|Year : 2013 | Volume
| Issue : 1 | Page : 17-22
Difference in effect between ischemic compression and muscle energy technique on upper trepezius myofascial trigger points: Comparative study
Gopal S Nambi1, Ronak Sharma1, Dipika Inbasekaran2, Apeksha Vaghesiya1, Urmi Bhatt1
1 Department of Physiotherapy, C.U. Shah Physiotherapy College, Surendranagar, Gujarat, India
2 Department of Physiotherapy, C.U. Shah Medical College, Surendranagar, Gujarat, India
|Date of Web Publication||17-Apr-2013|
Gopal S Nambi
C.U. Shah Physiotherapy College, Surendranagar - 363 001, Gujarat
Background: Myofascial trigger point (MTrP) is a hyperirritable point or spot, usually within a taut band of skeletal muscle or in the muscle fascia which is painful on compression and can give rise to characteristic-referred pain and motor dysfunction. Studies suggest that various types of massage forms are available for treating MTrPs. Aims: To find the difference in effect of two forms of massage techniques: Ischemic compression and muscle energy technique (MET) on upper trepezius MTrPs. Settings and Design: Quasi experimental design was conducted with convenient sampling method. Materials and Methods: Patients ( n = 30) who fulfil the screening criteria were randomly assigned to Group A ( n = 15) treated with ischemic compression and ultrasound and Group B ( n = 15) treated with MET and ultrasound for 4 weeks and they were assessed at baseline and after 4 weeks. Outcome measures included pain intensity by visual analog scale (VAS) and range of motion by universal goniometer. Statistical Analysis Used: Intergroup analysis was done with Mann-Whitney test and intragroup analysis was done with Wilcoxon signed-rank test. Results: Statistically, no significant ( P > 0.05) changes in the scores were found in the Groups A and B for VAS, and statistically significant ( P < 0.05) changes in the scores were found in the Groups A and B for Range of Motion (ROM) with greater change scores in the Group B compared with Group A. Conclusion: Treatment program consisting of MET with ultrasound may be more effective in reducing pain and improve ROM in patients in upper trepezius MTrPs.
Keywords: Ischemic compression, muscle energy technique, myofascial trigger point, range of motion, ultrasound, upper trepezius, visual analog scale
|How to cite this article:|
Nambi GS, Sharma R, Inbasekaran D, Vaghesiya A, Bhatt U. Difference in effect between ischemic compression and muscle energy technique on upper trepezius myofascial trigger points: Comparative study. Int J Health Allied Sci 2013;2:17-22
|How to cite this URL:|
Nambi GS, Sharma R, Inbasekaran D, Vaghesiya A, Bhatt U. Difference in effect between ischemic compression and muscle energy technique on upper trepezius myofascial trigger points: Comparative study. Int J Health Allied Sci [serial online] 2013 [cited 2014 Jul 29];2:17-22. Available from: http://www.ijhas.in/text.asp?2013/2/1/17/110570
| Introduction|| |
Myofascial pain syndrome is a complex pain disorder characterized by a steady dull ache referring to a specific reference zone from a myofascial trigger point (MTrP) within a palpable band of muscle. A MTrP is a hyperirritable spot, located within a taut band of a skeletal muscle that is painful on compression or stretch and that can give rise to a typical-referred pain pattern as well as an autonomic phenomena.  Abnormal stresses on the muscles from sudden stress on shortened muscle, leg-length discrepancies, or skeletal asymmetry are thought to be common causes of myofascial pain. Poor posture, assumption of a static position for a long period also has been implicated in myofascial pain.
Many studies have referred to the prevalence of MTrPs. Sola et al.,  assessed 200 asymptomatic young adults and found focal tenderness representing latent trigger points in the shoulder girdle muscles of 54% of female and 45% of male participants; 25% of these participants demonstrated referred pain. A similar study conducted in villages from rural Thailand, where 2463 subjects were examined, of which 36.2% had musculoskeletal pain with myofascial pain syndrome being the most common diagnosis.  In a similar manner, another study reported that of 283 consecutive admissions to a pain center program, MTrPs were the primary cause of pain in 85% of cases. 
Several features are commonly associated with the diagnosis of MTrPs. These include a confusing mixture of sensory and motor phenomena: History of spontaneous localized pain associated with acute overload or chronic overuse of the muscle. The mildest symptoms are caused by latent TrPs that cause no pain but cause some degree of functional disability. More severe involvement results in pain related to the position of the muscle or muscular activity. The most severe level involves intermittent or continuous pain at rest. 
An active trigger point is one that actively refers pain either locally or to another location (most trigger points refer pain elsewhere in the body along nerve pathways). A latent trigger point is one that exists, but does not yet refer pain actively, but may do so when pressure or strain is applied to the myoskeletal structure containing the trigger point. Latent trigger points can influence muscle activation patterns, which can result in poorer muscle coordination and balance. Active and latent trigger points are also known as "Yipe" points, for obvious reasons. A key trigger point is one that has a pain referral pattern along a nerve pathway that activates a latent trigger point on the pathway, or creates it. A satellite trigger point is one which is activated by a key trigger point. In contrast, a primary trigger point in many cases will biomechanically activate a secondary trigger point in another structure.
Trigger points form in the muscle's fibres, close to the motor end plate (neuromuscular junction). Excess acetylcholine (ACh) is released at the synapse, usually associated with overuse or strain, leading to release of calcium. Resulting ischemia creates an O2 deficit and energy crisis. Without available ATP, calcium ions, which are keeping the gates open for ACh to keep flowing, cannot be removed. A chemically sustained contracture (without motor potentials) is different from a contraction (voluntary with motor potentials) and a spasm (involuntary with motor potentials). Actin-myosin filaments shorten in the area of the motor endplate. A contracture "knot" forms the characteristic trigger point nodule. The remainder of the sarcomeres of that fibre are stretched, creating the palpable taut band.
Simons et al.,  defined ischemic compression (IC) as "trigger point pressure release" and described as follows, "Application of slowly increasing, nonpainful pressure over a trigger point until a barrier of tissue resistance is encountered. Contact is then maintained until the tissue barrier releases, and pressure is increased to reach a new barrier to eliminate the trigger point tension and tenderness."
Muscle energy technique (MET) is commonly utilized method for achieving tonus release (inhibition) in a muscle before stretching. The approach involves the introduction of an isometric contraction to the affected muscle producing postisometric relaxation through the influence of the Golgi tendon organs (autogenic inhibition). It may also be applied to the antagonistic muscle group producing reciprocal inhibition in the offending agonistic muscle(s). Fryer and Fossum have hypothesized that the sequence of muscle and joint mechanoreceptor activation evokes firing of local somatic efferents. This in turn leads to sympathoexcitation and activation of the periaqueductal gray matter, which plays a role in the descending modulation of pain. Owing to stimulation of mechanoreceptors, simultaneous gating of the nociceptive impulses takes place in the dorsal horn of the spinal cord .  Thus, the purpose of this study is to examine the effectiveness of IC versus MET in the treatment of upper trepezius MTrPs.
| Materials and Methods|| |
A quasi experimental design [Comparative study] was conducted with convenient sampling method. Study was done on upper trepezius MTrP patients. Thirty (n = 30) subjects who fulfilled the inclusion and exclusion criteria were included and they were divided into two groups, Group A (IC with ultrasound, n = 15) and Group B (MET with ultrasound, n = 15) and treated for three sessions/week for 4 weeks. [ 7 ] Study is done in outpatient Department of Physiotherapy.
Subjects for the study were selected based on the following inclusion criteria: Age 18-55 years, both genders, with a palpable tender spot in the upper trapezius muscle.  Reproduction of the subject's pain upon palpation,  jump sign characterized by patient vocalization or withdrawal.  Limitation of neck movements due to pain.  Pain of at least three on a visual analogue scale (VAS).  Decreased cervical lateral flexion to the opposite side of the active upper trepezius TrP.  Unilateral side pain.  Subjects were not included with history of recent surgery or open wounds in the neck region.  History of a whiplash injury.  History of cervical spine surgery.  History of trauma or fractures in the neck or back.  Skin diseases and lesions in the area of trapezius.  Any sensory disturbances in the trapezius region. Duration of pain less than 1 month.  Any vascular syndromes such as basilar insufficiency.  Neck and back deformities like torticollis, scoliosis, and so on.  Therapeutic intervention, either invasive or noninvasive or medication for myofascial pain within the past 1 month before the study.  Diagnosis of cervical radiculopathy or myelopathy determined by their primary care physician.  Diagnosis of fibromyalgia syndrome.  Inform consent form was signed by the subject, who fulfilled inclusion criteria before the treatment started.
VAS (qualitative outcome) and cervical lateral flexion range of motion (quantitative outcome) as outcome measurements were taken before and after the program schedule. The VAS was used to measure the subject's current level of pain intensity. VAS involves a 10 cm horizontal line with "No pain" anchored at the left end and "Pain as bad as it could be" anchored at the right end. The patient was asked to place a mark on the line that represented the severity of his or her pain at the moment. Pain intensity scores will be evaluated before and after 4 weeks of treatment with 10 cm VAS. The range of motion of the cervical lateral flexion was assessed actively with a universal double-armed goniometer by placing the subjects in sit upright position and laterally flexes their head toward one side. The measurements were taken for cervical lateral flexion. ROM will be evaluated before and after treatment.
Patients were placed supine on the couch with his head fully on the surface of the couch, to reduce tension in the upper trepezius muscle.  Arm was positioned in slight shoulder abduction with the elbow bent and their hand resting on their stomach. To perform this IC to the upper trapezius, therapist stands at the head of the couch.
First, using a pincer grasp moved throughout the fibers of the upper trepezius and made note of the any active trigger points. To locate a trigger point, palpate the muscle to feel for a taut band or a twitch response in the muscle belly. A common location of upper trapezius trigger points is in the middle of the muscle belly, approximately 1 to 2 inches medial to the acromion process of the scapula. Once located on the trigger point, apply an IC by gradually applying pressure to the trigger point with your thumb. The patient will likely feel referred pain in a question mark pattern (along the back of the neck, around the side of the head, and then a focused pain right behind the eye). Keep in communication with the patient, checking to ensure that in staying within the limits of his pain tolerance. Hold this technique for approximately 20 seconds to 1 minute, patient tells you that pain has diminished, or until feels the muscle fibers begin to relax under your pressure. Once feel this release, gradually release pressure. All identified trigger points were treated. Then apply a few effleurage strokes to flush out the area and follow-up with a passive stretch to the muscle. This was repeated for three to five times for three sessions per week for 4 weeks.
Muscle energy technique
The subjects were placed supine and the therapist stabilized the shoulder on the affected side with one hand, while the ear/mastoid area of the affected side was held by the opposite hand.  The head and neck were then side bent toward the contralateral side, flexed, and rotated ipsilaterally, placing the subject just short of their upper trapezius restriction barrier. The subjects then shrugged the involved/stabilized shoulder toward the ear at a submaximal, pain-free, effort (20% of their available strength). The isometric effort was held for 7-10 seconds while a normal breathing rhythm was maintained. During the relaxation phase, the head and neck were eased into increasing degrees of side bending, flexion, and rotation to advance the stretch placed on the muscle. Each stretch was held for 30 seconds. This was repeated for three to five times for three sessions per week for 4 weeks.
Frequency: 3 MHz , Intensity: 1.4 W/cm 2 , Time: 5 minutes, Mode: Continues , and No. of sessions: Three sessions were given for both groups. 
Statistical analysis used
Intergroup analysis was done with Mann-Whitney test and intragroup analysis was done with Wilcoxon signed-rank test.
The study has been reviewed and approved by the scientific and Ethical Committee of the Institution and University of Saurashtra.
| Results|| |
Group A have nine males (60%) and six females (40%). Group B have seven males (46.66%) and eight females (53.33%).
Group A mean age is 46.20 and an SD ± 5.88 and Group B mean age is 45.46 and SD ± 5.44.
Intergroup comparison of pre-VAS of Groups A and B
After analyzing the data with Mann-Whitney test, the calculated U value is 102, table U value is 64 and P value is 0.643 (P > 0.05) for VAS. The result shows that calculated U value is 102 and P value is 0.643, showing that there no significant difference between prevalues of VAS of Groups A and B. The null hypothesis is accepted and alternative hypothesis is rejected. Results show the sample homogeneity.
Intergroup comparison of post-VAS of Groups A and B
After analyzing the data, the calculated 'U' value is 81, table U value is 64, and P value is 0.105 (P0 > 0.05), showing that there is no significant difference between postvalues of VAS score of Groups A and B scores, so the null hypothesis is accepted. The result shows that there is no change in the VAS scores of Groups A and B after 4 weeks of treatment.
Pre- and postvalues of VAS of Group A
The mean and standard deviation of VAS of Group A measured before the treatment (pre) and at the end of the treatment (after 4 weeks). The mean of baseline of VAS is 7.07 and after 4 weeks is 3.13. The standard deviation of baseline of VAS is 0.799 and after 4 weeks is 0.640. In Group A, calculated Z value is –3.457 and P value is 0.001, showing that there is significant difference between pre-and postvalues of VAS of Group A. The null hypothesises rejected and alternative hypothesis is accepted.
Pre- and postvalues of VAS of Group B
The mean and standard deviation of VAS Group A measured before the treatment (pre) and at the end of the treatment (after 4 weeks). The mean of baseline of NPRS is 6.93 and after 4 weeks is 2.80. The SD of baseline of VAS is 0.799 and after 1 week is 0.414. In Group A, calculated Z value is –3.49 and P value is 0.001, showing that there is significant difference between pre-and postvalues of VAS of Group A. The null hypothesis is rejected and alternative hypothesis is accepted [Table 1].
|Table 1: Pre- and postmean of visual analog scale score of groups A and B|
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Intergroup comparison of pre-ROM of Groups A and B
After analyzing the data the calculate 't' value for Cervical side flexion is 0.269 and P value is 0.790 so the results shows that (P > 0.05), showing that there is no significant difference between pre values of ROM of Groups A and B scores, so it shows that baseline data are homogenous, and the null hypothesis is accepted.
Intergroup comparison of post-ROM of Groups A and B
After analyzing the data, the calculated 't' value for cervical side flexion is 2.87, showing that there is significant difference between postvalues of ROM of Groups A and B scores, so the null hypothesis is rejected.
Pre- and postvalues of range of Group A
The mean and standard deviation of ROM of Group A measured before the treatment (pre-Rx) and at the end of the treatment (after 4 weeks). The mean of baseline of flexion is 14.667 and after 4 weeks the mean is 25,000. It shows that there is improvement in range of motion at the end of 4 weeks of treatment when compared to the first day in ranges. After analyzing the data, the calculated 't' value for flexion is 11.37 (P0 < 0.05), showing that there is a significant difference between the scores in pre-and posttest scores of Group A. Statistical analysis shows 41.36% improvement in cervical side flexion.
Pre- and postvalues of ROM of Group B
The mean and standard deviation of ROM of Group B measured before the treatment (pre-Rx) and at the end of the treatment (after 4 weeks). The mean of baseline of cervical side flexion is 15.00 and after 4 weeks the mean is 28.33. It shows that there is improvement in range of motion at the end of 4 weeks of treatment when compared to the first day in all the ranges. After analyzing the data, the calculated ' t' value for cervical side flexion is 16.73. ( P < 0.05), showing that there is a significant difference between the scores in pre-and posttest scores of Group B. Statistical analysis shows 47.06% improvement in cervical side flexion.
Statistical analysis shows in Group A 41.36% improvement in cervical side flexion, whereas in Group B 47.06% improvement in cervical side flexion. When comparing the percentage in improvement in ROM between Groups A and B, shows there is more increase in ROM in Group B at the end of the treatment (after 4 weeks) compared to Group A [Table 2].
|Table 2: Pre- and postmean cervical side flexion range of groups A and B|
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| Discussion|| |
The incidence of myofascial pain syndrome is reported as high as 85% at certain American pain clinics. Many studies suggest various treatments available for MTrPs. Noninvasive methods include spray (freeze) and stretch, physical therapy (posture correction and body mechanics), IC, massage, MET, strain counter strain (SCS), electrical modalities such as laser, ultrasound therapy, TENS, electrical muscle stimulation, and invasive methods like acupuncture, trigger point injections (dry or wet needling). There is no general acceptance of one standard treatment.
The study was conducted on 30 patients with two groups of 15 each. Group A was intervened with IC and ultrasound, whereas Group B was intervened with MET and ultrasound. Outcome measures included pain intensity by VAS and range of motion by goniometer which was measured prior to treatment (pre-Rx) and at the end of 4 weeks of treatment.
First objective of this study was to find the effectiveness of IC combined with ultrasound on upper trepezius MTrP to reduce pain and improve the range of motion. In Group A, its overall effectiveness on VAS score was found using Mann-Whitney U test after 4 weeks of treatment which shows P value is equal to 0.001, which is significant. ROM was found using paired t-test which shows P = 0.000, which is very highly significant for cervical side flexion range after 4 weeks of treatment. This means that IC technique combined with ultrasound is effective in to reduce pain and improve the range of motion.
The second objective of this study was to find the effectiveness of MET with ultrasound (Group B) on upper trepezius MTrP. In Group B subjects who received MET with ultrasound its overall effectiveness on VAS score was found using Mann-Whitney U Test after 4 weeks of treatment, which shows P = 0.001, which is significant. ROM was found using paired t-test which shows P = 0.000, which is significant for cervical lateral flexion range after 4 weeks of treatment.
The third objective of the study was to compare the effectiveness of I C with ultrasound (Group A) versus MET with ultrasound (Group B) in the management of upper trepezius MTrP. The intergroup comparison of VAS score was done using Mann-Whitney test which showed 'P' significant after 4 weeks of treatment, comparison of ROM of both Groups A and B was done using independent t-test which showed 'P' value significant for all the ranges. Statistical analysis shows when comparing VAS score between Groups A and B, shows same reduction. There is no significant change in pain reduction. Statistical analysis shows in Group A 41.36% improvement in cervical side flexion, whereas in Group B 47.06% improvement in cervical side flexion. When comparing the percentage in improvement in ROM between Groups A and B, shows there is more increase in ROM in Group B at the end of the treatment (after 4 weeks) compared to Group A.
Our results support the study of Sabby et al., who have conducted a study on upper trepezius MTrP with help of MET and SCS and concluded that following a improved range of motion, reduced pain in patients with upper trepezius MTrP. Nagrale et al. has conducted a study on upper trepezius MTrP: With help of MET concluded that this technique may have a significant role in improved range of motion, reduced pain the management of upper trepezius MTrP. MET following, ischemic pressure may be applied to the trigger points in this area; pressure on the trigger point stops blood from flowing into the affected area making it ischemic (deprived of oxygen). The person should feel comfortable pain as if pressure is being released. After 8 to 20 seconds, the pressure is released and the circulation of blood, oxygen, and nutrients to the area increases. In addition, it is important to apply general massage to the surrounding muscles of the upper trepezius, this helps keep the cervical functioning correctly and speeds up the rehabilitation process. From this study, it can be said that MET and IC can be used as additional method of choice for the treatment of patient with upper trepezius trigger point.
Limitations of the study are sample size was limited, Male participants are more comparing to female participant, no long-term follow-up of the patients, no control group present. So, the further recommendations for future studies need to be done with large group and longer follow-up. The same study can be done on female participants and with control group.
| Conclusion|| |
The treatment program consists of IC and MET may be effective in reducing pain, but for range of motion MET may be more effective than IC in upper trepezius MTrP to reduce pain and improve the range of motion.
| Acknowledgments|| |
Dr. Gopal created the concept, design, and definition of intellectual content. Dr. Ronak did the literature search, clinical studies, and data acquisition. Dr. Gopal did the data analysis, statistical analysis, experimental studies, and manuscript preparation. Dr. Dipika edited and reviewed the manuscript, and is also the guarantor of the manuscript. The authors thank the management and the patients, who participated in the study.
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[Table 1], [Table 2]