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Krutika S. P et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-52 2017 342-348 342 IJAMSCR |Volume 5 | Issue 2 | Apr - Jun - 2017 www.ijamscr.com Research article Medical research Added effect of strain counter-strain technique on pain Cervical ROM in students with mechanical neck pain with upper trapezius trigger points. A RCT Krutika S. Panchal 1 Dr. Ravinder Kaur 2 Dr. Snehal Ghodey 3 1 BPTh Intern Muskuloskeletal Physiotherapy Department MAEER’s Physiotherapy College P.O. Talegaon General Hospital Talegaon Dabhade Tal. Maval Dist. Pune-410507 India. 2 Associate Professor Muskuloskeletal Physiotherapy Department MAEER’s Physiotherapy College P.O. Talegaon General Hospital Talegaon Dabhade Tal. Maval Dist. Pune-410507 India. 3 Principal MAEER’s Physiotherapy College P.O. Talegaon General Hospital Talegaon Dabhade Tal. Maval Dist. Pune-410507 India. Corresponding Author: Krutika S. Panchal Email id: panchalkrutika2139gmail.com ABSTRACT Objectives To assess the added effect of Strain Counter-strain SCS technique along with conventional treatment on pain cervical ROM in students with mechanical neck pain with upper trapezius trigger points. Methods In this experimental study forty students with mechanical neck-pain upper trapezius trigger points were randomly allocated into two groups control or experimental group. The control group received conventional therapy consist of moist heat supervised exercises and trapezius stretching and experimental group received Strain Counter-strain technique along with conventional therapy. Treatment was given once a day for 5 days. A numerical rating scale NRS was used to measure the intensity of pain functional disability was assessed using NDI i.e. neck disability index and cervical ROM was measured with universal goniometer. Data analysis was done on 5 th day. Results On pre post analysis NRS NDI scores and cervical ROM showed a statistically significant improvement in both control and experimental groups p 0.0001. However between group analysis both NRS and NDI scores showed statistically significant improvement in the experimental group p 0.0001. The range of motion for cervical flexion p 0.3184 and extension p 0.3126 was equally improved in both the groups. But lateral flexion and rotation on both sides were statistically significantly improved in experimental group than in control group p0.0001. Conclusion Strain counter strain technique along with conventional treatment is effective in relieving pain improving cervical lateral flexion and rotation ROM in students with mechanical neck pain with upper trapezius trigger points. Keywords: Neck pain Strain counter strain Upper trapezius Trigger points. ISSN:2347-6567 International Journal of Allied Medical Sciences and Clinical Research IJAMSCR

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Krutika S. P et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-52 2017 342-348 343 INTRODUCTION Neck pain is a common musculoskeletal disorder seen in the general population. Point prevalence ranges from 6 to 38 of the elderly population and lifetime prevalence is from 14.2 to 71 1. Prevalence in female is more than male 83. Worldwide 6 month prevalence of neck pain for 18 year old females is 45 2. The International Association for the Study of Pain defines neck pain as: ―Pain perceived from the region bounded superiorly by superior nuchal line inferiorly by an unoriginally transverse line through the tip of first thoracic spinous process and laterally by lateral border of neck 3. Myofascial pain syndrome is a muscle disorder caused because of presence of myofascial trigger points 4. Researchers clinically define a myofascial trigger point MTrP as ―a hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band.‖ These hypersensitive spots are painful when pressure is applied and can produce referred pain or tenderness motor dysfunction and autonomic reaction 5. Trigger points can be active or latent depending on their characteristics. The pain caused by trigger points is often described as spreading or radiating. The trigger point can be differentiated from tender point as tender point is associated with pain and tenderness at the palpation site only. The upper trapezius is the muscle most often affected by myofascial trigger points MTrPs. Fischer et al. measured the pressure pain threshold PPT with a pressure algometer of 8 different muscles and found that the upper trapezius was most sensitive muscle to the pressure. 6 Many researchers agrees that acute trauma or repetitive micro trauma are the reason for development of a trigger point. Lack of exercise joint problems prolonged bad posture vitamin deficiency and sleep disturbances all these may predispose to the formation of trigger points. 7 Many treatments are available in physical therapy to treat these MTrPs such as Ischaemic compression technique stretching technique Strain Counter-strain technique Trigger point pressure release therapy Ultrasound deep heat therapy Laser Therapy Dry needling Transverse Friction massage Cyriax Post isometric relaxation MET Electrical muscle stimulator etc.7 Strain-Counter strain S-CS Invented by Laweren Jones is a gentle indirect manipulation technique for the treatment of many somatic dysfunctions where positioning of the body is used to manifest a therapeutic effect. 7 There are different studies Which noted the use of strain counter-strain technique combined with other interventions for treating a variety of disorders like chondromalacia patellae low back pain pancreatitis and cervicothoracic pain. Many researchers did study on patients with localized myofascial pain syndrome and found that the strain counter strain technique was effective in pain reduction and improving functional ability. 8 Trapezius trigger points when in active state causes spreading pain and radiation and hence unsettling. Therefore it is important to find out the new easy and quick ways to treat these trigger points. 7 There are studies which prove that combination of SCS with other manipulation has immediate effect on pain reduction on tender points. But no study has been done to prove whether this technique alone has pain reduction effect on trigger points and improvement in cervical ROM. 7 Therefore it is important to find out the effect of strain counter-strain technique on trigger points so that it can be used in clinical practice. METHODOLOGY After receiving ethical clearance from the institutional committee of the Physiotherapy College students with neck pain having upper trapezius trigger points were evaluated according to the following criteria: 1Females between ages of 18-30 yrs. 2 Participants with mechanical neck pain with upper trapezius trigger points 3 reduced cervical ROM 4 upper trapezius spasm. 5 Subjects with unilateral bilateral involvement. 6Participants scoring above 5 on numerical rating scale NRS. 5Participants scoring 5-24 on neck disability index NDI. Participants with whiplash injury or fracture of cervical spine PIVD Cervical instability cervical spine or shoulder surgery in past 1 year cervical radiculopathy or myelopathy vertigo dizziness at rest were excluded from the study.

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Krutika S. P et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-52 2017 342-348 344 Forty participants met these criteria. A informed consent form was taken from all the participants in written format and the procedure was explained to every participant by the therapist. Formation of groups Individuals satisfying the inclusion criteria were randomly divided into Group A control or Group B experimental by chit method. The division was done by the therapist prior to the assessment. Group A underwent conventional therapy consist of moist heat supervised exercises and upper trapezius stretching. Group B underwent conventional therapy along with Strain Counter- strain SCS technique 9. Outcome measures  Numerical Rating Scale for assessment of pain10  Neck disability index NDI for functional assessment 11.  Universal Goniometer used for assessment of range of motion12 Myofascial trigger point Diagnosis: 13 The therapist used her thumb and pointer finger to palpate the muscle.Presence of a palpable taut band hypersensitive tender spot local twitch response induced by the palpation of the taut bands reproduction of reffered pain cause by the myofascial trigger points and a positive jump sign denotes the presence of MTrPs. INTERVENTION Group A control group Received conventional therapy 14 which includes Moist heat In the form of hot pack for 10mins. Position: In sitting on chair with head supported on table in front. Supervised exercises Neck isometrics for flexion extension lateral flexion rotations shoulder shrugs and scapular retraction with shoulder 90° abducted. 5 sec hold was given for 10 times for each exercise. Trapezius stretching Position of the subject was sitting on chair and subject’s head was passively taken into cervical flexion contralateral flexion and ipsilateral rotation. The position was maintained for 30 sec. The technique was given twice per session. 15 Group B experimental group Received strain counter-strain technique along with conventional therapy. For strain counter strain technique Subject’s Position: seated on chair with neck in a neutral position. Then therapist palpated the upper trapezius muscle with the thumb for locating trigger point. After locating trigger point the therapist applied gradually increasing pressure until the subject feels the pressure and pain at the same time. At that point the subject was passively taken into a position which reduces the tension under the therapist’s thumb and reduces the pain by around 70. For upper trapezius the position which reduces pain was upper extremity of treatment side in 90° of abduction cervical flexion ipsi-lateral side-flexion and 5-8° of contra-lateral cervical rotation. This position was maintained for 90 sec. After 90 sec the subject was slowly taken into the neutral position. Two trigger points were treated on each side per session for 5 consecutive days. On 5th day after treatment re-evaluation was done with NRS NDI and cervical ranges were taken with universal goniometer. RESULTS Table.1. Demographic data Number Mean Females Group A20 Group B 20 20 Age 18-25 21

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Krutika S. P et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-52 2017 342-348 345 Table.2: Analysis of numerical rating scale GROUPS Mean p value w value U value Pre Post NRS on activity Control 6.8± 0.915 3.6±0.7539 0.0001 210 0.5 p value0.0001 Experimental 7.25± 0.9105 0.7±0.7327 0.0001 210 NRS at rest Control 2.5±0.7609 1±0.7255 0.0001 190 47 p value0.0001 Experimental 3.35±1.309 0.05±0.2236 0.0001 190 Extremely Significant. Table 3: Analysis of neck disability index GROUPS Mean p value w value U value Pre Post Control 18.834 ± 6.438 9.457 ± 4.374 0.0001 210 46 p value 0.0001 Experimental 20.889 ± 7.425 4.097 ± 1.877 0.0001 210 Extremely significant

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Krutika S. P et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-52 2017 342-348 346 Table 4. Analysis of cervical range of motion GROUPS Mean p value t value Unpaired t value Pre Post FLEXION Control 36.4± 4.285 39.9± 4.723 0.0001 7 1.011 p value 0.3184 Experimental 32.95 ± 6.004 37.15 ± 4.637 0.0001 8.768 EXTENSION Control 47.25 ± 5.035 49.9 ± 5.17 0.0001 10.025 1.023 p value0.3126 Experimental 44.65 ± 8.197 47.85 ± 8.647 0.0001 6.839 LATERAL FLEXION Rt Control 21.1 ± 4.064 24.5 ± 3.804 0.0001 12.803 14.565 p value0.0001 Experimental 21.15 ± 3.843 29.05 ± 2.929 0.0001 14.565 LATERAL FLEXION Lt Control 19.7 ± 3.922 23.95 ± 3.591 0.0001 19.664 6.116 p value0.0001 Experimental 21.55 ± 3.395 29.6 ± 2.371 0.0001 13.819 ROTATION Rt Control 59.2 ± 13.548 64.5 ±12.775 0.0001 13.543 9.359 p value0.0001 Experimental 54.1 ± 7.88 68.60 ± 7.185 0.0001 16.08 ROTATION Lt Control 61.15 ± 10.525 66.20 ± 10.636 0.0001 16.195 9.211 p value0.0001 Experimental 58.7 ± 10.337 72.4 ± 7.789 0.0001 15.465 Extremely Significant Not Significant. Within group analysis of NDI and NRS done by Mann Whitney test showed improvement post treatment in both the groups but experimental group showed statistically significant improvement in pain as well as functionp 0.0001 Between group analysis of NRS and NDI done by Wilcoxon Sign Rank test which showed improvement in both groups post treatment but experimental group showed more statistically significant improvement. NRS: p value 0.0001 U value on activity is 0.5 and at rest is 47 NDI: p value0.0001 U value46 Within group analysis of cervical range of motion done by paired t test showed improvement in all movement. But cervical lateral flexion and rotation showed statistically significant improvement post treatment in experimental group. Between group analysis of cervical flexion and extension done by unpaired t test showed insignificant improvement in both the groups. P for flexion 0.3184and t value for flexion 1.011 p value for extension 0.3126 t value for extension1.023. On analysis of cervical lateral flexion and rotation found that there was statistically significant improvement in experimental group than control group. P value 0.0001 and t value for lateral flexion Rt. 7.451 Lt. 6.116 t value for rotation Rt. 9.359 Lt. 9.211 DISCUSSION He study was performed to assess the added effect of Strain Counter-strain SCS technique along with conventional treatment on pain cervical ROM in students with mechanical neck pain with upper trapezius trigger points. The study was performed on 40 subjects with chronic mechanical neck pain having myofascial

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Krutika S. P et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-52 2017 342-348 347 trigger point in trapezius muscle. Then Subjects were randomly divided into experimental and control group n20 respectively in which the experimental group received S-CS technique along with Moist Heat postural correction exercises stretching and control group received Moist Heat postural correction exercises stretching only. 12 Each patient received continuous 5 days treatment. The outcome measure was Numerical Rating Scale Neck Disability Index and Cervical Goniometry. In this study as shown in graph 1 the changes observed in NRS are statistically significant in both the groups control p0.0001 as well as experimental p0.0001 but experimental group showed more statistically significant improvement p0.0001 U at rest 47 U on activity0.5. This comparison between two groups of the study reveal that the amount of trigger point pain reduction is statically significant when conventional treatment was combined with strain counter strain technique than conventional treatment alone. Improvement in pain in control group is might be because of muscle relaxation and sedation of sensory nerve endings offered by moist heat 16 and passive slow sustained stretch as this stretch causes mechanical disruption of the cross-bridges as the filaments slide apart leading to reduction in muscle spasm in turn reducing pain. 15 The reduction in pain in experimental group can be explained by the neurophysiology 17 of Strain Counter Strain technique. Prolonged bad posture causes stretching of the muscles which increases motor firing in afferent nerve fibers. This aberrant afferent flow from muscle spindle causes reflex muscle spasm which resists the joint to come back to neutral position. This movement causes pain in muscle spindle. Diagnosis is made by the presence of trigger points. Using trigger point as monitor the operator is guided into a position of comfort where muscle is in most shortened position and this reduces aberrant afferent flow. Holding the position for 90 sec. allows spindle to slow down afferent firing frequency 17. Returning the muscle in neutral position in slow deliberate way will avoid re-excitation. This will help to normalize the tone and length of affected muscle. 8 On pre-post analysis of cervical flexion and extension ROM showed statistically significant improvement in both the groups p0.0001. But analysis between control and experimental group for cervical flexion p 0.3184 t value 1.011 and extension p 0.3126 t value 1.023 was not statistically significant. On contrary the pre and post value of both the groups for lateral flexion Rt and Lt and rotation Rt and Lt showed statistically significant improvement P0.0001. But the inter group analysis between both the groups showed that addition of SCS technique improved the outcomes remarkably as compared to conventional treatment alone P0.0001 t value for lateral flexion Rt. 7.451 Lt. 6.116 t value for rotation Rt.9.359 Lt. 9.211 The improvement in control group might be because of increase in muscle length caused by sustained stretch given to the muscle spindle 15. When sustained stretch is applied on a muscle there is mechanical disruption of the cross-bridges as the filaments slide apart leading to abrupt lengthening of the sarcomeres. Upper trapezius muscle is mainly associated with cervical rotation and lateral flexion 18. The automatic resetting of the muscle fibers done by application of SCS technique might be the reason of improvement in cervical rotation and lateral flexion in experimental group. Graph 2 shows functional disability on Neck Disability Index is evidently improved in both the groups control p 0.0001 as well as experimental p 0.0001 but it was found to be more statistically significant in experimental group p 0.0001 U 46. The reason for this statistically significant improvement must be reduction in pain and improvement in cervical range of motion. As this improvement was more in experimental group NDI score of experimental group showed remarkable change. The limitation for this study was that the pain pressure threshold was not measured because of unavailability of pressure algometer. This study can be performed with longer duration. It can be done in other field as well as other age group and gender. CONCLUSION Strain counter strain technique along with conventional treatment is effective in relieving pain improving cervical lateral flexion and rotation ROM in students with upper trapezius trigger points.

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Krutika S. P et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-52 2017 342-348 348 REFERENCES 1. R. Fejer K.O. Kyvik J. Hartvigsen The prevalence of neck pain in the world population: a systematic critical review of the literatureEur Spine J 15 2006 pp. 834–848. 2. Rene fejer Kristen Ohm Kyvik and Jan Hartvigsen. Prevalence of neck pain in the world population: a systematic critical review of the literature. European spine journal 2006 834-848. 3. V. Misailidou P. Malliou A. Beneka A. Karagiannidis G. Godolias Assessment of patients with neck pain: a review of definitions selection criteria and measurement tool.J Chiropr Med 9 2010 49–59 4. Hong CZ Hsueh TC. Difference in pain relief after trigger point injections in myofascial pain patients with and without fibromyalgia. Arch Phys Med Rehabil 77 1996 1161-6. 5. Simons DG Travell JG Simons LS. Travell Simons Myofascial pain and dysfunction: the trigger point manual. 2d ed. Baltimore: Williams Wilkins 1999. 6. Farshad Okhovatian Royah Mehdikhani Sedighehsadat Naimi: Comparison between the immediate effect of manual pressure release and strain/counter strain techniques on latent trigger point of upper trapezius muscle.Clinical Chiropractic 15 2012 55—61. 7. Amir Iqbal1 Hashim Ahmed2 Md Abu Shaphe: Efficacy of Muscle Energy Technique in Combination with Strain-counter strain Technique on Deactivation of Trigger Point Pain Indian Journal of Physiotherapy Occupational Therapy. July-September 73 2013 118. 8. Albert Atienza Meseguer Ce´sarFerna´ndez-de-las-Pen ˜asa Jose Luis Navarro-Pozaa Cleofa´s Rodr´ıguez- Blanco Juan Jose ´Bosca´Gandia: Immediate effects of the strain/counter strain technique in local pain evoked by tender points in the upper trapezius muscle. Clinical Chiropractic 9 2006 112—118 9. Christopher Kevin Wong and Carrie Schauer: Reliability Validity and Effectiveness of Strain Counter strain Techniques Journal Of Manual Manipulative Therapy 122 2004. 10. Ferraz MB Quaresma MR Aquino LR Atra E Tugwell P Goldsmith CH: Reliability of pain scales in the assessment of literate and illiterate patients with rheumatoid arthritis. J Rheumatol 17 1990 1022–4 11. HT Vernon Silvano Mior: The Neck Disability Index: A Study of Reliability and Validity Journal of Manipulative and Physiological Therapeutics 147 1991 409-15. 12. Muhammad Nazim Farooq Mohammad A. Mohseni Bandpei Mudassar Ali and Ghazanfar Ali Khan: Reliability of the universal goniometer for assessing active cervical range of motion in asymptomatic healthy persons. Pakistan Journal of Sciences Received Revised 2016 Accepted 2016. 13. Sakina Vohra BPTh Varoon C Jaiswal MPTh CMP CSMT Kiran Pawar MPTh. Effectiveness of Strain Counterstrain Technique on Quadratus Lumborum Trigger Point in Low Back Pain Journal of Sports and Physical Education IOSR-JSPE e-ISSN: 2347-6737 p-ISSN: 2347-6745 16 2014 PP 53-58. 14. Andrew M Leaver1 Kathryn M Refshauge1 Christopher G Maher2 and James H McAuley3 1The University of Sydney: Conservative interventions provide short-term relief for non-specific neck pain: a systematic review Journal of Physiotherapy 2010 Vol. 56 – © Australian Physiotherapy Association 201074 15. Therapeutic Exercises Foundations and techniques 5th edition by Kisner and Colby. 16. Clinical orthopedic rehabilitation 2 by Brodzman and Wilk. 17. Rational Manual Therapies 13 Strain Counter Strain Randall S. Kusunose. 18. B.D. Chaurasia’s Human Anatomy 5th edition volume 1. 19. Methods in Biostatistics for medical students 6 B.K. Mahajan. How to cite this article: Krutika S. Panchal Dr. Ravinder Kaur Dr. Snehal Ghodey. Added effect of strain counter-strain technique on pain Cervical ROM in students with mechanical neck pain with upper trapezius trigger points. A RCT. Int J of Allied Med Sci and Clin Res 2017 52: 342-348. Source of Support: Nil. Conflict of Interest: None declared.