Manual Treatment Regimens in Upper Trapezius Trigger Point
Condition: Trigger Point Pain, Myofascial
MeSH terms: Myofascial Pain Syndromes
Study type: Interventional

Summary: 
      To compare the effect of sustain pressure and Integrated Neuromuscular Inhibition Technique
      on individuals with upper trapezius Trigger points (TrPs). The Study Design was Randomized
      control trial. According to inclusive criteria 26 patients were randomly allocated by sealed
      envelope method in experimental and control group. Patients were assessed at baseline and 4th
      day of session on NPRS, NDI questionnaire and ranges were taken by Goniometer and pressure
      threshold by Algometer. There was 3 drop out and the reason was loss of follow up. Hot pack
      was applied to both groups for 10mints before session. Sustain pressure was given for 3sec
      hold and 2sec release till pain decreases in control group. While, in experimental group INIT
      was used. Sustain pressure was applied on MTrPs for 3sec hold and 2sec release till pain
      decreases, Post isometric relaxation (MET) was given with 6-10 sec hold and repeat 4 times
      and at last Strain counter-strain (SCS) was given to hold muscle in shortest position for
      90sec or pain reduced to 3 out of 10. At last cervical stretches were given and home plan was
      guided.
    

Detailed description: 
      In clinical practice the neck and head pain is the most shared problem throughout the
      population. 45% to 54% of the total population is affected by neck pain. Idiopathic neck
      prevalence during lifetime is approximately 67% to 71%, two third of whole population will
      experience some event of neck and head pain in some stage of their life. One of important
      health problem is headache which is increasing mechanism of these disorders. 38.3% population
      experienced tension type headache in a studies during 1 year and out of which 2.2% had the
      chronic cases. Occurrence of cervicogenic headache in a Scandinavian individuals was nearly
      16%. In recent years other studies done on general population the estimated percentage of
      migraine experienced by adults was 10% to 12%. And prevalence of other type of headaches is
      increased tremendously in past few years. Work and activity which is limited due to this
      disability was documented by 60% of patients having headache. 64% working capacity was
      reduced because of headache. So, it is important that headache has reduced the quality of
      life generally Trigger point are very common but still they are overviewed and poorly managed
      due to practitioners who have less information regarding management of trigger points. Since
      long time practitioners have acknowledged the management of painful and tender muscles by
      stretching or elongating its fibers. Muscles having trigger points are tense when examined
      and it has also restricted ranges. This exaggerated tension in muscle is misinterpreted with
      muscle spasm

        -  Trigger point pain is unique and tender point in skeletal muscle or fascia that does not
           occur due to injury, degenerative changes, malignancy, acute infection and others.

        -  On palpation trigger point is like a taut band, knot or a bump under the finger in a
           muscle which produces a local twitch response on activation.

        -  When trigger point is compressed the patient reports pain in a specific pattern and give
           jump sign.

      Clinical diagnosis presents with local tenderness and 'jump sign' due to hyperirritability of
      the taut band, but still it is not known that if MTrPs is due to joint and bone problem or it
      is a separate disorder. Current studies have theorized that pathophysiology of myofascial
      pain syndrome and the creation of trigger points are due to damaged or burdened muscle
      threads, which results in automatic shortening and decreased supply of oxygen and nutrient,
      and with greater metabolic demand on local tissues. While the lengthened muscle have
      different pathophysiology for activating MTrPs. It is also suggested that reduced elasticity
      of neural structures is due to decrease in length of upper trapezius muscle Referred pain
      pattern and location of central trigger point 1 in the middle of vertical fibers of upper
      part of trap muscle. The central trigger point 2 in the middle of the horizontal fibers of
      the upper part of the trapezius. Central point 3 is in lower fibers of trapezius muscle.
      Trigger point 4 is at the lateral attachment of the lower fibers of trapezius muscle. This
      painful area is enthesopathy at the end of the tight bands associated with trigger point 3.
      In middle fibers of trapezius trigger point 5 is found, whereas 6th trigger point is found at
      the lateral attachment of middle fibers. The trigger point 7 is also in middle fibers Sustain
      pressure is application of gradually strong, painful pressure on trigger point for management
      of trigger points. By applying progressive pressure the ischemia is produced at local point
      using thumb or pressure Algometer and gradually the pain is reduced thus the investigators
      increase the pressure and it should be followed by increasing the length of the shortened
      muscle Muscle energy technique (MET) is a manual procedure in which minimal energy is used
      for management of movement limitation in spine and extremities. Osteopathic MET is a unique
      procedure conventionally used to treat muscular tension, local edema, empty end feel and
      joint dysfunction. For achieving good results in MET co-ordination of patient and therapist
      is required, whereas patient actively participate by contracting his/her muscles actively. It
      defined MET as a manual method in which patient contracts actively against the opposing force
      applied by the therapist. MET is used for management of shortened, stiffened or tightened
      muscles fibers. It is also used to strengthened the weak muscles.

      Myofascial pain is managed better when treatment is applied at the specific point i.e. MTrPs
      there are many methods used manually for management of trigger points some of them are
      sustain pressure, MET, positional release technique and Integrated neuromuscular inhibition
      technique (INIT). Combined MET, sustain pressure and strain counter strain for the better
      management of the trigger points and it is known as integrated neuromuscular inhibition
      technique and its effect can be obtained by using multidimensional methodology Sustain
      pressure is most commonly used for the management of trigger points in clinical setups. The
      purpose of my study is to use INIT for the management of trigger points, in this technique
      the investigators apply sustain pressure along with muscle energy technique post isometric
      relaxation and Strain counter strain. After the sustain pressure it was necessary to stretch
      and lengthen the muscles so the reoccurrence of trigger point will be minimize. The strain
      counter strain normalized the sensory abnormal input to normal input and through this the
      investigators also minimize the chance of reoccurrence of trigger point. The significance of
      the study is to increase the quality of care that consequences the independent life
    

Intervention name(s): Control Group; Experimental Group
Intervention type(s): Other; Other
Intervention description(s): Hot fermentation was applied for 10 mints Sustain pressure on trigger point was applied with thumb for 3secs hold and 2 sec release (till pain is reduced).
Self-stretches of cervical muscles (10 reps× 1set) For home plan cervical muscles stretching and postural care was guided; Hot fermentation was applied for 10 mints. Integrated Neuromuscular Inhibition Technique [sustain pressure, Post Isometric Relaxation (PIR) and SCS]. Sustain pressure was applied on trigger points using thumb for 3 sec hold and 2 mints release (till pain is reduced).
Post isometric stretch (MET) was given with 4 repetitions (6-10sec hold). Strain counter strain was given in which upper trapezius shortened position was maintained by slight flexion, same side bending, opposite rotation and shoulder abduction for 90 sec and repeats this procedure till the pain is reduced to 3 out of 10.
Self-stretches for cervical muscles were done at the end of session to maintain the gained ranges (10 reps×1 set) For home plan cervical muscles stretching and postural care was guided
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Participant)
Primary purpose: Treatment
Keywords: Integrated Neuromuscular Inhibition Technique; Muscle Energy Technique; Neck Disability Index