International Journal of Science and Healthcare Research DOI: https://doi.org/10.52403/ijshr.20210452 Vol.6; Issue: 2; April-June 2021 Website: ijshr.com Original Research Article ISSN: 2455-7587

Immediate Effect of Strain Counterstrain Technique versus Muscle Energy Technique on Upper Trapezius Tenderness in Non-Specific Neck Pain

Nawal M Mulla1, Parag Kulkarni2, Ajay Kumar3

1M.P.T, DPO’s NETT College of Physiotherapy, Thane, Maharashtra, India. 2M.P.Th, Assistant Professor, DPO’s NETT College of Physiotherapy, Thane. 3Principal, DPO’s NETT College of Physiotherapy, Thane.

Corresponding Author: Nawal M Mulla

ABSTRACT statistical significant (p> 0.05) difference in the outcome measures between groups. Background: The most common form of neck Conclusion: The study concludes that both pain is non-specific which is deep, dull aching techniques are equally effective in treating pain, & poorly localized. Non-specific pain is increasing lateral flexion and rotation range of associated with upper trapezius tenderness. For motion, and improving pain pressure sensitivity. people who work at desks and computers, or who spend many hours driving, have poor Keywords: Strain Counterstrain, muscle energy ergonomics which causes the upper trapezius to technique, upper trapezius tenderness, visual become sore and painful. The soreness can lead analog scale, non-specific neck pain, pain to the development of tender points which can pressures sensitivity be the major reason for developing neck pain and muscle spasm. Physiotherapy techniques INTRODUCTION like muscle energy technique and Strain Neck pain is a condition that places counterstrain has been proposed to treat a large economic burden on the health care tenderness in trapezius. system. In majority of the cases, the Objective: To compare the immediate effect of pathoanatomical source of an individual’s Strain Counterstrain Technique & Muscle pain cannot be identified and is therefore Energy Technique on pain, pain pressure [1] sensitivity & mobility on non-specific neck pain termed as non-specific. Symptoms vary with upper trapezius tenderness using Visual with physical activity and change with time. analogue scale, Pressure Algometer & Universal Each form of acute, sub-acute or chronic Goniometer respectively. neck pain, where no abnormal anatomic Method: 60 subjects were selected as per structure can be identified as a source of inclusion and exclusion criteria& were pain is called non-specific neck pain. Non- randomly assigned to Group A (n=30) & Group specific neck pain is the commonest cause B (n=30); Strain Counterstrain and Muscle of neck symptoms & results from postural Energy Technique respectively. Visual & mechanical causes. Non-specific neck Analogue Scale, Pain Pressure Sensitivity & pain is diagnosed on clinical grounds alone Cervical Rotation & Lateral Flexion Motion bilaterally was noted before & after application provided there are no red flags suggesting of both techniques and the data was statistically any serious condition. The main symptoms analysed. being pain in the cervical region radiating to [2] Result: Both groups showed statistical the occiput, shoulders & upper limbs. significance (p< 0.05) differences in all outcome Non-specific neck pain is often associated measures between pre test and post test values with upper trapezius tenderness. Typically of Group A and Group B but there is no the area of pain involved with trapezius

International Journal of Science and Healthcare Research (www.ijshr.com) 289 Vol.6; Issue: 2; April-June 2021 Nawal M Mulla et.al. Immediate effect of strain counterstrain technique versus muscle energy technique on upper trapezius tenderness in non-specific neck pain. being superior fibres. There has been found dysfunctional joints and their muscles are that the prevalence of non-specific neck moved away from their restrictive barriers pain with upper trapezius tenderness to be into positions of ease in the treatment of around 13%-19% in general population. [3] musculoskeletal dysfunctions. The For people who work at desks and application of SCS technique requires a computers, or who spend many hours practitioner to first palpate a tender point driving, have poor ergonomics which causes (TeP) in the soft tissues, the patient’s limb is the upper trapezius muscle to become very then moved in such a way that the pain sore and painful. The soreness can lead to associated with pressure on the TeP is the development of tender points which can relieved by at least 70 percent to find the be the major reason for developing neck position of ease. [7][8][9] It is theorized that pain and muscle spasm. [4] Many studies the shortening or “folding-over” of aberrant have hypothesized that the probable cause tissues in SCS technique achieves its of tenderness pathogenesis results from the therapeutic modifications via both overloading and injury of muscle tissue proprioceptive (Korr, 1975) and nociceptive which leads to involuntary shortening of mechanisms (Bailey & Dick, 1992). [8] localized fibers. The area where the soft Bailey & Dick (1992) proposed a hypothesis tissue is stressed receives less oxygen, that tissue damage in dysfunctional muscles glucose, and nutrient delivery, and can be reduced by the positional release subsequently accumulates high levels of mechanism utilized by SCS. They suggest metabolic waste products. The result of this that relaxation of the damaged tissues may cascade of events is the creation of altered be achieved by placing patients in a position tissue status, pain, and the development of of ease which may advance local perfusion tender points. [1] Tender points (TePs) are of fluids (i.e. blood, and lymph) and defined as small, dense and hypersensitive enhance the removal of sensitizing points found within the subcutaneous, inflammatory mediators. [10] muscular or fascial tissues. Tender points Muscle Energy Technique (MET) and myofascial trigger points are usually incorporates precisely directed and associated in the literature, although the two controlled, patient initiated, isometric and/or disorders have different features. A tender isotonic contractions, designed to improve point is a localized area of tenderness in a musculoskeletal function and reduce pain. It muscle, muscle tendon junction, fat pad, or is an active muscle based treatment bursa region. [5] TePs have been associated approach that involves the voluntary with hyperalgesia and therefore limited contraction of a subject’s muscle in a range of motion (ROM) and are clinically precisely controlled direction, against a important to identify as these possess the counterforce provided by the therapist. The potential to restrict functional activities. MET may be used to decrease pain, stretch Identification is accomplished through the tight muscles and fascia, reduce muscle recognition of a pattern of clinical signs on tone, improve local circulation, strengthen physical examination. Signs may include the weak musculature and mobilize joint presence of a tender spot within the muscle, restrictions .Post isometric relaxation (PIR) the presence of restricted ROM of the is a division of MET used to relax and affected tissues. When local pressure lengthen a hypertonic and shortened muscle applied to a tender area produces local pain .Post Isometric Relaxation (PIR) is the without referred pain or pain reproduction, effect of the decrease in muscle tone in a this area is properly considered a tender single or group of muscles, after a brief rather than a trigger point. [6] period of submaximal isometric contraction Strain-counterstrain (SCS), also of the same muscle. PIR works on the known as Positional Release Technique, is concept of autogenic inhibition. Autogenic an indirect osteopathic technique, whereby inhibition occurs during PIR which causes

International Journal of Science and Healthcare Research (www.ijshr.com) 290 Vol.6; Issue: 2; April-June 2021 Nawal M Mulla et.al. Immediate effect of strain counterstrain technique versus muscle energy technique on upper trapezius tenderness in non-specific neck pain. muscle inhibition during contraction due to palpation and marked with a small dot on the activation of the Golgi tendon organ the skin. Subjects were encouraged to relax (GTO) and the muscle spindles. [11] as much as possible. The therapist applied gradually increasing pressure by thumb over MATERIALS AND METHODS the tender point of upper trapezius muscle Ethical committee approval was until the sensation of pressure became one obtained. 60 subjects(both genders) in the of pressure and pain. . At the same time, the age group of 20-30 years with non-specific therapist created a new position with less neck pain participated in this study & were tension resulting in a subjective reduction of recruited through Purposive Sampling & pain of up to 70%. The position that led to were randomly assigned to either Group A reduced pain was ipsilateral side flexion of (n=30) which received Strain Counter strain the cervical spine with slightly contra lateral Technique or to Group B (n=30) which rotation (5-8°). The patient’s upper received Muscle Energy Technique . The extremity was positioned in passive criteria for inclusion in this study was Non- abduction and maintained for 90s. Finally, specific neck pain of less than 3 weeks the subject was slowly placed into a neutral duration, unilaterally pain over upper position of the cervical spine. [20]. (Fig 1) trapezius of more than 5 on Visual Analogue Scale & Limitation of lateral flexion or rotation of neck due to pain. Subjects who had Signs of Recent surgery, whiplash injury or open wounds to neck, Cervical spine pathologies like radiculopathies, Sensory changes in the trapezius region, Deformities like torticollis, Taking medications for pain or Vascular syndromes were excluded.

Procedure: A written consent was taken from all the subjects in the language best understood Figure 1: Strain Counterstrain for upper trapezius. by them. Selection of the subjects was done Group B was given MET. MET as per the inclusion and exclusion criteria. technique was applied with the patient in Purpose of the study and procedure was supine lying position. The researcher, with explained to the subjects prior to the study. one hand on the occipital region and the Demographic data was noted down. Pre- other stabilizing the shoulder, performed a values of Active Range of Lateral Flexion passive contralateral flexion to the muscle, and rotation of cervical spine bilaterally taking the subject's head until an end-feel using universal goniometer, pain intensity point without creating discomfort. At this on VAS & PPT was checked by pressure point, subjects were asked to perform an algometer before treatment. isometric contraction of 20% (light resisted

effort) of their maximum force. The subject METHOD accomplished an ipsilateral flexion of the Patient position: Supine position. affected muscle that is the shrugging Group A was given strain movement caused by taking the stabilized counterstrain. The subject lies supine with shoulder towards the ear and the ear towards therapist standing on the affected side; the shoulder for 7 seconds, while the tender points are located along the upper researcher offered manual resistance. There fibres of the trapezius. The most dominant should be no pain. Afterwards, the subject is tender point was determined by pincer relaxed and the researcher gently eases the

International Journal of Science and Healthcare Research (www.ijshr.com) 291 Vol.6; Issue: 2; April-June 2021 Nawal M Mulla et.al. Immediate effect of strain counterstrain technique versus muscle energy technique on upper trapezius tenderness in non-specific neck pain. neck into an increased degree and the STATISTICAL ANALYSIS: shoulder was stretched caudally. This Collected data was entered in sequence was repeated 3 times. At the end Microsoft Excel and SPSS software version the researcher passively guided the cervical 16 was used for the data analysis. Normality spine into neutral position. (Fig 2) of the data was tested using the Shapiro- Wilk test. Since the data was not normally distributed for all the outcome measures, statistical analysis was done using the non- parametric tests. For intra group analysis the Wilcoxon test & inter group Mann Whitney U test was used.

RESULTS When analysed statistically using Mann Whitney test, scores of VAS& PPT showed no statistically significant difference in pain & pain threshold between the Group A & Group B (p value>0.05). Also scores of

Figure 2: Muscle Energy Technique for upper trapezius. AROM for Lateral Flexion & Rotation bilaterally showed no statistically significant After technique application again difference between the Group A & Group B scores for outcome measures were noted (p>0.05).However using Wilcoxon test intra down. group analysis of Group A & Group B The data was collected and showed statistical significance in all statistically analysed. outcome measures (p<0.05).

A. Comparison of Group A and Group B between the groups Values Inference for VAS Mean SD z value p value (between group) Difference post-treatment Group A 2.33 1.24 0.64 Non- Difference post-treatment Group B 2.10 0.90 -0.462 Significant

A) The above table and graph shows the mean pain scores between the groups: Group A and Group B. Inter-group comparison of mean VAS score post treatment did not show any statistically significant improvement between group A and group B (p value >0.05).

B. Comparison of Group A and Group B Values Inference between the groups for PPT Mean SD z value p value (between group) Difference post-treatment Group A 5.03333 2.235811 Non-Significant 0.06 Difference post-treatment Group B 3.633333 2.8343136 -1.8

International Journal of Science and Healthcare Research (www.ijshr.com) 292 Vol.6; Issue: 2; April-June 2021 Nawal M Mulla et.al. Immediate effect of strain counterstrain technique versus muscle energy technique on upper trapezius tenderness in non-specific neck pain.

B) The above table and graph shows the mean pain pressure threshold scores between the groups: Group A and Group B. Inter-group comparison of mean PPT post treatment did not show any statistically significant improvement between group A and group B (p value >0.05).

C. Lateral flexion Right Pre-Post mean difference Left Pre-Post mean difference Group A Group B Group A Group B Mean SD Mean SD Mean SD Mean SD 4.82 3.7 3.9 3.3 4.76 4.60 5.1 4.06 p value 0.328 0.889 z value -0.9 -0.1 Inference Non-Significant Non-Significant

C) The above table and graph shows the mean lateral flexion range between the groups: Group A and Group B. Inter-group comparison of mean AROM of Lateral Flexion post treatment did not show any statistically significant improvement between group A and group B (p value >0.05).

D. Rotation Right Pre-Post mean difference Left Pre-Post mean difference Group A Group B Group A Group B Mean SD Mean SD Mean SD Mean SD 3.36 4.3 2.16 3.1 3.267 5.1 3.06 3.3 p value 0.34 0.08 z value -0.9 -1.713 Inference Non-Significant Non-Significant

International Journal of Science and Healthcare Research (www.ijshr.com) 293 Vol.6; Issue: 2; April-June 2021 Nawal M Mulla et.al. Immediate effect of strain counterstrain technique versus muscle energy technique on upper trapezius tenderness in non-specific neck pain.

D) The above table and graph shows the This study found the immediate mean cervical rotation range between the effectiveness of SCS on upper trapezius groups: Group A and Group B. Inter-group tenderness to reduce pain, improve pain comparison of mean AROM of Rotation threshold and improve the range of motion. post treatment did not show any statistically In Group A, effectiveness on VAS score significant improvement between group A was found. Wong and Schauer-Alvarez and group B (p value >0.05). (2004) examined and compared the effects of SCS and SCS plus exercise on pain of the DISCUSSION hip musculature and concluded that SCS The purpose of the study was to had an immediate effect in reducing tender compare the immediate effects of Strain point pain. [12] Counter Strain Technique (SCS) and AROM of cervical lateral flexion & Muscle energy technique (MET) on pain, rotation improved immediately after pain pressure sensitivity and cervical spine treatment. Strain counter-strain technique mobility in upper trapezius tenderness in can reduce pain thereby increase the non specific neck pain. function of the neck. Dardzinski J A (2000) 60 patients who had complaints of found a reduction of pain and an increase in non-specific neck pain with upper trapezius neck function of 50%-100% in 19 of 20 tenderness were selected for this study patients immediately after SCS therapy. The following random sampling method. The partial improvement was maintained for six subjects were divided into two equal groups, months in 11 of 20 patients, and four were 30 subjects in each group. The subjects in still pain-free. [13] This shows that SCS Group A underwent Strain-Counterstrain technique is effective to reduce pain and Technique whereas the subjects in group B improve the range of motion. received Muscle Energy Technique. The present study demonstrated that Overall results of this study showed tender point sensitivity decreased i.e the improvements in the outcome measures Pain Pressure Threshold (PPT) increased in immediately after both treatments. These response to a single application of the improvements were seen in individual strain/counterstrain technique. Meseguer et groups but there was no statistically al. (2006) concluded that the application of significant difference in the outcome SCS technique may be effective in measures between the 2 groups. Therefore producing hypoalgesia and decreased the null hypothesis of the study was reactivity of TePs. The authors were able to accepted and the alternative hypothesis was demonstrate an immediate decrease in the rejected. sensitivity of a chosen TeP following the application of SCS technique. The results of

International Journal of Science and Healthcare Research (www.ijshr.com) 294 Vol.6; Issue: 2; April-June 2021 Nawal M Mulla et.al. Immediate effect of strain counterstrain technique versus muscle energy technique on upper trapezius tenderness in non-specific neck pain. the present study also agree with those of a significant reduction in pain and muscle Wong and Schauer-Alvarez who also found thickness and increase in lateral cervical that strain-counterstrain reduced sensitivity flexion ROM; none of the techniques being to palpation in subjects exhibiting tender superior to each other. [15] points in the hip musculature (p Cassidy et al found immediate value=0.000) Strain/counterstrain is thought increase in ROM of neck in all three planes to achieve its benefits by automatic resetting in patients with mechanical neck pain who of muscle spindles which would help to were mobilized using MET. [16] dictate the length and tone of the affected The effects of MET for increase in tissues. Strain/counterstrain technique is ROM post intervention can be explained on applied with the targeted muscle in a the basis of reflex muscle relaxation shortened position, and used to treat tender following contraction that has been points. It might be that pain relief from proposed to occur by activation of the golgi strain/counterstrain technique may result tendon organs and their inhibitory influence from the stimulation of A∂ fibers. [5] on the α-motor neuron pool. MET was This study also found the found to reduce pain perception. Activation effectiveness of MET on upper trapezius of muscle and joint mechanoreceptors leads tenderness amongst the subjects in Group B. to sympathoexcitation by somatic efferents The subjects who received MET its overall and causes localized activation of effectiveness on VAS score was found periaqueductal gray matter that plays a role immediately after treatment. AROM was in descending modulation of pain. [14][17][15] found to improve & PPT also improved. The objective of the study was to The results of studies with MET compare the effectiveness of SCS (Group intervention and outcome measures such as A) versus MET (Group B) in the pain on VAS, PPT and flexibility support management of upper trapezius tenderness. the results of the present study, which Statistical analysis shows, comparing VAS indicates an immediate increase in the active score between Groups A and B,(p cervical range of motion and PPT and an value=0.64) no significant change in pain immediate decrease in pain on VAS. reduction between the groups. Statistical Campelo et al. (2013) assessed the effects of analysis shows same improvement in Group different manual techniques such as A in cervical side flexion & rotation as ischemic compression (IC), passive compared to Group B (p value >0.05). Also stretching, and MET on the cervical ranges there was no statistically significant of motion and pressure pain sensitivity in difference in the improvement of PPT subjects with LTrPs of the upper trapezius between the groups (p=0.06). Our results are muscle. The outcomes were assessed prior supported by the study of Ellythy et al., who to the treatment, immediately after the conducted a study on low back dysfunction treatment, 24 hours after the intervention, with help of MET and SCS and proved that and one week later. All the manual both MET and SCS techniques are effective interventions on the upper trapezius with in reducing pain and functional disability in LTrPs seemed to improve the cervical range patients with chronic low back pain. [18] of motion and the pressure pain sensitivity Sabby et al., who have conducted a immediately after the treatment. [14] study on upper trapezius MTrP with help of Sadria G et al. (2016) compared the MET and SCS also concluded an improved immediate effects of two manual treatment range of motion, reduced pain in patients regimens: MET and Active Release Therapy with upper trapezius MtrP in both the (ART) on individuals with upper trapezius groups. [19] trigger points. The outcomes were pain on Naik Prashant P (2010). in his study VAS, upper trapezius thickness and active “Comparison of muscle energy technique lateral cervical flexion. The results showed and positional release therapy in acute low

International Journal of Science and Healthcare Research (www.ijshr.com) 295 Vol.6; Issue: 2; April-June 2021 Nawal M Mulla et.al. Immediate effect of strain counterstrain technique versus muscle energy technique on upper trapezius tenderness in non-specific neck pain. back pain” found both MET and PRT along involve centrally mediated pathways, like with HMP for acute low back pain showed the periaqueductal gray in the midbrain and improvement following 8 days of treatment noradrenergic descending inhibitory as per significant decrease in pain (VAS), pathways. MET may increase fluid drainage amount of lumbar extension ROM, and and augment hypoalgesia. Rhythmic muscle disability level as per MODQ. [20] contraction increases muscle blood and It was found by Bhojan Kannabiran., lymph flow rates, & increases transcapillary et al. that there was significant decrease in blood flow. [15] pain and increase in lumbar range in both the groups with muscle energy technique FURTHER SCOPE OF STUDY and positional release technique but there Long-term follow-up should be was no significant difference between the evaluated .Study should be performed using groups which is similar to our study. [21] trigger points/tender points of other muscles associated with non-specific neck pain. Mechanism: Study can be performed with SCS is believed to achieve its different treatment techniques for different benefits by means of an automatic resetting age-group patients with different type’s of muscle spindles, which would help to neck pain. dictate the length and tone into the affected Study should be performed including tissues and increase the length of flexion and extension of the cervical sarcomere.PPT and local pain intensity vertebra improvement after application of SCS can also be due to the manual contact CONCLUSION component of the treatment and the The study concludes that Strain stimulation of A∂ fibres; a process that can Counter Strain Technique & Muscle Energy lead to blockage of the pain. [5][22] Technique are effective in treating pain, In this method, following the release increasing lateral flexion and rotation range of pressure on TeP, tissue blood and of motion, and improving pain pressure lymphatic circulation of that area increases sensitivity. which removes the hypoxic conditions in But comparing both groups proved the muscle and results in cellular that there is no difference between groups metabolism leading to the removal of on comparing pain, cervical range of inflammatory chemical substances such as motion, & pain pressure sensitivity. prostaglandins, histamine, and bradykinin; Hence both techniques are equally therefore, reduction of sensitization of effective in treating patients with non- nociceptors occurs. Also, one of the specific neck pain with upper trapezius advantages of SCS is breaking the cycle of tenderness. pain-spasm-pain. [23] In case of MET, its application Clinical Implication: seems to affect the viscoelastic and plastic Results suggested that both the tissue properties. MET may also influence techniques i.e. strain counterstrain technique pain mechanisms and promote hypoalgesia. & muscle energy technique are effective in Studies have suggested that MET related reducing Pain and in improving Cervical post-isometric techniques reduce pain and Range of Motion & Pain Pressure discomfort when applied to the muscles. Sensitivity in non-specific neck pain with Although the mechanisms of such an upper trapezius tenderness. On the initial influence are not known, they may involve day, SCS & MET make an excellent central and peripheral modulatory approach because treatment is both gentle mechanisms, such as the activation of the and effective. SCS & MET can be muscle and joint mechanoreceptors that performed prior to other rehabilitation

International Journal of Science and Healthcare Research (www.ijshr.com) 296 Vol.6; Issue: 2; April-June 2021 Nawal M Mulla et.al. Immediate effect of strain counterstrain technique versus muscle energy technique on upper trapezius tenderness in non-specific neck pain. techniques, such as strengthening exercises, Ofmedical And Dental Sciences. 2014 Mar; to decrease pain and improve disability. 3(9):2161-7. Manual therapy is also found to be more 5. A.A. Meseguer Et Al. Immediate Effects Of cost-effective for treating nonspecific pain The Strain/Counterstrain Technique In than physiotherapy or care by a general Local Pain Evoked By Tender Points In The Upper Trapezius Muscle Clinical practitioner. Chiropractic (2006) 9, 112—118 6. Borg-Stein & Stein Trigger Points And Abbreviations Tender Points One And The Same? Does SCS- Strain Counterstrain, MET- Muscle Injection Treatment Help? Rheumatic Energy Technique, VAS- Visual Analogue Disease Clinics Of North America 1996 Scale, May; Volume 22 Number 2. PPT- Pain Pressure Threshold, AROM – 7. D’Armbrogio, K.J., Roth, G.B. Positional Active Range Of Motion, TePs-Tender Release Therapy: Assessment & Treatment points Of Musculoskeletal Dysfunction. St. Louis: Mosby; 1997. Pp. 20. ACKNOWLEDGEMENTS 8. Jones, L. H. Strain And Counterstrain. Indianapolis, USA: The American Academy I express my deep sense of gratitude Of Osteopathy ; 1981. and sincere thanks to our respected sir Dr. 9. Ward, R. . Foundations For Osteopathic Ajay Kumar and guide Dr. Parag Kulkarni Medicine, 2 Ed. Philadelphia, USA: who immensely helped me with sincere Lippincott Williams & Wilkins; 2003. guidance, untiring cooperation, valuable 10. Bailey, M., & Dick, L. Nociceptive advice and endless inspiration during the Considerations In Treating With course of the study. I also take this Counterstrain. J Am Osteopath Assoc, 1992; opportunity to thank my family members 92(3), 334-341. and friends for their help and support. 11. Chaitow L. Muscle Energy Techniques. : Elsevier Health Sciences; 2013. Conflict of Interest: None 12. Wong CK, Schauer-Alvarez C. Effect of strain/counterstrain on pain and strength in

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