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ORIGINAL ARTICLE
Year : 2018  |  Volume : 9  |  Issue : 1  |  Page : 1-6

Efficacy of integrated neuromuscular inhibition technique in improving cervical function by reducing the trigger points on upper trapezius muscle: A randomized controlled trial


Department of Physiotherapy, Institute of Applied Medical and Research, Ghaziabad, Uttar Pradesh, India

Date of Web Publication24-Jan-2018

Correspondence Address:
Dr. Shagun Aggarwal
Department of Physiotherapy, Institute of Applied Medical and Research, Duhai, Ghaziabad - 201 206, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjmsr.mjmsr_40_17

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  Abstract 

Background: The efficacy of ischemic compression, strain/counterstrain, and muscle energy techniques were supported by literatures to relieve myofascial trigger points. However, no high-level research is available regarding the integrated neuromuscular inhibition technique (INIT). Objective: To document the efficacy of INIT in improving cervical function by reducing the trigger points on upper trapezius muscle over the traditional approach. Methods: Thirty adults in the age group of 18–35 years diagnosed with mechanical neck pain with upper trapezius trigger point were selected by the simple random sampling for two group pretest-posttest design. They were allocated randomly into two equal groups, Group A and Group B, respectively. Group A received hydrocollator pack, INIT, neck strengthening exercises, scapular stabilization exercises, shoulder stabilization exercises, postural correction, and ergonomic advice while Group B received the same treatment except INIT. They were treated for six sessions on alternate days for 2 weeks. Visual analog scale, neck disability index, and tenderness grading scale were noted at baseline, 3rd session, and 6th session after the above treatment on both the groups and analyzed. Results: In all the outcome measures, Group A showed significant (P < 0.05) improvement when compared to Group B. Conclusion: There is a sufficient evidence to prove the efficacy of INIT in improving cervical function by reducing the trigger points on upper trapezius muscle

Keywords: Inhibition technique, myofascial trigger point, neck pain, trapezius


How to cite this article:
Aggarwal S, Bansal G. Efficacy of integrated neuromuscular inhibition technique in improving cervical function by reducing the trigger points on upper trapezius muscle: A randomized controlled trial. Muller J Med Sci Res 2018;9:1-6

How to cite this URL:
Aggarwal S, Bansal G. Efficacy of integrated neuromuscular inhibition technique in improving cervical function by reducing the trigger points on upper trapezius muscle: A randomized controlled trial. Muller J Med Sci Res [serial online] 2018 [cited 2018 Dec 12];9:1-6. Available from: http://www.mjmsr.net/text.asp?2018/9/1/1/223911


  Introduction Top


The trapezius pain is the classic stress pain of the neck and upper back, and it is the most common type musculoskeletal disorder. Although the trapezius was designed as postural muscle, it is highly susceptible for overuse. The tighten muscle can reduce the cervical range of motion (ROM) thereby affects the mobility of cervical joints, which increases the tightness of other soft tissue, with an ensuing pain-spasm cycle which is difficult to break and may result in myofascial trigger points (MTPs).[1]

There are two types of MTPs which may present in trapezius, one is at the middle portion of the anterior border of the upper portion of trapezius and involves the vertical fibers. It is the major source of tension neck ache. Its referral area is unilaterally upward along the posterolateral aspect of the neck to the mastoid process, side of the head, centring in the back of the orbit, including the angle of the jaw (masseter area), occiput, lower molar teeth and in the pinna, but not deep in the ear. Another is at the middle of horizontal fibers of the upper trapezius. Its reference area lies slightly posterior to the cervical reference area which causes neck pain, without headache. Circulatory disturbances secondary to increased intramuscular pressure, low-level muscle contractions, eccentric and submaximal (concentric) contractions, and postural stress may result in MTP.[2]

Three minimum clinical diagnostic criteria have been proposed to diagnose MTP which are taut band (TB), spot tenderness (SP), and referred pain (RP) sensation with mechanical stimulation of the SP. An additional six confirmatory features include local twitch response with snapping palpation of the TB, jump sign, patient recognition of the elicited pain, predicted RP patterns,muscles weakness or muscle tightness, and pain with stretching or contraction of the affected muscle.[3] Ischemic compression (IC), strain/counterstrain (SCS), and muscle energy techniques (METs) are most commonly used technique to treat MTP.[4],[5] Another method to relieve MTP is integrated neuromuscular inhibition technique (INIT). This is the combination of MET, IC, and SCS which allows for delivery of the techniques in a single coordinated manner.

The present study aimed to determine the efficacy of INIT and neck strengthening exercises (NSE), scapular stabilization exercises (ScSE), shoulder stabilization exercises (ShSE), postural correction, and ergonomic advice in improving cervical function by reducing MTP on upper trapezius muscle.


  Methods Top


The study protocol was approved by the institution research and ethics committee and strictly bound to the guidelines of Helsinki Declaration, revised 2013. 56 adults from age group of 18–35 years working with multinational company, engineering, procurement and construction, and business process outsourcing were screened by the simple random sampling method for the presence of mechanical neck pain (MNP) with upper trapezius trigger point. Adults with neuromuscular entrapment or compression syndrome of cervical spine or shoulder origin and those who were receiving treatments such as vapocoolants, dry needling, acupuncture, analgesics, and nonsteroidal anti-inflammatory drugs were excluded from the study. They have been recruited if they have reported neck disability index (NDI) <20% and pain in visual analog scale (VAS) below 70 mm in 100 mm scale. By this, 12 adults have been excluded from the study, and in addition, two adults were excluded for other reasons. Written informed consent was obtained from all the participating adults. Twelve adults who have declined to provide written informed consent were also excluded from the study. Thus, 30 adults with MNP lasting more than 2 weeks' duration were recruited finally to participate in this study with two group pretest–posttest designs. They were allocated randomly into two equal groups, Group A and Group B, respectively. Group A receives hydrocollator pack, INIT, NSE, ScSE, ShSE, postural correction, and ergonomic advice and Group B also receives the same treatment except INIT. Along with demographic and anthropocentric data, baseline NDI, VAS, and tenderness grading scale (TGS) were noted. The diagrammatic representation of the study is portrayed in [Figure 1].
Figure 1: CONSORT diagram describing the study flow

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The INIT protocol consisted of three techniques that were performed in coordinated passion. At first, IC was done by using a pincer grip over the active trigger point till the tissue barrier was felt, [Figure 2]. The process was repeated till the tension reduced for 90 s. Followed by that, SCS was applied, which involved identification of trigger point and applying further pressure till the production of nociceptive response. The pressure maintained for 20–30 s and slowly returned to neutral and repeated 3–5 times. Adults with MNP position were positioned in supine and turned their head and neck laterally toward the MTP side to lessen the pain.
Figure 2: Ischemic compression for trapezius myofascial trigger point

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MET was applied as last part of INIT in the supine position with the arm on the side to be treated in line with trunk with head and neck bent laterally to the opposite side (nontreating side), flexed, and rotated to the MTP side and the therapist stabilized the shoulder with one hand and covered the ear area of MTP side by the other hand. Then, the adult with MNP was asked to shrug the involved shoulder toward ear at submaximal and pain-free effort (20% of the available strength) and held for 7–10 s with normal breathing rhythm for five repetitions. During the relaxation, the head and neck was moved into lateral flexion to opposite side with flexion and rotation to MTP side as the shoulder was stretched caudally to advance the stretch, [Figure 3].
Figure 3: Muscle energy technique for trapezius muscle

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The NSE included the isometric strengthening of neck and head lift in prone and supine position. The ScSE consisted of shoulder blade squeeze, shoulder blade shrug, and shoulder blade forward against the wall. The adult with MNP was treated for 6 sessions on alternate days for 2 weeks. VAS, NDI, and TGS were recorded at baseline, 3rd session, and 6th session after the above treatment on both the groups and analyzed.

Data analysis

The normality of the collected data was analyzed using Shapiro–Wilk test of normality. As demographic data and all the outcome measure fit to be considered under normal distribution, parametric tests were used for analysis. Hence, the demographic characteristics of the two groups, Group A and Group B follow normal distribution; we express the descriptive statistics in mean and standard deviation and compared with independent t-test for statistical significance. The outcome measures were compared using paired t-test to describe between the session differences. While independent t-test was for between the group comparisons. All the analyses were performed using IBM SPSS version 22.0 (IBM Corp., Armonk, NY, USA) and the prior level of significance was set at P ≤ 0.05 to minimize Type I error.


  Results Top


Thirty adults diagnosed with MNP with upper trapezius trigger point had participated in this study. Among them, 18 were males and 12 were females. The demographic characteristics were elaborated in [Table 1]. There exists no significant difference between the two groups. Between the session and group comparison at before, 3rd session, and 6th session for the outcome measures, VAS [Figure 4], NDI [Figure 5], TGS [Figure 6], neck flexion [Figure 7], neck extension [Figure 8], neck lateral flexion [Figure 9], and neck rotation [Figure 10] were displayed. In all the outcome measures, Group A shows significant (P< 0.05) improvement when compared to Group B.
Figure 4: Mean visual analog score at baseline, end of 3rd session, and end of 6th session between Group A and Group B

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Figure 5: Mean neck disability index score at baseline, end of 3rd session, and end of 6th session between Group A and Group B

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Figure 6: Mean tenderness grading scale score at baseline, end of 3rd session, and end of 6th session between Group A and Group B

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Figure 7: Mean cervical flexion at baseline, end of 3rd session, and end of 6th session between Group A and Group B

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Figure 8: Mean cervical extension range of motion at baseline, end of 3rd session, and end of 6th session between Group A and Group B

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Figure 9: Mean cervical lateral flexion range of motion at baseline, end of 3rd session, and end of 6th session between Group A and Group B

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{Figure 10}
Table 1: Demographic characteristic of the subjects recruited in group A and group B

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  Discussion Top


The study was done with the aim to compare the effect of INIT and stabilization exercise in patients with upper trapezius trigger points. Patients who were taking medication were not selected. The pain was the most common factor in all the patients. The pain was the main factor and is common in the patients having trigger points. Trigger points in the upper trapezius occur due to continuous overload and microtrauma as it has minimal antigravity function. Pathogenesis results from the overloading and injury of muscle tissue leading to involuntary shortening of localized fibers. The areas of stressed soft tissue receive less oxygen, glucose, and nutrient delivery and subsequently accumulate high levels of metabolic waste products. The end of this cascade of events results in altered tissue status, pain, and the development of TrPs.[3]

The mean of VAS score in Group A and Group B at the baseline was 5.87 and 5.80, respectively. After the treatment, VAS score showed significant improvement in Group A in comparison with Group B after the treatment, at the end of 3rd session, and at the end of 6th session. Improvement in Group B was also observed. In support of our study for Group B, one of the previous studies demonstrated that combination of hot pack in addition to active ROM and stretch with spray, hot pack plus active ROM and stretch with spray and TENS, and hot pack plus active ROM and interferential current and myofascial release technique are most effective for easing MTrP pain.[6] We have also used the heat therapy as a part of conventional therapy in both groups. Pain relief from thermotherapy may result from relief of muscle spasm as a consequence of reduced activity of (Group B) afferent fibers and increased activity of primary (Group A) afferent fibers, from a reduction of painful inflammatory reactions as a consequence of increased blood flow or from the counterirritant effects of a remote reflex phenomenon or an endorphin-related mechanism. The effect of active ROM exercise involves moving the joints into various positions and gently stretching the muscle to maintain the freedom of joint movement by releasing the TB. The release of TBs is essential to break the cycle that induces the ischemic contractions in the TB that perpetuate myofascial pain syndrome.

Another study using the IC therapy with quantified pressure and duration found that it provided immediate pain relief and reduced the MTrP sensitivity of the cervical myofascial pain.[6],[7],[8] Our results are also in agreement with previously published trial, which proved to have significantly greater improvement in VAS score in favor of the INIT group at the 4-week follow-up points. They have compared the effects of two manual treatment regimens (MET and INIT) on individuals with upper trapezius trigger points.[1] Pain relief through IC treatment was achieved from reactive hyperemia in the MTPt region, counterirritant effects, and a spinal reflex mechanism for the relief of muscle spasm. The pain reduction may be due to the stimulation of mechanoreceptors which has influence on pain gate during the application of trigger point pressure release and increased circulation, after releasing the pressure which ultimately resulted in pain reduction.[6],[8]

Positional release technique helps in reducing tender point in the affected muscle by the mechanism of automatic resetting of the muscle spindles. The shortened position of the muscle is a nonthreatening position for a muscle in spasm and reduced pain.[8] In MET, the sequence of muscle and joint mechanoreceptor activation evoked firing of local somatic efferents. This in turn led to sympathoexcitation and activation of the periaqueductal gray matter, which resulted in the activation of descending modulation of pain. In addition, stimulation of mechanoreceptors and simultaneous gating of the nociceptive impulses occur in the dorsal horn of the spinal cord. Therefore, this study is in agreement with earlier studies which indicate that strength training leads to a decrease in pain. A decrease in pain leads to an improvement in function as can be seen by the improvement in the score of NDI for both the groups.

Based on our findings, we suggest that the therapeutic combinations of INIT along with stabilization exercises could be opted as a treatment of choice for reduction of MTrP pain, enhancing the cervical ROM and reduction of neck disability.


  Conclusion Top


There is a sufficient evidence to prove the efficacy of INIT in improving cervical function by reducing the trigger points on upper trapezius muscle.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgments

The authors are very thankful to Dr. Asir John Samuel, BSc (Psychology), BPT, MPT (Neurosciences and Pediatric Neurology), DYScEd, MAcu, (PhD), Associate Professor, Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Maharishi Markandeshwar University, Mullana, Haryana, India, for providing logistic and technical support in editing.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Rickards LD. The effectiveness of non-invasive treatments for active myofascial trigger point pain: A systematic review of the literature. Int J Osteopath Med 2017;9:120-36.  Back to cited text no. 1
    
2.
de las Peñas CF, Sohrbeck Campo M, Fernández Carnero J, Miangolarra Page JC. Manual therapies in myofascial trigger point treatment: A systematic review. Bodyw Mov Ther 2017;9:27-34.  Back to cited text no. 2
    
3.
Alvarez DJ, Rockwell PG. Trigger points: Diagnosis and management. Am Fam Physician 2002;65:653-60.  Back to cited text no. 3
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4.
Grieve R, Clark J, Pearson E, Bullock S, Boyer C, Jarrett A, et al. The immediate effect of soleus trigger point pressure release on restricted ankle joint dorsiflexion: A pilot randomised controlled trial. J Bodyw Mov Ther 2011;15:42-9.  Back to cited text no. 4
    
5.
Borg-Stein J. Treatment of fibromyalgia, myofascial pain, and related disorders. Phys Med Rehabil Clin N Am 2006;17:491-510, viii.  Back to cited text no. 5
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6.
Hou CR, Tsai LC, Cheng KF, Chung KC, Hong CZ. Immediate effects of various physical therapeutic modalities on cervical myofascial pain and trigger-point sensitivity. Arch Phys Med Rehabil 2002;83:1406-14.  Back to cited text no. 6
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7.
Mathew G, Vishal K. Effectiveness of integrated neuromuscular inhibitory technique and LASER with stretching in the treatment of upper trapezius trigger points. J Exerc Sci Physiother 2009;5:115-21.  Back to cited text no. 7
    
8.
Nagrale AV, Glynn P, Joshi A, Ramteke G. The efficacy of an integrated neuromuscular inhibition technique on upper trapezius trigger points in subjects with non-specific neck pain: A randomized controlled trial. J Man Manip Ther 2010;18:37-43.  Back to cited text no. 8
    


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