Integration of Neuromuscular Inhibition Technique On Trapezius Trigger Points.

Study Overview
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Brief Summary
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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
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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.

Official Title
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Effects Of Integrated Neuromuscular Inhibition Technique On Upper Trapezius Trigger Points In Patients With Non-Specific Neck Pain

Conditions
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Myofascial Trigger Point Pain

Intervention / Treatment
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* Other: Integrated Neuromuscular Inhibition technique
* Other: Ischemic Compression,Hotpack,TENS


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients with non specific neck pain < 3 months duration Patients who have TrPs in upper trapezius confirmed on basis of Travel and Simons diagnostic criteria Exclusion Criteria: • Patients having any trauma Signs of any serious pathology ( e.g malignancy, inflammatory disorder or fracture) Signs of spinal cord compression Signs of nerve root involvement History of neck surgery in previous 12 months History of cervical degenerative joint disease Autoimmune conditions

Ages Eligible for Study
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Minimum Age: 25 Years
Maximum Age: 45 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional 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)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Integrated Neuromuscular inhibition technique<br>Experimental group received 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. M If pain was reproduced the pressure was maintained over the active trigger point as the position of ease was identiﬁed. 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 iINIT.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 | Other: Integrated Neuromuscular Inhibition technique<br>* 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<br>|
| Active Comparator: Ischemic Compression,Hotpack,TENS<br>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 | Other: Ischemic Compression,Hotpack,TENS<br>* 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<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Neck Disability Index | Neck Disability Index (NDI) questionnaire ( for measuring neck disability). Total score 50,minimum score is 0 and maximu,m score is 50 parameter minimum and max | 6 months | 
| Numeric Pain Rating Scale | NPRS, for measuring pain intensity.minimum score is o and maximum is 10 | 6 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| range of motion (Cervical flexion) | inclinometer(For measuring flexion range of motion) | 6 months | 
| range of motion (Cervical extention) | inclinometer(for measuring extension range of motion) | 6 months | 
| range of motion (Cervical side bending,right left ) | inclinometer(for measuring cervical side bending range of motion) | 6 months | 
| range of motion (Cervical rotation right left,) | inclinometer(for measuring cervical rotation range of motion) | 6 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Neck pain, Trapezius trigger points, INIT