelopathy.
5. Malignancy
6. Infections
STATISTICAL METHOD:
Descriptive statistics like mean, standard deviation etc. will be computed for quantitative variables like age, lateral flexion etc. All qualitative variables will be expressed in terms of proportion.
Independent T-test/Mann – Whitney would be used to compare the mean values of lateral flexion, pain pressure threshold in between the control group and experimental group.
MATERIALS REQUIRED:
1. Measuring tape
2. Pressure Algometer (Wagner Inc. , USA)
3. Gravity Inclinometer (Dayton Tech Inc. , USA)
4. VAS scale
5. Fabric marker
7.3 Does the study require any investigations or interventions to be conducted on the patients or other humans or animals?
Yes.
7.4. Has ethical clearance been obtained from the institution in case of 7.3?
Yes.
8) LIST OF REFERENCES:
1. Ssavedra-Hernandez M, Castro-Sanchez A M, Fernandez-de- las penas C, Cleland J A, Ortega-Santiago R, Manuel Arroyo-Morales M. Predictors for identifying patients with mechanical neck pain who are likely to achieve short term success with manipulative interventions directed at the cervical and thoracic spine. Journal of manipulative and physiological therapeutics. 2011; 34(1):144-152.
2. Barens J. Myofascial release: The search for excellence, paoli; rehabilitation services;1990.
3. Simons DG, Travell JG, Simons IS. Travell and Simons’ myofascial pain and dysfunction: the trigger point manual: Vol 1, Upper half of body, Second edition. Baltimore, Maryland: Williams and Wilkins.2vols.ISBN0-683-08366-X; 1999.
4. Chaitow L, Liebenson C. Muscle energy technique. 2nd Ed. New York: Churchill Livingstone.1996; P: 50-2, 125-9.
5. Daul RJ. Specific manual physical therapy technique;2007: 1-2
6. Esenyel M. Treatment of myofascial pain. American journal of physical medicine and rehabilitation.2000, January- February; volume 79(1): 48-52.
7. PP Mohanty et al. Muscle energy technique in myofascial trigger point treatment; A randomized trial. The Journal of the Indian association of Physiotherapists.2006; Volume 2, Issue: 1.
8. Veeliming. Effectiveness of MFR and US for upper trapezius trigger point. 1999;11: 212-32.
9. Amit V Nagrale, Paul Glynn, Aakanksha Joshi, and Gopichand Ramteke. The efficacy of an integrated neuromuscular inhibition technique on upper trapezius trigger points in subjects with non-specific neck pain: a randomized controlled trial, Journal of Manual & Manipulative Therapy.2010; Volume 18, Number 1, (7): 37-43.
10. Simons DG. Review of enigmatic MTrPs as a common cause of enigmatic musculoskeletal pain and dysfunction. J Electro Kinesiol. 2004; 14:95-107.
11. Chaitow L, Judith, W D. Clinical application of neuromuscular technique. The Upper Body. Churchill Livingstone;2001, vol-1.
12. Chuen-Ru Hou et al. Immediate effects of various Physical Therapeutic modalities on cervical Myofascial pain and trigger point sensitivity.Journal of Arch Phys Med Rehabil. 2002; 83:1406-1414.
13. Lewit K. Myofascial pain: relief by post-isometric relaxation. Journal of Arch Phys Med Rehabil.1984; 65(8):452-6.
14. Lewit K, Simons.D G. Myofascial pain: relief muscle energy technique, Archives of physical medicine rehabilitation.1999; volume 65: 452-456.
15. Viswas Rajadurai. The effect of muscle energy technique on temporomandibular joint dysfunction: a randomized clinical trail. Asian journal of scientific research. 2011;vol 4: 71-77.