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This study aims to investigate the effects of the integrated neuromuscular inhibition technique on patients with upper trapezius myofascial trigger points by evaluating its impact on neck pain intensity, pressure pain threshold, hand grip strength, pinch grip strength, wrist joint range of motion, and upper extremity function.
Myofascial pain syndrome (MPS) is one of the most common musculoskeletal disorders. Approximately, 30% to 85% of the population with musculoskeletal disorders would experience Myofascial trigger points (MTrPs) in their life. Also, the prevalence of MTrP has been reported as 21%, 30%, and 93% in the patients of a general orthopedic clinic.
Myofascial trigger points (MTrPs) are hypersensitive, cord-like or nodular tender spots found in a skeletal muscle. They are painful on palpation, compression or stretch. The prevalence of affection of these trigger points have found to be more in postural muscles such as the trapezius. It has been found that 85% of people who come to pain clinics show presence of trigger points in the neck, and that occurs more commonly in women than men.
The trigger point sites in the upper trapezius commonly refer pain along the posterolateral aspect of the neck, behind the ear to the temple. MTrP in the upper trapezius is known to usually present with complains of neck pain, headache, muscle stiffness, restricted range of motion (ROM) of the cervical joint, and insomnia by the patient. It is frequently caused by poor posture, acute trauma, muscle stress, and psychological stress.
The trapezius muscle has a supporting and stabilizing function on the movement of the upper extremities, such as in many everyday work tasks (computer work, cleaning, eating). The trapezius muscle is involved in many activities related to the high prevalence of neck pain. This muscle participates in long-term low-level activity, which is typically appreciated by office workers. Tightness of the upper trapezius lead to muscle imbalance in the scapulothoracic region, leading to neck pain and cervicogenic headaches.
The most important functions of the upper extremity for independent and smooth activities of daily living are the functions of the hand. A representative function of the hand is to hold something. The strength of the fingers when holding something is known as grip strength and it is an important index in the evaluation of motor function of the hand.
It is widely accepted that grip strength provides an objective index of the functional integrity of the upper extremity. Physical and occupational therapists commonly measure grip strength to monitor the success or failure of their treatment programs, besides, grip strength serves to be an important contributor to quality of life, functional ability, and independence.
A previous study has revealed the effectiveness of conventional treatment in reducing neck pain in patients with upper trapezius trigger points. Stretching techniques, Myofascial release, proprioceptive neuromuscular facilitation, and ischemic compression are a few types of manual therapy. Applying massage therapy to the sensitive region is one of the treatment modalities that patients choose in addition to their therapies for greater relaxation.
Integrated neuromuscular inhibition (INI) has also been proposed to alleviate neck pain, improve cervical range of motion, and eliminate neck dysfunction. INI has been approved as an efficient treatment for MTrPs, allowing the use of the three techniques in a single and coordinated manner. It was suggested that combination of Muscle energy technique (MET), ischemic compression and Strain Counter-strain (SCS) producing a most effective, targeted approach to TrP release. This method is termed as integrated neuromuscular inhibition technique (INIT). The benefit of the technique lies in its multifaceted approach allowing delivery of the techniques in a single coordinated manner.
Neuromuscular Inhibition Technique (INIT) has gained attention for its potential efficacy in deactivating MTrPs and enhancing musculoskeletal function. It was revealed that results with INIT in reducing pain and improving function in patients with upper trapezius MTrPs. For instance, a previous study has demonstrated that a single session of INIT significantly lowered pain intensity and pressure pain threshold in individuals with chronic neck pain.
There is a gap in the literature regarding the effect of integrated neuromuscular inhibition technique on hand grip strength in upper trapezius trigger points.
So, this study will conduct to discuss the effect of integrated neuromuscular inhibition technique on neck pain intensity level, pressure pain threshold (PPT), hand grip strength, pinch grip strength, wrist joint range of motion, and upper extremity function in upper trapezius myofascial trigger points.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Integrated Neuromuscular Inhibition Technique + Conventional Physical Therapy | Experimental | It will consist of 30 participants who will receive the integrated neuromuscular inhibition technique, including muscle energy techniques (MET), ischemic compression (IC), and strain-counterstrain (SCS), in addition to conventional physical therapy consisting of deep friction massage, passive stretching, and isometric strengthening exercises for the neck muscles. All participants will receive 12 treatment sessions, conducted three times weekly over a period of four weeks. |
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| Conventional Physical Therapy | Active Comparator | It will consist of 30 participants who will receive conventional physical therapy only, including deep friction massage, passive stretching, and isometric strengthening exercises for the neck muscles. All participants will receive 12 treatment sessions, conducted three times weekly over a period of four weeks. |
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| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Integrated Neuromuscular Inhibition Technique | Other | Participants in the experimental group will receive the integrated neuromuscular inhibition technique three times per week for four consecutive weeks. The integrated neuromuscular inhibition technique protocol will include ischemic compression, strain-counterstrain (SCS), and muscle energy technique (MET). |
| Measure | Description | Time Frame |
|---|---|---|
| Hand Grip Strength assessment | Hand grip strength will be assessed using a Baseline Digital Hand Dynamometer following the standardized guidelines of the American Society of Hand Therapists (ASHT). Participants will be seated comfortably with back support, shoulders abducted, elbows flexed to 90°, and forearms and wrists maintained in a neutral position. The contralateral hand will rest on the thigh during testing. Participants will be instructed to grip the dynamometer maximally for approximately 3 seconds after one practice trial for each hand. Grip strength values will be recorded in kilograms using the same device throughout the study. | 4 weeks |
| Pinch Grip Strength assessment | Pinch grip strength will be assessed using a Baseline Digital Pinch Dynamometer according to the standardized posture recommended by the American Society of Hand Therapists (ASHT). Participants will be seated comfortably with the back straight and feet fully supported on the floor. The shoulders will remain stable without rotation, the elbow will be flexed to 90°, and the forearm will be maintained in a neutral position. The wrist will be positioned between 0-30° of extension and 15° of ulnar deviation, with the arm unsupported by the chair handle during testing. | 4 weeks |
| Wrist Range of Motion assessment | It will be assessed by using Digital Goniometer. A goniometer was placed at the ulnar styloid next to the little finger and set the initial state as the zero-degree position for wrist flexion and extension measurements. The radial deviation and ulnar deviation were measured by placing the goniometer at the center of the hand and in the middle of the middle finger. | 4 weeks |
| Measure | Description | Time Frame |
|---|---|---|
| Pain Intensity Level assessment | Pain intensity level will be assessed using the Visual Analog Scale (VAS). Participants will be asked to mark a point on a 100 mm horizontal line that best represents their pain intensity. The examiner will measure the distance in millimeters from the "no pain" anchor to the marked point using a ruler, yielding a score ranging from 0 to 100. | 4 weeks |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| Nouran Ali El-Metwally Ali El-Agamy, B.Sc | Contact | +20 10 19835158 | nouranelagamy01@gmail.com | |
| Rania Reda Mohamed, PhD | Contact |
| Name | Affiliation | Role |
|---|---|---|
| Rania Reda Mohamed, PhD | Ass. Prof, Cairo university | Study Chair |
| Hoda Ibrahim Abbas, PhD | Lecturer, Cairo university | Study Director |
| Amr Abdalla Azzam, PhD |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| out patient clinic of Delta University hospital | Gamasa | Egypt |
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| Conventional Physical Therapy | Other | Participants in the two groups will receive conventional physical therapy three times per week for four consecutive weeks. It consists of deep transverse friction massage (DTFM), passive stretching, and isometric strengthening exercises for the neck muscles. |
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| Pressure Pain Threshold assessment | Pressure pain threshold will be assessed using a pressure algometer. Participants will be positioned comfortably, and the upper trapezius trigger point will be identified by palpation. Gradual vertical pressure will be applied at a rate of 1 kg/sec until slight discomfort is reported by the participant. The procedure will be repeated three times with 30-second rest intervals, and the mean value will be calculated as the pressure pain threshold. The pressure algometer is considered a reliable assessment tool for pressure pain threshold measurement. | 4 weeks |
| Upper Extremity Function assessment | Upper extremity function will be assessed using the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH). The questionnaire consists of 11 items scored on a five-point Likert scale, with total scores ranging from 0 to 100, where higher scores indicate greater disability. Item scores will be summed, averaged, and transformed into the final score according to the standardized scoring method. Scores below 15 will indicate minimal symptoms, whereas scores above 40 will reflect marked functional limitation and reduced work ability due to upper limb dysfunction. | 4 weeks |
| Consultant, National Institute of Neuromotor System |
| Study Director |
| ID | Term |
|---|---|
| D009209 | Myofascial Pain Syndromes |
| ID | Term |
|---|---|
| D009135 | Muscular Diseases |
| D009140 | Musculoskeletal Diseases |
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