Spray Stretch Technique Versus Sustain Pressure for Trapezius Triggers
Condition: Trigger Point Pain, Myofascial; Mechanical Neck Pain
MeSH terms: Myofascial Pain Syndromes; Neck Pain
Study type: Interventional

Summary: 
      The aim of this research is to determine the effects of spray and stretch technique versus
      sustain pressure for the management of upper trapezius triggers. A randomized control trail
      is conducting at Khyber Teaching Hospital Peshawar and Northwest General Hospital and
      Research center Peshawar. The sample size is 54. The Participants divide into two groups, 27
      participants in Group A (receive the spray and stretch technique) and 27 in Group B (receive
      sustain pressure). The study duration is 6 months. Purposive non probability sampling
      technique applied. Only 20 to 35 years participants with upper trapezius trigger is including
      in this trial. Tools use in this study are visual analogue scale (VAS), Neck Disability Index
      (NDI), Hospital Anxiety and Depression Scale (HADS), Goniometer, Algometer and Manual muscle
      strength (MMT). Data analyzed through SPSS version 25.
    

Detailed description: 
      Myofascial Trigger Point (MTrP) is a hyperirritable spot in the taut bands of the skeletal
      muscles' fascia which is palpable and tender, on direct compression can produce referred pain
      in its reference zone, local tenderness and elicit a local twitch response. MTrP can be
      identified as either active or latent. According to Simons et al. that active and latent
      trigger points are associated with tenderness, muscle dysfunction, muscle weakness and
      restricted muscle length. An active MTrP causes spontaneous pain complaint in surrounding
      tissue and generally in its pain reference zone while latent MTrP physically exist but
      doesn't associate with spontaneous pain complaint. However, by direct compression latent MTrP
      can cause local pain on the site of taut band. Myofascial trigger points (MTrP) are
      considered one of the most common cause of musculoskeletal pain. Active MTrP are considered
      to be more prevalent in upper fibers of trapezius muscle (45% in right upper trapezius and
      25% in left upper trapezius and cause neck pain and shoulder discomfort. Predisposing Factors
      associated to MTrP can be either mechanical stress (such as overuse of muscles, repetitive
      strain injury, work related mechanical disorder, awkward posture and degenerative condition)
      or metabolic stress( such as hypo metabolic state and vitamin deficiency).According to
      integrated hypothesis presented by Simon, MTrP is believed to develop after a local injury
      either repetitive micro trauma or gross trauma to the muscle fibers. The diagnostic criteria
      of MTrP used by recent studies which is presented by Simons et al. is based on palpation of
      muscle. A well-trained clinician palpates the muscle to localize the active MTrP. During
      physical examination, a hyper sensitive spot within taut bands of muscle fibers, Palpation of
      recognized spot results in referred pain within reference zone, palpation of recognized spot
      elicits a jump sign (defensive movement), palpation may result in local twitch response
      defined as visible contraction of muscle. There are varieties of physiotherapy interventions
      for the management of MTrP which maybe invasive and non-invasive such as dry needling,
      anesthetic injections, spray and stretch, ischemic compression and muscle energy techniques.
      A very limited evidence found on effects of spray and stretch technique versus sustain
      pressure for the Management of upper trapezius trigger points with flaws in methodology
      design. To fill the gap, this study is formulated to determine the effects of spray and
      stretch technique vs sustain pressure for the management of upper trapezius MTrP. Study will
      find out most effective treatment for management of upper trapezius and would contribute to
      educate and treat the patient with most simple and effective treatment approach.

      Literature review A systematic and evidence-based search of relevant literature were
      performed by utilizing PubMed and Google Scholar as search engines.

      A study conducted in 2017 regarding spray and stretch technique versus progressive pressure
      release on treatment of myofascial pain trigger point reported that spray and stretch
      technique was more effective in increasing functional activities while progressive pressure
      release was more effective in decreasing pain

      Another study in 2017 regarding Immediate effect of spray and stretch on trapezitis
      demonstrated that spray and stretch technique is effective in terms to increases range of
      motion and increase pain pressure threshold on acute trapezitis.

      A study in 2017 found that the number of active MTrP was positively associated with the
      physical burden of headache and trait anxiety.

      Study in 2013 concluded that Vapocoolant spray may be more effective than ice as an analgesic
      for IV insertion. Subjects were more satisfied with vapocoolant spray.

      Another study in 2014 investigated that spray and stretch had a short-term (<6h) effect in
      reducing post needling soreness of a latent MTrP and Pressure pain threshold did not
      significantly change after spray and stretch.

      Study in 2018 reported that ischemic compression and progressive sustained pressure both have
      significant effect on improving the pain of patients with chronic musculoskeletal pain
      pathologies.
    

Intervention name(s): Spray and Stretch technique (Ethyl chloride); Sustain pressure release
Intervention type(s): Other; Other
Intervention description(s): Group A receive spray and stretch technique (Ethyl chloride) with conventional treatment.
The upper trapezius muscle stretches on the basis of the Technique originally described by Simons. The subject is seated in a relaxed position on their homolateral hand for anchoring the distal end of the studied muscle. Initially, 3 to 5 parallel sweeps of ethyl chloride spray is applied covering the Upper trapezius muscle. Then, the muscle are positioned in a maximal but tolerable stretch and lengthened until the Physical Therapist felt the muscle tension barrier. This procedure repeated 2 or 3 times.; Group B receive sustain pressure release with conventional treatment. Progressive pressure release are considered in two stages. The initial step is to recognize and find the trigger in upper fiber of trapezius, utilizing trigger point palpation. Trigger point felt as firm and restricted hyperirritable knots with in gut of the muscle.
The second step is to applying pressure release ranging from eight to twelve second for each pressure, then it increases gradually for maximum of twenty seconds. The total duration of pressure is five minutes or more until the discharge is felt by the fingers.
Intervention MeSH terms: Ethyl Chloride
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Assignment
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Treatment
Keywords: Spray and Stretch technique; Progressive Pressure release technique; Active myofascial trigger points; Upper Trapezius Triggers