Adding Instrument Assisted Soft Tissue Mobilization to Core Stability Training in Chronic Mechanical Neck Pain

Study Overview
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Brief Summary
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Purpose of the study is to investigate effect of adding instrument assisted soft tissue mobilization to core stability training in treatment of chronic mechanical neck pain on pain level, cervical ROM, proprioception , Muscle activity ,H-reflex and Functions

Detailed Description
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Neck pain (NP) is a common musculoskeletal condition with a lifetime incidence rate between 22% and 70%. Neck pain is commonly a recurrent condition with remissions and exacerbation that do not completely resolve. A history of previous injury to the neck (including whiplash, sports and work injuries etc.) increases the likelihood of chronic pain. As one ages, more chronic neck pain persists. Mechanical neck pain is pain and/or stiffness in the neck or shoulder girdle region which was reproducible with neck movements. Mechanical neck pain is the most common type found in neck-pain disorders. Studies have demonstrated altered behavior of the cervical muscles in mechanical neck-pain patients. Mechanical neck pain produces mobility restriction, functional disability, decrease in muscle strength and decrease in health related quality of life. Several treatment techniques and methods are used to rehabilitate pathologies of the cervical spine, including manual therapy, massage, stretching, soft-tissue techniques, and therapeutic exercise. Manual therapy includes hands-on therapy techniques, such as soft tissue mobilization and massage techniques, as well as techniques using therapeutic equipment, such as stainless steel tools, that allow clinical therapists to identify and treat soft tissue dysfunctions. Instrument-assisted soft tissue mobilization (IASTM) encompasses a broad range of techniques to treat soft tissue deficiencies. Tools used for IASTM produce micro-trauma to soft tissue for healing and restoring normal elasticity and function. In recent years, Core stability training has become a popular fitness trend that has begun to be applied in rehabilitation programs and in sports medicine. Core exercises have a positive effect on reducing lower back pain, improving upper extremities in breast cancer patients and lower extremities in patients with total hip and knee arthroplasty, as well as performance improvement for athletes. Core exercises are taken seriously in rehabilitation, medical care, and sports. The core stability exercise program can be described as enhancing the ability to ensure a stable neutral spine position. Statement of the problem This study will answer the following question: Is there is effect of adding instrument assisted soft tissue mobilization to core stability in treatment of mechanical neck pain? Purpose of the study: Purpose of the study is to investigate effect of adding instrument assisted soft tissue mobilization to core stability in treatment of mechanical neck pain on pain level, cervical ROM, proprioception , Muscle activity ,H-reflex and Functions. Significance of the study: Study of Mohamed et al., (2020) investigated and compared the effects of instrument assisted soft tissue mobilization (IASTM) using m2t blade and trigger point release (TPR) in terms of neck lateral flexion and rotation range of motion on upper trapezius (UT) myofascial trigger points (MTrPs) in mechanical neck pain. Both groups showed significant effects in improving range of motion. There was no significant difference in neck lateral flexion and rotation between the two groups. The improvements in patients who received IASTM by M2t blade could be explained through loosening and removal of scar tissues and adhesions secondary to skin scraping which decreased soft tissue consistency and improved range of motion. It also induced vasodilation response and microvascular hemorrhage; so provided oxygen, nutrients and removed metabolic end products and inflammatory mediators which improved pain level and ppt. Konstantinos et al., (2012) found that IASTM techniques combined with neuromuscular retraining exercises can significantly reduce pain and improve the corresponding function of patients with cervical pain compared to the application of the same exercises and a simple massage. Rajalaxmi et al., (2020) analyzed the efficacy of multistep core stability exercise with and without conventional neck exercises in the treatment of chronic non-specific neck pain a Randomized Controlled Trial. GROUP A received neck stability exercise and GROUP B received neck stability and core stability exercises. Both the groups received exercises for 45 min session per day for 6 days a week for 12 weeks. Pre and post-test measured using VAS, NDI, CCFT. Both the group received a hot pack for 10min as a common intervention. On comparing the mean value of Group A & Group B on VAS and NDI Group B (neck stability with core stability exercise) showed 3.5 and 33.4 post-test values which were more effective than Group A (neck stability exercise) 5. 3 and 45.2 at P≤ 0.001. On the Craniocervical flexion Group B had shown 29.5 greater mean value when compared to Group A 24.7 at P≥ 0.001. Higher proportions of patients improved in group B compared to group A. Core stability exercise group demonstrated and benefited significant improvements in NDI, VAS, and CCFT scores. Mohsen et al., (2019) showed that 12 sessions of neck, core, and combined stabilization training in the neck region could improve the tolerance and pain of the elderly with non-specific chronic neck pain. This is the first study to investigate the effect of adding IASTM to core stability exercise in treatment of mechanical neck pain. Delimitation This study will be delimited to: Subjects will be divided randomly into two groups. Age of the subjects ranged from 18 and 55 with mechanical neck pain. (Mohamed et al., 2020) Subjects will be selected from outpatient clinic of Ismailia Medical Complex. Pain level will be measured by VAS. Cervical range of motion and proprioception will be measured using CROM. Functions will be measured by Arabic version of Neck Disability Index. Muscle activity and H-reflex will be measured by EMG. Basic Assumption It will be assumed that: All subjects will exert their best effort to be relaxed during testing procedures. All subjects will follow the researcher's instructions and advices. Psychological condition will be the same for all subjects. Hypotheses: There will be no statistically significant effect of adding IASTM to core stability on pain level. There will be no statistically significant effect of adding IASTM to core stability on cervical ROM. There will be no statistically significant effect of adding IASTM to core stability on proprioception. There will be no statistically significant effect of adding IASTM to core stability on muscle activity. There will be no statistically significant effect of adding IASTM to core stability on H-reflex. There will be no statistically significant effect of adding IASTM to core stability on functions.

Official Title
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Adding Instrument Assisted Soft Tissue Mobilization to Core Stability Training in Chronic Mechanical Neck Pain

Conditions
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Neck Pain

Intervention / Treatment
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* Device: istrument assisted soft tissue mobilization


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients diagnosed as having chronic mechanical neck pain. Patient's age between 18-55 years old. Exclusion Criteria: Subjects with any specific neck pathology as radiculopathy, rheumatoid arthritis and systemic diseases. sensory problems at mid or upper back. A history of head and upper trunk trauma or surgery. severe disorders of the cervical spine such as disk prolapse and cervical stenosis.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 55 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

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
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: conventional physiotherapy<br>They will receive conventional physical therapy (Superficial thermotherapy will be applied by an infrared lamp (250 watts), located 50cm from the patient's neck for 15 minutes. Electrotherapy will be provided in the form of TENS with a frequency of 100Hz and 250 microsecond pulses for 45 minutes using two 4x6cm electrodes placed bilaterally at the spinous process of C7 vertebra. Stretching exercises for Upper Trapezius, Levator Scapulae, Sternocleidomastoid and Scalenes muscles, each stretching exercise maintain 30 second and repeated 5 times for each side. Active range of motion exercises for neck extension, neck flexion, neck rotation, and neck lateral flexion to both directions, that includes active movement without resistance as follow: Patient sitting on the chair, therapist standing behind the patient, asking the patient to move his neck smoothly in extension, flexion, rotation, and lateral flexion to both directions for 1set 5 repetitions. | Device: istrument assisted soft tissue mobilization<br>* Each subject in group (A) will receive 12 sessions of physical therapy 3 sessions per week for 4 weeks). Each subject in group (B) will receive 8 sessions of physical therapy(two sessions per week for four weeks).<br>* Other names: core stability exercises;|
| Experimental: conventional physiotherapy,core stability training and istrument assisted soft tissue mobilization<br>They will receive conventional physical therapy core stability exercise and IASTM technique. | Device: istrument assisted soft tissue mobilization<br>* Each subject in group (A) will receive 12 sessions of physical therapy 3 sessions per week for 4 weeks). Each subject in group (B) will receive 8 sessions of physical therapy(two sessions per week for four weeks).<br>* Other names: core stability exercises;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| pain level | pain level will be measured by visual analogue scale.The VAS is a 100-mm horizontal line anchored by word descriptors at each end by ''no pain'' on the left and ''worst imaginable pain'' on the right. The minimum score means it is better. | four weeks following end of treatment | 
| Cervical range of motion and proprioception | Cervical range of motion and proprioception will be measured using CROM. | four weeks following end of treatment | 
| Functions | Functions will be measured by Arabic version of Neck Disability Index.It is consisting of 10 items with six choices (0-5), Each item is scored from zero (no disability) to five (total disability). Minimum score means it is better | four weeks following end of treatment | 
| Muscle activity | Muscle activity measured by EMG. | four weeks following end of treatment | 
| H-reflex | H-reflex will be measured by EMG | four weeks following end of treatment |