Integration of Neuromuscular Inhibition Technique On Trapezius Trigger Points.
Condition: Myofascial Trigger Point Pain
MeSH terms: Myofascial Pain Syndromes
Study type: Interventional

Summary: 
      The purpose of the study is to find the effects of integrated neuromuscular inhibition
      technique on upper trapezius trigger points in patients with non specific neck pain. A
      randomized control trial was conducted at Iqbal hospital. The sample size was 24calculated
      through open-epitool.But 30 patients were added in the study to increase the statistical
      power of analysis.The participants were divided into two interventional groups each having 15
      participants. The study duration was six months. Sampling technique applied was Purposive
      sampling for recruitment and group randomization using sealed envelope method. Only 25 to 45
      years participants (both male and female) with upper trapezius trigger points and non
      specific neck pain of less than 3 months were included in the study. Tools that were used in
      this study are NDI questionnaire, NPRS and inclinometer. Data was collected at baseline , 2nd
      and 4th of treatment. Data was analyzed through SPSS version 20.
    

Detailed description: 
      Neck pain is a common musculoskeletal disorder. The cause of neck pain is variable and can
      result from specific musculoskeletal conditions, infections, inflammatory conditions, trauma,
      rheumatic diseases, or congenital diseases. When neck pain is not attributed to a specific
      pathology, and is of a vague musculoskeletal origin which is difficult to identify, the
      condition is labelled non-specific. Up to 67% of world's population may present with
      non-specific neck pain at least once in their lives. Although the duration and course of the
      pain may vary, most patients experience chronic or recurrent pain. Evidence suggests that
      myofascial trigger points are commonly present in patients with non specific neck pain.

      The myofascial trigger point ''a hyperirritable 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, motor dysfunction, and autonomic phenomena. Patients may have
      regional ,persistent pain resulting in decreased range of motion in the affected muscles.
      Trigger points may develop after an initial injury to muscle fibers. This injury may include
      a noticeable traumatic event or repetitive micro trauma to the muscles. The trigger point
      causes pain and stress in the muscle or muscle fiber. As the stress increases, the muscles
      become fatigued and more susceptible to activation of additional trigger points. When
      predisposing factors combine with a triggering stress event, activation of a trigger point
      occurs. This theory is known as the ''injury pool theory'.

      Trigger points are classified as active or latent. Active myofascial trigger point is
      spontaneously painful and gives rise to a number of well described symptoms: local and/or
      referred pain; muscle weakness and tightness. Latent myofascial trigger points on the other
      hand, are generally considered minor, sub-clinical neuromuscular lesions that are pain-free
      unless compressed though shown to be associated with increased sensitivity to muscle stretch,
      decreased strength. In the upper quadrant, postural muscles, in general, and the upper
      trapezius , in particular, are most affected by trigger points .It extends from the external
      protuberance of the occipital bone to the lower thoracic vertebrae and laterally to the spine
      of the scapula. The trapezius has upper, middle, and lower groups of fibers. Neck pain is
      provoked by trigger points of trapezius.Patients with trigger points of trapezius usually
      present with neck pain,decreased cervical range of motion,tightness of trapezius Various
      treatment techniques that are utilized for treating trigger points are LASER , dry needling,
      ultrasound, TENS, trigger point pressure release /ischemic compression, muscle energy
      technique , myofascial release therapy , positional release therapy i.e. strain counter
      strain technique and integrated neuromuscular inhibitory technique.The integrated
      neuromuscular inhibition technique is a manual deactivation trigger points technique and
      includes the application of ischemic compression, muscle energy technique and strain counter
      strain technique. Ischemic compression ('inhibition') is applied to an active trigger point
      by means of direct finger or thumb pressure until local or referred pain begins to modify.
      Following this, the tissues in which the trigger point lies are positioned in such a way as
      to modify the pain . After 90 seconds the patient is asked to introduce an isometric
      contraction into the tissues and to hold this for 7-10 seconds. This recruits the precise
      fibers which had been repositioned to obtain the positional release. These previously
      hypertonic or fibrotic tissues are then stretched so that the specifically targeted fibers
      are lengthened. A rhythmic activation of antagonist muscles in a series of 'pulsed'
      contractions is a useful final stage of this sequence.
    

Intervention name(s): Integrated Neuromuscular Inhibition technique; Ischemic Compression,Hotpack,TENS
Intervention type(s): Other; Other
Intervention description(s): Integrated Neuromuscular inhibition technique At first ischemic compression was given using a pincer grip over the active trigger point till the tissue barrier was felt .The process was repeated till the tension reduced for 90 seconds.Ischemic compression was followed by the application of strain counterstrain. Once the position of ease was identiﬁed, it was held for 90 seconds and repeated for three to ﬁve repetitions. Muscle energy technique was applied as last part of integrated neuromuscular inhibition technique . Each isometric contraction was held for 7-10 seconds and was followed by further contralateral side bending, ﬂexion, and ipsilateral rotation to maintain the soft tissue stretch. Each stretch was held for 30 seconds and was repeated three to ﬁve times per treatment session; Control group received conventional physical therapy. It included HOT Packs ( 20 minutes) , TENS (10 minutes) ,Ischemic compression .Using a pincer grasp, we identified the trigger point. Once the trigger point was identiﬁed we applied ischemic compression by placing the thumb and index ﬁnger over the active TrP. Slow, increasing levels of pressure was applied until the tissue resistance barrier was identiﬁed. Pressure was maintained until a release of the tissue barrier was felt. At that time, pressure was again applied until a new barrier was felt. This process was repeated until tension/tenderness is unable to be identiﬁed
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Official Title: Effects of Integrated Neuromuscular Inhibition technique on upper trapezius trigger points in patients with non-specific neck pain.
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Neck pain; Trapezius trigger points; INIT