Journal of Manipulative and Physiological Therapeutics
Effects of Exercise and an Integrated Neuromuscular Inhibition Technique Program in the Management of Chronic Mechanical Neck Pain: A Randomized Controlled Trial
Introduction
Neck pain shows a high rate of recurrence and chronicity. Three out of 10 neck pain patients will develop chronic symptoms that last more than 6 months,1,2 whereas 34% will show symptoms for more than 12 months.3 Chronic mechanical neck pain (CMNP) is characterized by a persistence of symptoms for a period longer than 3 months.4 The exact origin and pathophysiological mechanisms of chronic neck pain remain unclear. Many researchers have linked chronic symptoms to changes in neck muscles.5, 6, 7 Individuals with CMNP exhibit muscle weakness and reduced endurance in the neck flexor muscles compared to healthy adults,8 which is highly associated with pain and disability.8,9
Therapeutic exercise (TE) has proven to be beneficial to individuals with CMNP.1,2,9,10, 11, 12, 13 Improvement of neck muscle strength and endurance has been associated with pain reduction and improved functional capacity. Six weeks of TE in people with CMNP resulted in short-term effects by reducing pain and improving neck muscle weakness and isometric strength,14 but these effects do not seem to remain after 6 months. In contrast, Ylinen et al13 reported long-term benefits with pain reduction and disability improvement following a 12-month TE program.
The TE programs of individuals with CMNP often involve resistance and endurance training for neck and shoulder muscles. The combination of both is a more complete approach with better results.4,13,15,16
Many researchers have pointed out the therapeutic value of combining TE with manual therapies.2,17,18 Miller et al16 reported that the combination of exercise and manipulation or mobilization of the cervical and thoracic spine brought better short- and medium-term reduction of pain and disability than the application of each type separately. However, in studies that have implemented a combination of exercise and manipulation in contrast to manipulation only, it is not clear whether the differences identified between the groups are due to the exercise alone or to the particular combination.19 Thus, the appropriate choice of techniques and dosage requires further investigation.18
Many researcher studies associate neck pain with the presence of myofascial trigger points (MTrPs) in the neck muscles.20, 21, 22 MTrP has been defined as a hyperirritable spot within a taut band of skeletal muscle fibers painful on compression.23 It has been shown that in people with chronic neck pain there are almost always more trigger points in more than 1 muscle. Cerezo-Téllez et al20 in a study of 2000 patients with chronic neck pain found that all participants displayed trigger points in the cervical muscles with a higher incidence of trigger points in the upper trapezius. However, although the occurrence rate is so high, few studies in chronic neck pain have used a combination of exercise and MTrPs deactivation techniques.21,24 This portrays an important literature gap in the research field of manual therapy. The presence of MTrPs in individuals experiencing chronic pain is associated with increased intramuscular electromyographic activity of the agonist25 and antagonist26 muscles during synergistic muscle activation and with increased muscle fatigue during isometric muscle contraction.27 At the same time, Ylinen et al28 reported that people with chronic neck pain have decreased values in strength and endurance in all muscle groups of the neck compared with healthy individuals. For this reason, this specific combination of exercise and trigger point deactivation technique presents a research interest.
The integrated neuromuscular inhibition technique (INIT) is a manual MTrPs deactivation technique, which has been described by Chaitow.29,30 It includes the combination of the ischemic compression technique, the strain-counterstrain technique, and the muscle energy technique. Sadaat et al31 reported that 1 session of the INIT is able to reduce pain and pressure pain threshold (PPT) in individuals with CMNP due to MTrPs in the upper trapezius muscle. Nagrale et al32 claimed that the INIT is more effective than the muscle energy technique in improving pain, disability, and range of motion (ROM) in individuals with neck pain, whereas Sibby et al33 suggested that the INIT is equally effective with laser application in upper trapezius MTrPs.
The INIT, based on the phenomenon of reciprocal inhibition and post-isometric relaxation, can resolve muscle spasm in painful areas29,30 and thus could be optimally combined with TE in muscles housing MTrPs. The combination of TE and manipulation, mobilization, or connective tissue massage has been employed recently for treating CMNP.19,34, 35, 36, 37, 38 However, the combination of TE and a MTrPs deactivation technique has not been widely applied. The purpose of this study was to evaluate the effect of adding INIT to a TE program for management of CMNP. The hypothesis of this study was that the combination of INIT and TE yields greater improvement in pain, disability, neck muscle tenderness, neck ROM, and quality of life of patients with CMNP than TE alone. To better monitor treatment effects, several intermediate measurements were performed.
Section snippets
Design
This was an assessor-blind, randomized controlled trial (clinicaltrials.gov number: NCT02802189). Two experienced physiotherapists applied the 2 protocols, the first was responsible for supervising and conducting the exercise program and the second was implementing the INIT and relaxation exercises. It was not possible for care providers or participants to be unaware of group allocation. A masked assessor conducted the measurements.
Participants signed an informed consent and were randomly
Participants
During the recruitment period 62 individuals applied for evaluation. Of these, 8 people refused to participate in the research and 14 did not meet the inclusion criteria. Forty were randomly assigned to the 2 groups. Counseling and education of patients on the benefits of cervical muscle exercise was provided to the participants of both groups at the beginning of the study. According to O'Riordan et al,4 the fear of suffering pain and the lack of knowledge of exercise benefits are strictly
Discussion
The results of this study suggest that both groups experienced a clinically meaningful improvement in all the variables examined during the intervention period. However, the IG showed greater improvement in several variables over CG. This provides support to our hypothesis that the addition of the INIT to TE may be beneficial for treating patients with CMNP.
The VAS score was reduced in both groups during the intervention period. However, this reduction was greater in the IG in all follow-ups (
Conclusion
The results of this preliminary study suggest that the therapeutic combination of TE and the INIT may be more effective than TE alone in the management of CMNP, as reflected by a greater reduction in pain, disability, local tenderness of the muscles, and some indices of health-related quality of life.
Funding Sources and Conflicts of Interest
No funding sources or conflicts of interest were reported for this study.
Contributorship Information
Concept development (provided idea for the research): D.E.L., E.I.S., K.I.C., E.K.
Design (planned the methods to generate the results): D.E.L., E.I.S., K.I.C., I.S.M., E.K.
Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): D.E.L., E.I.S., K.I.C., E.K.
Data collection/processing (responsible for experiments, patient management, organization, or reporting data): D.E.L., E.I.S., I.S.M.
Analysis/interpretation (responsible for statistical
References (61)
- et al.
The annual incidence and course of neck pain in the general population: a population-based cohort study
Pain
(2004) - et al.
Chronic neck pain and exercise interventions: frequency, intensity, time, and type principle
Arch Phys Med Rehabil
(2014) - et al.
Evaluation of repeatability of pressure algometry on the neck muscles for clinical use
Man Ther
(2007) - et al.
Decreased neck muscle strength is highly associated with pain in cervical dystonia patients treated with botulinum toxin injections
Arch Phys Med Rehabil
(2004) - et al.
Myoelectric manifestations of sternocleidomastoid and anterior scalene muscle fatigue in chronic neck pain patients
Clin Neurophysiol
(2003) - et al.
An endurance-strength training regime is effective in reducing myoelectric manifestations of cervical flexor muscle fatigue in females with chronic neck pain
Clin Neurophysiol
(2006) - et al.
Exercises for mechanical neck disorders: a Cochrane review update
Man Ther
(2016) - et al.
Manual therapy and exercise for neck pain: A systematic review
Man Ther
(2010) - et al.
Myofascial trigger points, pain, disability, and sleep quality in individuals with mechanical neck pain
J Manipulative Physiol Ther
(2012) - et al.
Latent myofascial trigger points are associated with an increased intramuscular electromyographic activity during synergistic muscle activation
J Pain
(2014)
Latent myofascial trigger points are associated with an increased antagonistic muscle activity during agonist muscle contraction
J Pain
Decreased isometric neck strength in women with chronic neck pain and the repeatability of neck strength measurements
Arch Phys Med Rehabil
Effects of integrated neuromuscular inhibition technique on pain threshold and pain intensity in patients with upper trapezius trigger points
J Bodyw Mov Ther
Cervical and scapulothoracic stabilization exercises with and without connective tissue massage for chronic mechanical neck pain: a prospective, randomised controlled trial
Man Ther
Spinal manipulative therapy and exercise for seniors with chronic neck pain
Spine J
Patient rating of care at a rheumatology out-patient unit
Arch Med Res
The Neck Disability Index: state-of-the-art, 1991-2008
J Manipulative Physiol Ther
Psychometric properties of the Neck Outcome Score, Neck Disability Index, and Short Form-36 were evaluated in patients with neck pain
J Clin Epidemiol
Effect of long-term neck muscle training on pressure pain threshold: a randomized controlled trial
Eur J Pain
Pressure pain thresholds, clinical assessment, and differential diagnosis: reliability and validity in patients with myogenic pain
Pain
Multimodal group rehabilitation compared to usual care for patients with chronic neck pain: A pilot study
Man Ther
Short- and medium-term effects of manual therapy on cervical active range of motion and pressure pain sensitivity in latent myofascial pain of the upper trapezius muscle: a randomized controlled trial
J Manipulative Physiol Ther
Effect of therapeutic exercise on pain and disability in the management of chronic nonspecific neck pain: systematic review and meta-analysis of randomized trials
Phys Ther
Neck pain: Clinical practice guidelines linked to the international classification of functioning, disability, and health form the orthopaedic section of the American Physical Therapy Association
J Orthop Sport Phys Ther
Feedforward activity of the cervical flexor muscles during voluntary arm movements is delayed in chronic neck pain
Exp Brain Res
Exercises for mechanical neck disorders
Cochrane Database of Syst Rev
Conservative management of mechanical neck disorders: a systematic review
J Rheumatol
Active neck muscle training in the treatment of chronic neck pain in women: a randomized controlled trial
JAMA
A randomized controlled trial on the efficacy of exercise for patients with chronic neck pain
Spine (Phila Pa 1976)
Effects of long-term home-based exercise on health-related quality of life in patients with chronic neck pain: a randomized study with a 1-year follow-up
Disabil Rehabil
Cited by (10)
Training-induced hypoalgesia and its potential underlying mechanisms
2022, Neuroscience and Biobehavioral ReviewsCitation Excerpt :However, caution is needed when interpreting results from these studies as groups were not randomly assigned. In individuals with chronic neck and/or shoulder pain, some studies without a control group showed that the pressure pain threshold increased higher in a group that performed multimodal training in combination with manual therapy (Lytras et al., 2020; Rodríguez-Sanz et al., 2020; Corum et al., 2021; Camargo et al., 2015) and connective tissue massage (Celenay et al., 2016b), when compared to a group that performed multimodal training only. Contrary to these studies, there were studies that reported no differences in pressure pain threshold changes between groups that performed multimodal training with or without additional treatments (e.g., manual therapy, laser therapy, and percutaneous electrolysis) (Celenay et al., 2016a; Aceituno-Gómez et al., 2019; de Miguel Valtierra et al., 2018).
The effects of combined sternocleidomastoid muscle stretching and massage on pain, disability, endurance, kinesiophobia, and range of motion in individuals with chronic neck pain: A randomized, single-blind study
2021, Musculoskeletal Science and PracticeCitation Excerpt :The sample size calculation was considered as a power calculation to detect between-group differences in the primary outcome measures. According to the relevant literature, the effect of massage and stretching exercises on CNP were determined as a small effect size (0.02–0.194), (Lizis et al., 2020; Lytras et al., 2020; Pal and Misra, 2019; Rajalaxmi et al., 2019). To obtain 80% statistical power (1−β error probability) with an α error level probability of 0.05, we used repeated-measure analysis of variance (ANOVA), within-between interaction, and a small effect size of 0.20 to consider the two groups and two measurements for primary outcome, generating a sample size of approximately 51 participants.
Exercise therapy including the cervical extensor muscles in individuals with neck pain: A systematic review
2023, Clinical RehabilitationResistance, Motor Control, and Mindfulness-Based Exercises Are Effective for Treating Chronic Nonspecific Neck Pain: A Systematic Review With Meta-Analysis and Dose-Response Meta-Regression
2023, Journal of Orthopaedic and Sports Physical TherapyComparison of two different manual techniques for an exercise program for the management of chronic neck pain: A randomized clinical trial study
2023, Journal of Back and Musculoskeletal Rehabilitation