|Year : 2020 | Volume
| Issue : 2 | Page : 191-195
Effectiveness of strain-counterstrain technique versus digital ischemic compression on myofascial trigger points
Divya Gohil, Shilpa Vaishy, Gaurang Baxi, Akhil Samson, Tushar Palekar
Department of Kinesiotherapy and Movement Science, Dr. D. Y. Patil College of Physiotherapy, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
|Date of Submission||01-Jun-2020|
|Date of Decision||24-Jun-2020|
|Date of Acceptance||17-Jul-2020|
|Date of Web Publication||23-Dec-2020|
Dr. Shilpa Vaishy
Dr. D. Y. Patil College of Physiotherapy, Sant Tukaram Nagar, Pimpri, Pune - 411 018, Maharashtra
Source of Support: None, Conflict of Interest: None
Background and Aim: Neck pain is a typical disorder among people from diverse populations. Myofascial trigger points are located on upper trapezius with a high incidence. These trigger points are commonly found in individuals with mechanical neck pain. This study was conducted to compare the effectiveness of strain-counterstrain and digital ischemic compression on pain, range of cervical lateral flexion and the Neck Disability Index (NDI) score in individuals with Myofascial trigger points of upper trapezius. Materials and Methods: Fifty-five subjects between the age group of 25–45 years clinically diagnosed with neck pain associated with myofascial trigger points were enrolled after ethical approval. Subjects were randomly allocated into Group A (n = 28) (Strain-counterstrain) and Group B (n = 27) (Ischemic compression) for 5 sessions in a week. Outcomes were measured using numerical pain rating scale for pain, NDI for disability and cervical lateral range of motion (ROM) using a goniometer. Results: The intragroup comparison was done using Wilcoxon signed-rank test whereas the intergroup comparison was done using the Mann–Whitney test for data that were not normally distributed. The level of significance was determined by P < 0.05 at 95% confidence interval. Statistically significant improvements were seen in both groups (P < 0.001) whereas in between group analysis, there was no statistically significant difference found (P > 0.05). Conclusion: Both techniques were equally effective in reducing pain, improving ROM of cervical lateral flexion, and NDI score in individuals with myofascial trigger points of upper trapezius.
Keywords: Digital ischemic compression, neck disability index, range of motion, strain-counterstrain technique, upper trapezius myofascial trigger point
|How to cite this article:|
Gohil D, Vaishy S, Baxi G, Samson A, Palekar T. Effectiveness of strain-counterstrain technique versus digital ischemic compression on myofascial trigger points. Arch Med Health Sci 2020;8:191-5
|How to cite this URL:|
Gohil D, Vaishy S, Baxi G, Samson A, Palekar T. Effectiveness of strain-counterstrain technique versus digital ischemic compression on myofascial trigger points. Arch Med Health Sci [serial online] 2020 [cited 2021 Jan 24];8:191-5. Available from: https://www.amhsjournal.org/text.asp?2020/8/2/191/304705
| Introduction|| |
Neck pain is a typical disorder predominantly within the individuals of various populations. Prevalence ranges from 0.4% to 86.8% of population. In general population, 14%–17% of adults are affected by neck pain at some point during their lifetime. The prevalence of neck pain is highly seen in middle-aged group, women are more commonly affected than men. Trigger points are seen to commonly develop in people with mechanical neck pain. The signs and symptoms related to myofascial trigger points are neck and head pain, limited range of motion (ROM), muscle stiffness, dizziness, insomnia, and limited daily activities. Myofascial trigger points are found among in those patients who have suffered from neck pain and upper back pain. These are placed on the upper trapezius with greatest incidence. Palpation is one of the most reliable and symptomatic criteria for locating trigger points in subjects suffered from myofascial pain syndrome. According to Simons and Travells, trigger points are defined as: A hyperirritable foci combined with a hypersensitive palpable nodule, located within the tense bands of skeletal tissue. On compression, the spot is tender and painful that provide classic sensory, motor, and autonomic components. Sensory components include referral pain, local tenderness, and central and peripheral sensitization. Motor components include disturbed motor functions such as muscle stiffness, muscle fragility, and restricted ROM of joint. The myofascial trigger points can be classified according to pain intensity are active and latent trigger points. Active trigger point refers pain at rest without applying any pressure and during activity. On palpation, it is tender with a referred pain. Referred pain is a unique feature of trigger point. A latent trigger point does not induce voluntary pain however may limit the activity and lead fragility of muscle. Strain-counterstrain is a gentle, indirect manipulative technique used for treating of somatic dysfunction. It involves the identification of active trigger point followed by use of pressure till a nociceptive response is generated. When the position of ease is achieved, the stressed tissues are perceive the most relaxed and reduction in muscle tone is achieved. Strain-counterstrain has been seen to be effective in reducing pain and improving function in localized myofascial pain syndrome. Digital ischemic compression is the application of constant digital tension to trigger points with tolerable force. This would lead to a gradual fall in blood supply and alleviate tension in muscle. Ischemic pressure on trigger points stops blood flow to affected area, producing local ischemia. After ischemic pressure is released after 8–20 s, an increase in oxygen supply and nutrients to the local area is seen due to increased blood circulation. This also flushes muscle inflammatory exudates and pain metabolites, desensitizes the nerve endings, break down the scar tissue, and reduces tone of muscles. Relief of muscle spasm and pain from direct digital pressure lead to reactive hyperemia and mechanism of spinal reflex.
| Materials And Methods|| |
Ethical clearance was obtained from the Institutional Ethics Committee at the institute where the study was conducted. One hundred patients clinically diagnosed with neck pain associated with myofascial trigger points were screened for the study. Individuals aged 25–45 years with neck pain <3 months associated with active trigger point at upper trapezius, spot tenderness at one mark along the length of tense band of upper trapezius, palpable myofascial trigger point on bilateral sides of upper trapezius, decreased cervical side flexion to contralateral of active upper trapezius of myofascial trigger point and numerical pain rating scale (NPRS) is <7 were included. Any individual with a history of recent cervical spine surgery, malignancy of cervical region, history of neck trauma/fracture in neck, skin disease in area of neck, sensory disturbances in neck, cervical radiculopathy, myelopathy, and NPRS greater than 7 were excluded from the study. A sample of 60 patients who fulfilled the inclusion criteria was conveniently selected. A written informed consent was taken. Among these, 5 dropped out due to personal reasons. The subjects were then randomly allocated by chit method into two groups. Group A (n = 28) received strain-counterstrain and Group B (n = 27) received ischemic compression, for 3–5 repetitions and 5 sessions in a week along with conventional treatment where, pain was measured by NPRS, functional disability assessed with neck disability index (NDI) and cervical side flexion range was measured using a standard goniometer.
Intervention protocol for Group A (strain-counter strain group)
The patient's position was in supine lying. The therapist palpated the upper trapezius muscle locating trigger points with thumb. While maintaining the pressure, the patient's head was side flexed toward the same side. At that point, the individual was passively taken into zone which reduced tension under therapist's thumb and decreased the pain by around 70%. For upper trapezius, the common position was shoulder flexion, abduction, and external rotation. This position was maintained for 30 s and repeated for 3–5 times. After 30 s, the head was slowly taken into neutral position.
Intervention protocol for Group A (ischemic compression group)
The patient was taken in a sitting position. The affected side and trigger point in upper trapezius was marked with skin marker. Using a pincer clasp, pressure was applied on the active trigger point. Compression was continued until release of tissue limit perceived by patient. This was continued intermittent, then continuously for 30 s according to the patient desirability. This technique was given for 3–5 times.
In addition to the above intervention, both groups received conventional therapy, which included the following: hot pack for cervical region (10 min), neck isometrics (5 s hold for 10 repetitions), scapular retraction exercises (5 s hold for 10 repetitions), and upper trapezius muscle stretching (30 s hold with twice per session). Summary of the procedure is given in [Figure 1].
| Results|| |
There were five dropouts. A total of 55 subjects completed the treatment protocol for 5 days (28 in Group A and 27 in Group B). Data analysis and interpretation was done using WINPEPI (version 11.65) and Primer of Biostatistics (version 7). Initially, normality of data was analyzed using Shapiro–Wilk Test in WINPEPI software version 11.65 [This is an online software]. The intra-group comparison was done using Wilcoxon signed-rank test whereas the intergroup comparison was done using the Mann–Whitney test for data that were not normally distributed. The level of significance was determined by P < 0.05 at 95% confidence interval.
[Table 1] shows within and between group analysis of NPRSin Groups A and B. Wilcoxon signed-rank test was applied for within group analysis and Mann–Whitney U-test for between group analysis. NPRS was significantly reduced (P < 0.001) on both sides postintervention within both groups. However, no significant difference was seen (P > 0.05) when compared between both groups.
[Table 2] shows within and between group analysis of ROM in Groups A and B. Wilcoxon signed-rank test was applied for within group analysis and Mann–Whitney U-test for between group analysis. ROM was significantly improved (P < 0.001) on both sides postintervention within both the groups. However, no significant difference was seen (P > 0.05) when compared between both the groups.
[Table 3] shows within and between group analysis of NDI in Groups A and B. Wilcoxon signed-rank test was applied for within group analysis and Mann–Whitney U-test for between group analysis. NDI was significantly reduced (P < 0.001) within both groups. However, no significant difference was seen (P > 0.05) when compared between both groups.
| Discussion|| |
This study compared the effectiveness of strain-counterstrain and digital ischemic compression technique on pain, ROM and NDI in subjects with neck pain associated with trigger points.
The result showed that there is significant improvement within both groups with respect to pain, cervical lateral ROM, and NDI score (P < 0.001). However, there was no significant difference seen between both groups with respect to pain, cervical lateral ROM, and NDI score (P > 0.05). This shows that both the techniques were equally effective in reducing pain and improving cervical lateral ROM and NDI score.
There are various studies that are found to have effective results of strain-counterstrain technique in managing pain, cervical ROM and disability index. Strain-counterstrain helped to decrease pain and disability index score as well as improve the ROM. In strain-counterstrain technique, the muscles are placed in the greatest comfort position. This causes the relaxation of tissue that improves the vascular circulation and removes the inflammatory chemical mediators, thus leads in enhancing the symptoms.
By means of an automatic resetting of muscle spindles, this helps to dictate tone and length of the affected tissues by strain-counterstrain technique in pain relief and increasing pain pressure threshold. The descending inhibitory pathways are activated with the application of manual intervention techniques.
Studies have shown significant improvement of pain in strain-counterstrain in combination with electrotherapeutic modalities as well as other manual therapy interventions such as neural tissue mobilization. When strain-counterstrain and muscle energy technique were used in management of acute low back pain (LBP), both were found to be equally efficient in decreasing pain.
Strain-counterstrain and muscle energy techniques (METs) have been shown to be effective in decreasing the functional disability score and pain in chronic LBP. The soother effect of strain-counterstrain technique could be because of a nociceptive hypothesis that tissue damage in dysfunctional muscle can be diminish by positional release mechanism that is utilized by strain-counterstrain. There is diminished pain and muscle tension in upper trapezius, which confirms the assumptions that application of strain-counterstrain lead to relieve the spasm of muscle and improve the relevant painless movement and tissue flexibility. The current study has shown similar supportive findings in improving pain.
In contrast, there was a study to consider that effect of strain-counterstrain increasing the hamstring flexibility and concluded strain-counterstrain technique is not efficient in improving the ROM of the extension of knee who have reduced hamstring flexibility in healthy subjects.
Studies found beneficial results of digital ischemic compression in managing pain, ROM of cervical side flexion, and disability index score in subjects with neck pain associated with upper trapezius myofascial trigger point. Ischemia implies there is the absence of blood supply, associated with tissue disturbance and obstruction. The aim of ischemic compression is to apply pressure on trigger points which stops the blood to flow into the affected area depriving it of oxygen. This washes away waste products, supplies needed oxygen, and helps healing of involved tissue. Rapidly after release, blanching of skin is followed by increase in circulation, oxygen, and nutrients at the site of pressure. After release of pressure, these helped in flushing out of muscle inflammatory exudates, pain metabolites, impart the scar tissue, decrease of muscle tone, and desensitization of nerve endings. A counterirritant effect or a spinal reflex mechanism occurs from reflex relaxation of affected muscle and helps in decreasing the pain. Local pressure may equalize the length of sarcomere in the involved trigger point that reduces the energy consumption and will cease the release of noxious substances and therefore decreasing the pain. Ischemic compression lessen the sensitivity of painful nodules in the muscle which is helpful in decreasing the pain.
Another study compared the effect of myofascial release and ischemic compression techniques on pain, cervical ROM of lateral flexion, and function in acute trapezitis in young adults, concluded that both techniques were efficient in decreasing pain and neck disability and improving cervical lateral flexion ROM. However, myofascial release technique was more efficient than the ischemic compression. A comparative study on the efficacy of ischemic compression and dry needling with MET in upper trapezius myofascial trigger point subjects showed that both ischemic compression and dry needling with MET were equally effective in increasing pain pressure threshold, disability index score, and contralateral cervical lateral flexion ROM in upper trapezius myofascial trigger points subjects.Another study showed that ischemic compression and MET treatment create a powerful decrease in pain at upper trapezius myofascial trigger points. Ischemic compression was high efficient than MET in decreasing pain sensitivity at myofascial trigger point. Thus, ischemic compression technique might be helpful in reducing pain, improving functional status, and increasing pain pressure threshold in myofascial trigger point subjects.
The use of digital pressure given manually instead of a pressure algometer is one of the limitations of this study, as the pressure applied was subjective and not quantified. Further studies can be conducted considering longer follow-up and carry-over effects. Studies examining the role of chemical irritants produced at the local site are also warranted.
Limitations and future scope of the study
Instead of digital pressure given manually, an instrument like a pressure algometer could have been used to deliver the ischemic compression. This would have allowed to quantify the pressure applied. Furthermore, future studies can explore the long-term effects of the interventions. In addition to active trigger points, the effects on latent trigger points can also be explored.
| Conclusion|| |
The study concluded that the strain-counterstrain and ischemic compression techniques are equally effective in decreasing the pain and disability index score and improving the cervical ROM of lateral flexion in subjects with neck pain associated with upper trapezius myofascial trigger points.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ravichandran P, Ponni HK, Aseer P, Leo A. Effectiveness of ischemic compression on trapezius myofascial trigger points in neck pain. Int J Physiother 2016;3:186-92.
RodrÍguez-Huguet M, Gil-Salú JL, RodrÍguez-Huguet P, Cabrera-Afonso JR, Lomas-Vega R. Effects of myofascial release on pressure pain thresholds in patients with neck pain: A single-blind randomized controlled trial. Am J Phys Med Rehabil 2018;97:16-22.
Chaudhary ES, Shah N, Vyas N, Khuman R, Chavda D, Nambi G. Comparative study of myofascial release and cold pack in upper trapezius spasm. Int J Health Sci Res 2013;3:20-7.
Jonsson E, Nachemson AL. Neck and Back Pain: The Scientific Evidence of Causes, Diagnosis, and Treatment. Washington D.C: Lippincott Williams & Wilkins; 2000.
Bron C, Franssen J, Wensing M, Oostendorp RA. Interrater reliability of palpation of myofascial trigger points in three shoulder muscles. J Man Manip Ther 2007;15:203-15.
Hanten WP, Olson SL, Butts NL, Nowicki AL. Effectiveness of a home program of ischemic pressure followed by sustained stretch for treatment of myofascial trigger points. Phys Ther 2000;80:997-1003.
Segura-OrtÍ E, Prades-Vergara S, Manzaneda-Piña L, Valero-MartÍnez R, Polo-Traverso JA. Trigger point dry needling versus strain-counterstrain technique for upper trapezius myofascial trigger points: A randomised controlled trial. Acupunct Med 2016;34:171-7.
McPartland JM. Travell trigger points--molecular and osteopathic perspectives. J Am Osteopath Assoc 2004;104:244-9.
Chaitow L. Ligaments and positional release techniques? J Bodyw Mov Ther 2009;13:115-6.
Kumar GY, Sneha P, Sivajyothi N. Effectiveness of muscle energy technique, ischaemic compression and strain counterstrain on upper trapezius trigger points: A comparative study. Int J Phys Educ Sports Health 2015;1:22-6.
Abd El-Azeim AS, Ahmed SE, Draz AH, Elhafez HM, Kattabei OM. Integrated neuromuscular inhibition technique versus kinesiotape on upper trapezius myofascial trigger points a randomized clinical trial. Int J Physiother 2018;5:105-12.
Mense S, Schmidt RF. Muscle Pain: Which receptors are responsible for the transmission of noxious stimuli. In: Physiological Aspects of Clinical Neurology. Vol. 102. Oxford: Blackwell Scientific Publications; 1977. p. 575.
Hopwood MB, Abram SE. Factors associated with failure of trigger point injections. Clin J Pain 1994;10:227-34.
Chaitow L, Crenshaw K. Muscle Energy Techniques. London: Elsevier Health Sciences; 2006.
Meseguer AA, Fernández-de-las-Peñas C, Navarro-Poza JL, RodrÍguez-Blanco C, Gandia JJ. Immediate effects of the strain/counterstrain technique in local pain evoked by tender points in the upper trapezius muscle. Clin Chiropract 2006;9:112-8.
Nagrale AV, Glynn P, Joshi A, Ramteke G. The efficacy of an integrated neuromuscular inhibition technique on upper trapezius trigger points in subjects with non-specific neck pain: A randomized controlled trial. J Man Manip Ther 2010;18:37-43.
Nambi GS, Sharma R, Inbasekaran D, Vaghesiya A, Bhatt U. Difference in effect between ischemic compression and muscle energy technique on upper trepezius myofascial trigger points: Comparative study. Int J Health Allied Sci 2013;2:17. [Full text]
Hou CR, Tsai LC, Cheng KF, Chung KC, Hong CZ. Immediate effects of various physical therapeutic modalities on cervical myofascial pain and trigger-point sensitivity. Arch Phys Med Rehabil 2002;83:1406-14.
Gowda N. A study to compare the effectiveness of classical strain/counterstrain technique with ultrasound therapy and myofascial release technique with ultrasound therapy on unilateral upper trapezius trigger points. Int J Med Health Res 2018;4:133-8.
Fereira OA, Satralkar A. Effectiveness of strain counterstrain technique and neural tissue mobilisation on cervicogenic headache. Indian J Physiother Occup Ther 2017;11:57-61.
Iqbal A, Khan SA, Miraj M. Efficacy of ischaemic compression technique in combination with strain counterstrain technique in managing upper trapezius myofascial trigger point pain. Indian J Physiother Occup Ther 2010;4:10-5.
Patel VD, Eapen C, Ceepee Z, Kamath R. Effect of muscle energy technique with and without strain–counterstrain technique in acute low back pain – A randomized clinical trial. Hong Kong Physiother J 2018;38:41-51.
Ellythy MA. Efficacy of muscle energy technique versus strain counter strain on low back dysfunction. Bull Faculty Phys Ther 2012;17:29-35.
Rakholiya SR, Ved V. Effect of ischaemic compression on upper trapezitis. Int J Curr Adv Res 2016;5:1131-4.
Basak T, Pal TK, Sasi MM, Agarwal S. A comparative study on the efficacy of ischaemic compression and dry needling with muscle energy technique in patients with upper trapezius myofascial trigger points. Int J Health Sci Res 2018;8:74-81.
Desai S, Jeswani K. To compare the effect of myofascial release and ischaemic compression on pain, cervical lateral flexion and function in acute Trapezitis in young adults. IJAR 2018;4:448-54.
Khan A, Khan AR. Comparative effectiveness of integrated neuromuscular inhibition techniques and ischemic compression technique in managing upper trapezius myofascial trigger point pain in computer professionals. IJRSR 2019;10:34269-79.
[Table 1], [Table 2], [Table 3]