“ COMPARISON OF STATIC STRETCHING VERSUS TAPING ALONG

WITH CONVENTIONAL PHYSIOTHERAPY TREATMENT FOR TRIGGER

POINTS OF UPPER TRAPEZIUS ”

DISSERTATION SUBMITTED TO
Ras Bihari bose subharti university,Dehradun (UK)
In Partial Fulfillment of the Requirements for the Award of Degree of

MASTERS OF PHYSIOTHERAPY
(ORTHOPAEDICS)

Submitted by
Gaurav Guleria

Guide Co-Guide
DR. DEEPALI PAL PT

DR.AMIT GOEL Assistant Professor

(ORTHOPAEDIC) Department of Physiotherapy

Associate Professor
Department of Physiotherapy Ras Bihari Bose Subharti University
Ras Bihari Bose Subharti University
Ras Bihari Bose Subharti University, Dehradun
DECLARATION BY THE CANDIDATE

I the undersigned solemnly declare that thesis work entitled is based on my own work
carried out during the course of our study under the supervision of Dr. D E E P A L I P A L
PT (ORTHO).
I assert the statements made and conclusions drawn are an outcome of my thesis work. I
further certify that

I. The work contained in the report is original and has been done by me
under the general supervision of my supervisor.

II. The work has not been submitted to any other Institution for any other
degree/diploma/certificate in this university or any other University of
India or abroad.

III. We have followed the guidelines provided by the Ras Bihari Bose
Subharti University Dehradun-248001, Uttarakhand in writing the report.

IV. Whenever we have used materials (data, theoretical analysis, and text)
from other sources, we have given due credit to them in the text of the
report and giving their details in the references.

Name:

GAURAV
GULERIA
Enrollment No.:
 Ras Bihari Bose Subharti University, Dehradun

ENDORSMENT BY THE
HOD

This is to certify that Mr Gaurav Guleria submitted thesis under the supervision and guidance of Dr
DEEPALI PAL PT [ortho]. Assistant Professor Department of Physiotherapy, Ras Bihari Bose
Subharti University, Dehradun. His work carried on the topic entitled “COMPARISON OF
STATIC STRETCHING VERSUS TAPING ALONG WITH CONVENTIONAL
PHYSIOTHERAPY TREATMENT FOR TRIGGER POINT OF UPPER TRAPEZIUS” In
partial fulfillment of the requirement for the award of degree of Master of Physiotherapy to Ras Bihari
Bose Subharti University, Dehradun, Uttarakhand.

Place: Name/Signature of HOD)

Date:
 Ras Bihari Bose Subharti University, Dehradun

GUIDE CERTIFICATE

This is to certify that Mr. Gaurav Guleria submitted thesis to Ras Bihari Bose Subharti University,
Dehradun, Uttarakhand. His work carried out on the topic entitled “COMPARISON OF STATIC
STRETCHING VERSUS TAPING ALONG WITH CONVENTIONAL PHYSIOTHERAPY
TREATMENT FOR TRIGGER POINT OF UPPER TRAPEZIUS” Under my supervision and
guidance at Department of Physiotherapy, Ras Bihari Bose Subharti University, Dehradun for the partial
fulfillment of requirement for the degree of Master of Physiotherapy.

Place: Name/Signature Of Guide

Date:
Ras Bihari Bose Subharti University, Dehradun

CERTIFICATE BY THE EXAMINER

Certificate

This is to certify that the thesis work entitled “COMPARISON OF STATIC STRETCHING
VERSUS TAPING ALONG WITH CONVENTIONAL PHYSIOTHERAPY TREATMENT
FOR TRIGGER POINT OF UPPER TRAPEZIUS” submitted
by Mr. Gaurav Guleria in partial fulfillment of the requirement for the

award of degree of Master of Physiotherapy of the Ras Bihari Bose

Subharti University, Dehradun, Uttarakhand has been thoroughly

examined and approved by us.

(Sign of Internal Examiner) (Sign. Of External Examiner)

Place:

Date:
COMPARISON OF STATIC STRETCHING VERSUS TAPING
ALONG WITH CONVENTIONAL PHYSIOTHERAPY
TREATMENT FOR TRIGGER POINT OF UPPER TRAPEZIUS
Name of Student: Gaurav Guleria MPT ( ORTHO)

Name and designation of guide and co-guide

1. Dr. AMIT GOEL (ORTHOPAEDIC)

Associate Professor

2.Dr. DEEPALI PAL PT (ORTHOPAEDIC)

Assistant Professor

Ras Bihari Bose Subharti

University,Dehradun
Place of work:- Ras Bihari Bose Subharti University, Dehradun

Signature

1. Student 2. Guide 3.Co-Guide 4.Internal

5.External

…………… …………… ………………

……………. ………………
 ACKNOWLEDGMENT

I take this opportunity to express my deep gratitude to the almighty for showering
his blessings and who always have been my source of strength and inspiration.

I humbly thank Dr. Rashmi Bhardwaj, HOD, Physiotherapy department for her
support and guidance while carrying out my research work successfully.

I express my deep sense of gratitude and thanks to my supervisor Dr. AMIT

GOEL, (ASSOCIATE PROFESSOR) for her kind support and careful guidance,
precious advice and invaluable tips in driving the research in the right direction and
correcting it whenever needed against all odds.

I would also like to acknowledge and extended my sincere thanks to my co-guide

Dr. DEEPALI PAL, MPT, (Assistant professor) for the support she has provided in the
completion of this work.
I wish to thank all my teachers of Physiotherapy Department for their constant
support and help during this work and other staff for their immense support.
I also owe special thanks to my parents and my family members specially my
classmates for their sustained and silent inspiration.

Gratefully acknowledged
GAURAV GULERIA
 DECLARATION BY THE CANDIDATE

I hereby declare that the Ras Bihari Bose Subharti

University, Dehradun Uttrakhand shall have the right to

preserve, use and disseminate this dissertation/ thesis in

print of electronic format for academic research purpose

DATE Gaurav Guleria

PLACE MPT 2nd year (ortho)

DEDICATION
Every challenging work needs self-efforts as well as guidance of

elders especially those who are very close to our heart.

To almighty God

My humble effort I dedicate to my sweet and loving

Father and Mother

Whose affection, love, encouragement and prays of day and night made

me able to get Such success and honor

Hard working and Respected

Teachers

Who guided and enlightened me to the right path with the beauty

of knowledge Along with generous and humble

Family, Friends, Colleagues

 TABLE OF CONTENT

CONTENTS

Page No.

1. INTRODUCTION……………………………………….1-7

2. REVIEW OF LITERATURE……………………………8-36

3. METHODOLOGY……………………………………....37-55

4. DATA ANALYSIS……………………………………...56-57

5. RESULTS ……………………………………………….58-68

6. DISCUSSION…………………………………………....69-74

7. CONCLUSION…………………………………..……....75-76

8. REFERENCES…………………………….…………….77-85

9. APPENDICES…………………………….……………..86-99

APPENDIX A: Criteria for fibromyalgia………………87-89

APPENDIX-B: Consent Form…………………………90-91

APPENDIX-C: Master Chart……………..……...……..92-94

APPENDIX-D Evaluation Performa.…….…………..…95-97

APPENDIX-E: Data Collection Form………………….98-99

LIST OF TABLES / GRAPHS

Tables / Graphs Page.

No

5.1 Baseline comparison of the two groups for Age, Height, Weight and Duration of
Symptoms (DOS)
……………………………………………………………………….62

5.2 Comparison of VAS1 and VAS2; CLF1 and CLF2 in Group

1………………………....63

5.3 Comparison of VAS1 and VAS2; CLF1 and CLF2 in Group 2……………………...
….63

5.4 Comparison for VAS1, VAS2, VAS’ (VAS1-VAS2) between two

Groups
………………………………………………………………………………………..
…64

5.5 Comparison for CLF1, CLF2, CLF (Difference) between two

Groups………………...64

5.6 Graphical representation of pre and post treatment VAS scores for group
1 and

group 2.
………………………………………………………………………………………
…..65

5.7 Graphical representation of pre and post-cervical lateral flexion ranges

for
 group 1 and group 2.
…………………………………………………………………………………….….
…66

5.8 Comparison of V9 (VAS 1- VAS 2) between two groups…………………………...

….67

5.9 Comparison for gain in ROM (Cervical lateral flexion) between two
groups
……………………………………………………………………………………….….68
 LIST OF FIGURES

Figures
Page. No

2.1 Anatomical Attachments of Trapezius…………………………..……....10

2.2: Causes for the Development of Trigger Points…………………………13

2.3: Positive Feedback Cycle……………………………………….……....16

2.4 Contraction Knot………………………………………………..……....19

2.5 Trigger Point TP1 of Upper Fibers Trapezius (shown an X) and

its

Referred Pain Area (Red)………………………………………..

……..24

3.1
Instrumentation…………………………………………………………..43

3.2 Application of ultrasound on trigger point of upper trapezius…………..44

3.3 Position for static stretching of upper trapezius……………………...….45

3.4 Application of soft tissue mobilization on trigger point of

upper

trapezius…………………………………………………………………46
3.5 Application of contract – relax on trigger point of upper

trapezius……………………………………………………………….…46

3.6 Application of PNF pattern of neck (end position)....................................47

3.7 Upper Trapezius Kinesiotaping (1).........................................................48

3.8 Upper Trapezius Kinesiotaping (2).........................................................49

3.9 Upper Trapezius Kinesiotaping (3).........................................................50

3.10 Upper Trapezius Kinesiotaping (4).......................................................51

 LIST OF ABBREVIATIONS USED

PNF - Proprioceptive neuromuscular facilitation

CLF - Cervical lateral flexion

ROM - Range of motion

VAS - Visual analogue scale

CHAPTER 1

INTRODUCTION
 Myofascial trigger point is a hyperirritable spot, usually within a taut band of

skeletal muscle or in the muscle’s fascia, which is painful on compression and can give

rise to characteristic referred pain, tenderness and autonomic phenomena. 3 Its types

include active, latent, primary, associated, satellite and secondary.3

Trigger points can arise from multiple causes. Muscles become vulnerable when

they are under acute or chronic stress. 5 Trigger points described as ‘active’ are always

tender on direct palpation, may be painful in the absence of applied pressure, and are

more likely to elicit a jump sign when adequately stimulated. In comparison, ‘latent’

trigger points are painful and elicit a pain referral pattern only when direct pressure is

applied. Without perpetuating factors, an active trigger point tends to revert to and persist

as a latent trigger point.

Trigger points can arise virtually in any muscle group however, they occur most

frequently in axial muscles used to maintain posture, due to constant tension and micro

trauma of poor postural habits, both in everyday living and in the workplace. The

trapezius muscle appears to be the most frequently cited in clinical settings. It is a

frequently overlooked source of temporal headache. Six trigger points with distinctive

pain patterns are found in the upper, middle and lower portion of the trapezius with two

trigger points are located in each portion. A seventh trigger point refers a non painful

autonomic response.3

Trapezius TP1 (trigger point 1, in upper fibers of trapezius) is observed the most

often of all myofascial trigger points in the body. This TP1 area makes a significant

contribution to the facial pain of myofascial pain dysfunction syndrome, which is widely

recognized by the dental profession3 .The severity of symptoms from myofascial trigger

points ranges from painless restriction of motion due to latent trigger points, so common

in the aged, to agonizing incapacitating pain caused by very active trigger points. 3
 Manual palpation skills, in conjunction with patient feedback, have primarily been

used for trigger point diagnosis and treatment. 6The major goal of myofascial trigger point

therapy is to relieve pain and tightness of the involved muscles. 1Predisposing and

perpetuating factors in chronic overuse or stress injury on muscles must be eliminated, if

possible. Non pharmacologic treatment modalities include acupuncture, osteopathic

manual medicine techniques, massage, acupressure, ultrasonography, application of heat

or ice, diathermy, transcutaneous electrical nerve stimulation, ethyl chloride spray and

stretch technique, dry needling and trigger point injections with local anesthetic, saline, or

steroid.8

In this study, a comparison between immediate effects of ultrasound combined

with static stretching and ultrasound combined with soft tissue mobilization (STM) and

PNF on active trigger point of upper fibers of trapezius is done.

Ultrasound treatment involves the use of high frequency acoustic energy that is

generated using the reverse piezoelectric effect to produce thermal and non thermal

effects in tissue. Pain relief is theorized to be related to washout of pain mediators by

increased blood flow, changes in nerve conduction velocity, or alterations in cell

membrane permeability that decrease inflammation.1, 9

Stretching exercises form the basis of exercise treatment of myofascial pain. This

treatment addresses the muscle tightness and shortening that are closely related with pain

in this disorder and permits gradual restoration of normal activity.10

Soft tissue mobilization is the application of specific and progressive manual

forces with the intent of promoting changes in the myofascia, allowing for elongation of

shortened structures.2 Soft tissue mobilization procedures are often combined with PNF

procedures because they are both used to effect changes in myofascial length. Contract-
relax PNF procedures have been shown to be effective in increasing range of motion. 2

Initially a pilot study was conducted utilizing a soft tissue mobilization protocol of seven

minutes along with contract-relax procedure on the active trigger point of upper fibers of

trapezius. This soft tissue mobilization protocol included the use of effleurage and

kneading starting with 10 seconds of effleurage, then 20 seconds of kneading and then

both alternating for 30 seconds each, ending with effleurage. Favorable results were

shown with an immediate reduction in pain and improvement in cervical lateral flexion

range of motion. Thus, the same protocol was used in this study.

Treatment of trigger points in upper trapezius utilizing ultrasound and static

stretching has also been studied and compared with treatment by trigger point injection

and stretching exercise, wherein both the treatments showed significant results.1

However, the immediate effects of ultrasound combined with static stretching on

trigger points of upper trapezius and its comparison with ultrasound combined with

Taping have not been studied. Thus, in this study, both these treatment options are used

to determine their immediate effects in reducing the symptoms and then are compared for

their effectiveness.

This study will determine the efficacy of the two chosen treatment interventions

for the active trigger point in upper trapezius muscle and thus may help in developing an

effective physiotherapy treatment protocol for such problems.

(NOTE- Conventional physiotherapy treatment includes Ultrasound, soft tissue

mobilization and PNF technique).

 Aims and Objectives

To compare the efficacy of

1) Combination of Taping along with conventional physiotherapy treatment and

2) Combination of Static stretching along with conventional physiotherapy

treatment

on active trigger point of upper fibers of trapezius.

Statement of question

Is a combination of Taping along with conventional physiotherapy treatment is

more efficacious than Static stretching along with conventional physiotherapy

treatment when applied on active trigger point of upper fibers of trapezius?

Hypothesis

A combination of Taping along with conventional physiotherapy treatment more

efficacious than Static stretching along with conventional physiotherapy treatment when

applied on active trigger point of upper fibers of trapezius.

Operational Definitions

Active Myofascial Trigger Point

A focus of hyperirritability in a muscle or its fascia that is symptomatic with respect to

pain; refers a pattern of pain at rest or on motion. An active trigger point is tender,

prevents full lengthening of the muscle, weakens muscle, refers pain on direct

compression, mediates local twitch response of fibers when adequately stimulated, often

produces specific referred autonomic phenomena, generally in its pain reference zone. 3
 Latent Trigger Point

A focus of hyperirritability in muscle or its fascia that is clinically quiescent with

respect to spontaneous pain; it is painful only when palpated.3

Myotactic Unit

A group of agonist and antagonist muscles, which function together as a unit

because they share common spinal-reflex responses. The agonist muscles may act in

series, or in parallel. It is emphasized because the presence of an active trigger point in

one muscle of myotactic unit generally increases the likelihood that other muscles of the

unit also will develop trigger point. Dysfunction (weakness/ shortening) of the affected

muscle tends to overload other muscles of that myotactic unit.3

Zone of Reference

The specific region of the body at a distance from a trigger point, where the

phenomena (sensory, motor, autonomic) that it causes are observed.3

Soft Tissue Mobilization

It is the application of specific and progressive manual forces with the intent of

promoting changes in the myofascia, allowing for elongation of shortened structures.2

Contract- relax

It is a variation of PNF stretching technique. It is a method that uses a maximum

voluntary isometric muscle contraction followed by relaxation.51

 Limitations

1. Sample size of the study was small.

2. Convenient sampling was done.

3. The study used a single-intervention session design. The long term

effects of the interventions were not seen.

4. Subjects studied were only females.

Organization of Remaining Chapters

Chapter 2 deals with review of literature, chapter 3 deals with methods used in the

study, chapter 4 deals with data analysis, chapter 5 deals with results obtained, chapter 6

deals with discussion of the results obtained, chapter 7 with conclusion of the study,

chapter 8 has references. Appendices contain the criteria for classification of

fibromyalgia, consent form, master chart, evaluation performa and data collection form.
 CHAPTER 2

REVIEW OF LITERATURE
 This chapter deals with anatomy of the trapezius muscle, epidemiology, causes

and pathophysiology of trigger points. Clinical features, predisposing factors and criteria

for diagnosis of trigger point of upper trapezius fibers are also dealt with. It also contains

an overview of various treatment options available for its treatment stressing upon the

treatment intervention chosen for this study.

Anatomy of Trapezius11

The Trapezius (Fig. 2.1) is a flat, triangular muscle, covering the upper and back part of

the neck and shoulders.

Attachments11

It arises from the external occipital protuberance and the medial third of the

superior nuchal line of the occipital bone, from the ligamentum nuchae, the spinous

process of the seventh cervical, and the spinous processes of all the thoracic vertebrae,

and from the corresponding portion of the supraspinal ligament.

The superior fibers are inserted into the posterior border of the lateral third of the

clavicle; the middle fibers into the medial margin of the acromion, and into the superior

lip of the posterior border of the spine of the scapula. The inferior fibers converge near

the scapula, and end in an aponeurosis, which glides over the smooth triangular surface

on the medial end of the spine, to be inserted into a tubercle at the apex of this smooth

triangular surface.
Fig 2.1 Anatomical Attachments of Trapezius
 The two trapezius muscles together resemble a trapezium, or diamond- shaped

quadrangle: two angle corresponding to the two shoulders; a third to the occipital

protuberance; and the fourth to the spinous process of the twelfth thoracic vertebrae.56

Innervation

Motor innervation of the trapezius is supplied by the spinal portion of the spinal

accessory nerve (cranial nerve XI). 3

Action of Upper Fibers of Trapezius12

The upper fibers of trapezius elevate the scapula when their origin is fixed. Acting

unilaterally, with their insertion being fixed, they extend, laterally flex and rotate the head

and cervical spine joints so that face turns towards the opposite side. When acting

bilaterally with their insertion fixed, they lead to neck extension.

Myotactic Unit3

The paired trapezius muscles are synergistic for extension of the head, neck, or

thoracic spine, and during symmetrical upper extremity activities.

Upper Trapezius

It acts synergistically with the sternocliedomastoid for some head and neck

motions. It is an antagonist to the levator scapulae and to the upper digitations of the

serratus anterior during scapular rotation. During abduction of the arm, the rotation of the

scapula by the trapezius is synergistic with the glenohumeral movement by the

supraspinatus and deltoid muscles to produce the “scapulohumeral rhythm”.

 Epidemiology

Myofascial pain has a high prevalence among individuals with regional pain

complaints. The prevalence varies from 21% of patients seen in a general orthopedic

clinic to 30% of general medical clinic patients with regional pain, to as high as 85% to

93% of patients presenting to specialty pain management centers.56

A study by Skootsky and associates found that myofascial pain in the upper body

was more common than in other areas of body.56

Four muscles- the trapezius, levator scapulae, infraspinatus and scalene-

accounted for 84.7% of the trigger points, those in the trapezius (34.7%) and the levator

scapulae (19.7%) occurring most frequently.5 Higher incidence has been found in women

than men.5 Most commonly, trigger points are found in 30-50 years of age range.5

Trigger Points in Upper Trapezius3

Six trigger points with distinctive pain patterns are found in the upper, middle and

lower portions of the trapezius with two trigger points are located in each portion. A

seventh trigger point refers a non-painful autonomic response.

Trapezius trigger point (TP1), in upper fibers is observed the most often of all myofascial

trigger points in the body.

Fig. 2.2: Causes for the Development of Trigger Points5
 Pathophysiology for the Development of Trigger Point

Integrated Trigger Point Hypothesis

A) Energy Crisis Hypothesis13, 14, 15

It postulates that an initial insult, such as

mechanical rupture of either the sarcoplasmic reticulum or the muscle cell

membrane (sarcolemma), would release calcium that would maximally activate

actin and myosin contractile activity. If the damage were repairable, however, the

abnormality would be temporary. It is now apparent that a more likely mechanism

is abnormal depolarization of the postjunctional membrane, which could persist

indefinitely, based on excessive acetylcholine release from the dysfunctional nerve

terminal. In this way, maximum contracture of the muscle fibers in the vicinity of

the motor end plate could be sustained indefinitely with motor unit action potential.

The sustained contractile activity of the sarcomeres would markedly increase

metabolic demands and will squeeze shut the rich network of capillaries that supply the

nutritional and oxygen needs of that region. Circulation in the muscle fails during a

sustained contraction that is more than 30-50% of maximum effort (depending on the

involved muscle). This combination of increased metabolic demands and impaired supply

could produce a more severe, albeit local, energy crisis. The calcium pump that returns

the calcium into the sarcoplasmic reticulum is dependent on an adequate supply of ATP

and appears to be more sensitive to low ATP levels than is the contractile mechanism

itself. Thus, when the pump fails, the contractile mechanism persists, assuring continued

failure of the pump. When the ATP supply of the contractile mechanism is exhausted, a

sustained contracture develops, as in Mc Ardle’s disease. This completes a vicious cycle.

In addition, the severe local hypoxia and tissue energy crisis could be expected to

stimulate production of neurovasoreactive substances that sensitize local nociceptors.

This hypothesis accounts for

1) The lack of motor unit action potential because of the endogenous contracture

rather than a nerve initiated contraction of the muscle fibers.

2) The frequency with which muscle overload activates trigger points most likely

reflecting the mechanical vulnerability of the synaptic cleft region of an end plate.

3) The release of substances that could sensitize nociceptors in the region of the

dysfunctional endplate as a result of tissue distress caused by the energy crisis.

4) The effectiveness of essentially any technique that elongates the muscle out to its

full stretch length, decreasing energy demand. This can be explained by the fact that

the continued activity of the actin myosin interaction depends on physical contact

between the actin and myosin molecules, which occurs fully when the sarcomere is

approximately mid length or less. The molecules lose overlap contact at full length.

With cessation of contractile activity because of actin myosin separation, both the

energy consumption and compression of capillaries would be released. This

opportunity to restore energy resources could help to block two critical steps in the

energy crisis cycle.14

Abnormal acetylcholine release Sustained sarcomere
Contracture

Local ischemia Increased

Metabolism

PAIN Sensitizing Energy Crisis

Substances

Fig 2.3: Positive Feedback Cycle.15

It summarizes the integrated hypothesis. Increase in release of acetylcholine at

motor endplate due to mechanical trauma or chemical stimulation of the nerve terminal

induces sustained sarcomeres contraction. This occurrence results in localized ischemia,

which in turn results in the release of substances that sensitize nociceptors, produce pain

and induce release of neurovasoreactive chemicals. These chemicals lead to increase in

acetylcholine release, sustaining the cycle.15

B) Integrated Concept of Trigger Point Formation 14When combined, the two lines of

experiment evidence, electro-physiologic and histologic, indicate that the

spontaneous electrical activity and spikes observed at active loci in trigger point are

the end plate potentials that are currently recognized by electromyographers as

normal end plate potentials. Physiologic experiments however have shown that

these potentials are not normal but are the result of a grossly abnormal increase in

acetylcholine release by the nerve terminal. An end plate exhibiting the spontaneous

electrical activity is identified as an active locus. Since it appears likely that the

contraction knot is located at an end plate and is caused by this endplate

dysfunction, the two are likely intimately related.

The core of the hypothesis is the continuous excess acetylcholine release from the

motor nerve terminal into the synaptic cleft. At the synaptic cleft, the acetylcholine

activates acetylcholine receptors in the post junctional membrane to produce greatly

increased number of motor end plate potentials. The potentials produced are so numerous

that they superimpose in order to produce endplate noise or spontaneous and a sustained

partial depolarization of the post junctional membrane. The excessive demand for

production of the acetylcholine packets in the motor nerve terminal would increase its

energy demand (evidenced by abnormal mitochondria the nerve terminal). The increased

activity of the post junctional membrane and sustained depolarization would impose an

additional energy demand.

The calcium channels that trigger release of calcium from sarcoplasmic reticulum are

voltage gated by depolarization of the T-tubule at the triad where the T-tubule

communicates with the sarcoplasmic reticulum. The T-tubule is a part of the same
sarcolemmal membrane that forms the post junctional membrane. This depolarization is

one mechanism that might account for a tonic increase in the release of calcium from the

sarcoplasmic reticulum to produce sarcomere contraction that is the most likely

explanation for contraction knots (Fig 2.4). These knots could also explain why clinicians

often describe palpating a nodule at the trigger point in addition to a taut band. This

contracture process appears to be much more intense in the immediate vicinity of the

affected endplate. Sustained release of calcium from the sarcoplasmic reticulum would

increase the energy demand of the calcium pumps in the sarcoplasmic membrane that

return the calcium into the sarcoplasmic reticulum. Recent studies have indicated the

increased spontaneous electrical activity measured in trigger points could be attributed to

the result of presynaptic, synaptic or postsynaptic dysfunction (i.e., excessive release of

acetylcholine, defects of acetyl cholinesterase and up regulation of nicotinic acetylcholine

receptor activity, respectively)16.

This sustained contracture of sarcomere in the muscle fiber supplied by the

affected endplate fits in nicely with the previously proposed energy crisis hypothesis.

This energy crisis in the vicinity of the end plate can be expected to release neuroactive

substances that sensitize and modify the function and autonomic nerves in that region.

Sensitization of local nociceptors could readily account for the exquisite

tenderness of the trigger point, the referred pain originating at the trigger point and the

origin of the local twitch response. Several lines of experimental evidence suggest that

autonomic (probably sympathetic) nervous systems activity can strongly modulate the

abnormal release of acetylcholine from the nerve terminal.14

 Fig. 2.4 Contraction Knot

(A) The band of dark muscle fibers running the length of the muscle represents
the increased tension of palpable taut band fibers. The nodular region in the middle of
that band represents a central trigger point (CTrP) that is exquisitely tender and may be
palpable as a nodule in the taut band. The regions at each end of the taut band represent
attachment trigger points (ATrPs). ATrPs result in an inflammatory reaction at the
musculotendinous junctions of the taut band muscle fibers due to the sustained tension in
those fibers. (B) The microscopic view of the CTrP shows several swollen contraction
knots, which represent the result of the Ach-induced maximal sarcomere contraction in
the region of an end plate. The dense region of contracted sarcomeres increases tension in
that fiber and causes compensatory stretching of the remaining sarcomeres of the fiber,
which increases their resting tension. Involved fibers have an uneven distribution of fiber
length.15
 Clinical Features of Upper Trapezius Trigger Point1, 3, 14

It has been suggested that the spontaneous evoked activity originates at a

contraction knot and that the contraction knot may be caused by a dysfunctional end

plate. This pathophysiological interpretation explains a number of clinical features.

Taut Band

The taut band of trigger point would be caused by the increased tension of

involved muscle fibers because of both the tension induced by the maximally shortened

sarcomeres in the contraction knot and the increased (elastic) tension produced by all the

remaining elongated (and abnormally thin) sarcomeres.

Fig.2.4 shows clearly the abnormally shortened and abnormally lengthened

sarcomeres of the muscle fiber that contains the contraction knot. These abnormal lengths

contrast to the normal resting length of sarcomeres in the muscle fibers running across the

lower part of the figure. With the involvement of a sufficient number of muscle fibers in

each of several fascicles, the increased tension of the involved muscle fiber should be

palpable as a taut band running the length of the muscle.

In muscle accessible to palpation, a myofascial trigger point is consistently found

within a palpable taut band. Clinically, the taut band is a basic diagnostic criterion of a

trigger point.22

Palpable Nodule

It is explained by the presence of many contraction knots (fig.2.4). Since a

sarcomere must maintain a nearly constant volume, it becomes broader as it shortens. The

sarcomeres in a contraction knot appear to be at least twice the diameter of the distant

sarcomere in the same fiber. The nodule feels larger and firmer than surrounding tissue

because of the greater volume occupied by the contraction knots and the highly

condensed state of there contractile elements.

 Spot Tenderness

Tender spot in one or more palpable taut bands is present. The spot tenderness of

both trigger points and nodules would be the result of sensitized nociceptors. The

nociceptors are most likely sensitized by substances released as a result of the local

energy crisis and tissue distress. Bradykinin is an effective sensitizing agent that is

released in hypoxic or ischemic tissue.

Range of Motion Restriction

The most restricted movement is lateral flexion of the head and neck (side

bending) away from the involved upper trapezius. When the trapezius alone is involved,

there is minimal limitation of head and neck rotation.

Pain with Movement

Active rotation of the head to the opposite side is usually painful at the extreme

range of motion, since the muscle contracts strongly in this shortened position.

Active rotation to the same side is usually pain free, unless either the levator

scapulae muscle on the same side, or the opposite upper trapezius, also harbor trigger

points.

Local Twitch Response

It is a brisk transient contraction of the palpable band of muscle fibers elicited by

mechanical stimulation of the trigger point in that taut band. Mechanical stimulation may
19
be produced by needle penetration of the trigger point, by mechanical impact applied

directly to the muscle (or to the skin over the trigger point), or by snapping palpation of

the trigger point.20

 Clinically the response is most valuable as a confirmatory sign. When injecting a

trigger point, a local twitch response signals that the needle has reached a part of trigger

point that will be therapeutically effective. 21 It is often not practical as primary diagnostic

criteria of a trigger point because it can be prohibitively painful to the patient when it is

elicited, it is often inaccessible to manual palpation because of overlying fat and/or

muscle, and it requires a particularly high degree of manual skill for reliable

examination.22

Referred Pain

Trigger points in upper fibers of trapezius consistently refer pain unilaterally

upward along the posterolateral aspect of the neck to the mastoid process, and are a major

source of “tension neck ache”. The referred pain, when intense, extends to the side of the

head, centering in the temple and back of the orbit, and also may include the angle of the

jaw. Occasionally, pain extends to the occiput, and rarely mild pain is referred to the

lower molar teeth. Pain referred from TP1 may appear in the pinna, but not deep inside

the ear.3

TP2: The referred pain pattern of this trigger point lies slightly posterior to the

essential cervical reference zone of TP1, blending with its distribution behind the ear.

The location of TP2 is caudal and posterior to the free border of the upper trapezius.3

The referred pain resulting from trigger points arises from central convergence

and facilitation. It is known from experimental data that, under pathologic conditions,

convergent connections from deep afferent nociceptors to dorsal horn neurons are

facilitated and amplified in the spinal cord. Referral to adjacent myotomes occurs due to

spreading of central sensitization to adjacent spinal segments. 1This pattern results in both

referred pain and in expansion of the region of pain beyond the initial nociceptive region.
 At the level of the central nervous system, spinal neuroplastic changes occur in

the second order neuron pool of the dorsal horn due to persistent pain. These changes

produce a long lasting increase in the excitability of nociceptors pathways. Central

sensitization results are characterized by increased excitability of the neurons and

expansion of the receptor pool of neurons. Neurotransmitters involved in the process of

central sensitization include substance P, N-methyl-D-aspartate, glutamate and nitric

oxide. In addition, there may also be impairments in supraspinal inhibitory descending

pain control pathways releasing inhibitory neurotransmitters such as γ-amino butyric

acid, serotonin and norepinephrine.15

Posture

Activity of TP1 and TP2 may cause intolerance to the weight of heavy clothing

such as a misfitting heavy overcoat which presses on the trapezius at the angle and back

of the neck (coat-hanger muscle), instead of an the acromion processes.

Patient with trigger point in upper fibers of trapezius is likely to assume a habitual

posture of bilateral shoulder elevation with a slight tilt of the neck toward the more

affected side.

With very active upper trapezius trigger points and with additional involvement of

the levator scapulae or splenius cervicis muscles, the patient may develop an acute “stiff

neck”. This also limits rotation of the head toward the same side, which stretches the

upper trapezius.
Fig 2.5 Trigger Point TP1 of Upper Fibers Trapezius (shown an X) and its

Referred Pain Area (Red)

 When patients have both neck and shoulder pain, it was found that levator

scapulae and infraspinatus trigger points were more frequently the cause than were

trapezius trigger points.

Enthesopathy

The enthesopathy (tenderness at the muscle attachment) is explained by the

inability of the muscle attachment structures to withstand the unrelieved sustained tension

produced by the taut band. In response, these tissues develop degenerative changes that

are likely to produce substances that could sensitize local nociceptors.14

Myoglobin Response

The myoglobin response to massage of fibrositis nodules can be explained on the

basis of the observed histopathologic changes in nodules. Repeated deep massage of the

fibrositic nodules (trigger point) produced transient episodes of myoglobinuria that were

not produced by similar massage of normal muscle.17, 18, 14

Predisposing Factors for Upper Trapezius Trigger Point3

Structural Inadequacies

A short leg or small hemi pelvis (body asymmetry) tilts the pelvis laterally, which

bows the spine into a functional scoliotic curve and, in turn, tilts the shoulders, causing

one to sag. The upper trapezius must work constantly to keep the head and neck vertical

and the eyes level. A cane too long tilts the axis of the shoulder girdle and causes a

similar trapezius problem by forcing the shoulder up on the side of the cane. A cane is

properly fitted if, with the shoulders level, the elbow bends 30-40 degrees with the cane

held beside the foot.

 Postural Stresses

Postural stresses to a muscle can be due to misfitting furniture, poor posture,

abuse of muscles ( by poor body mechanics that render movements needlessly stressful,

sustained isometric contraction, too many repetitions of same movement and by

excessively quick and jerky movements) and immobility.

Any position or activity in which the trapezius helps to carry the weight of the

arm for a prolonged period: telephoning or sitting without armrest support, particularly

when the upper arms are congenitally short, holding the forearms up to reach a high

typewriter keyboard or sewing on the lap with the elbows unsupported

Armrests that are too high push the scapulae up and shorten the upper trapezius

for long periods. The muscle’s accessory function of head rotation can be overstressed by

the quick repetitive movement of flicking long hair out of the eyes.

Muscle can be strained by chronic injury due to overload that is obscure. Such

microtrauma can be caused by clothing and accessories, by the large strap of a ponderous

purse or backpack, or by a heavy coat. It may also be caused by a sustained load in

habitual elevation of the shoulders, as an expression of anxiety or other emotional

distress, during long telephone calls, playing the violin, or by rotation of the head far to

one side in a fixed position (holding the head turned to converse with a person seated at

the side, or sleeping prone with the head fully rotated).

Acute Trauma

If the trauma leads to prolonged myofascial involvement as in the case of

whiplash and other motor vehicle related injuries. 5 Upper fibers trapezius trigger point

may be activated by, and remain as a sequel to, cervical radiculopathy.

 Criteria for Trigger Point Examination of Upper Trapezius

With the patient supine, or possibly seated, the muscle is placed on moderate

slack by bringing the ear slightly toward the shoulder on the same side. In a pincer grasp,

the entire mass of the free margin of the upper trapezius is lifted off the underlying

supraspinatus muscle and apex of the lung. Then the muscle is firmly rolled between the

fingers and thumb to palpate firm bands and elicit local twitch responses of the bands and

to locate the spot tenderness of trigger point. Sustained compression (4 to 10 seconds) of

the trigger point often evokes pain referred to the neck, occiput and temple.3

Several sets of criteria have been published to establish the presence of an active

trigger point 22, 23, 24, 25, 26

The criteria chosen for the purpose of this study includes: 22

Essential criteria

● Palpable tender spot in the upper trapezius fibers.

● Pain recognition upon palpation (time=10 sec)

● Taut band

Confirmatory Signs

● A typical pattern of referred pain in the ipsilateral, postero-lateral cervical spine,

mastoid or temporal area.

● Palpable local twitch response on snapping palpation at the most sensitive spot in

the taut band.

 Treatment Options

Evaluation of myofascial pain includes locating the trigger points and muscles

involved as well as recognition of all contributing factors. Management of the syndrome

naturally follows, treating the muscular trigger points and reducing all contributing

factors to prevent the trigger points from redeveloping. Treating the trigger points

involves repetitive action with cutaneous counter stimulation, coupled with active and

passive muscle stretching and postural rehabilitation. The goal is to restore the muscle to

normal length, posture and full joint range of motion. Preventing the redevelopment of a

trigger point includes maintaining the exercise program and controlling all contributing

factors that initiate the development of trigger points, perpetuate the persistence of trigger

points, and result from the chronic pain.27

W.H.Mc Nulty suggested that trigger points are activated directly by stress, thus

helping individuals modify their sympathetic response to stress with therapeutic

techniques, such as progressive muscle relaxation, autogenics, imagery and biofeedback

should be a major goal of treatment.28

Pharmacologic treatment of patients with chronic musculoskeletal pain includes

analgesics and medications to induce sleep and relax muscles. Antidepressants,

neuroleptics, or anti inflammatory drugs are often prescribed for these patients. Non

pharmacologic treatment modalities include acupuncture, osteopathic manual medicine

techniques, massage, acupressure, ultrasonography, application of heat or ice, diathermy,

transcutaneous electrical nerve stimulation, ethyl chloride Spray and Stretch technique,

dry needling and trigger point injections with local anesthetic, saline, or steroid.8
 In this study, effectiveness of static stretching technique for trigger points in

upper fibers of trapezius is being compared with Taping technique along with ultrasound,

soft tissue mobilization and PNF technique.

Ultrasound Effectiveness

In 1986, Talaat et al compared the effectiveness of muscle relaxant drugs, short

wave diathermy and ultrasound therapy on patients with myofascial pain dysfunction

syndrome. In their study the patients treated with use of physical therapy modalities

showed marked reduction of pain and muscle tenderness and improvement of the TMJ

clicking, particularly in the group where ultrasound therapy was used. According to them

the effectiveness of ultrasonic therapy could have been explained by its spasmolytic

action on the muscles which reduce hypertonicity or tension. This effect in turn may be

dependent upon some effects on the nervous systems. Unlike the short waves, the

ultrasonic waves show evidence of having greater effectiveness in muscle tissue than in

fat; thus, they permit deeper penetration by avoiding absorption of the energy in

subcutaneous fat.29

Other studies as done by Majlesi et al30 and Esenyl et al1 also support the use of

ultrasound therapy combined with stretching exercises for the treatment of trigger points.

A study done by Hong et al31 in 1993 showed the immediate effectiveness of

ultrasound therapy in improving the pain threshold of active myofascial trigger points.

But a study done by Gam et al54 in 1998 showed that that the treatment groups

(massage, exercise) had a reduction of number and intensity of myofascial trigger points

compared with a control group but no difference was found in ultrasound versus sham

ultrasound with respect to reducing pain assessed by analgesic usage, visual analogue

scale (VAS) on function and at rest. 32 No explanation was given for the failure of

ultrasound therapy by the authors.

 Stretching

Stretching exercises form the basis of exercise treatment of myofascial pain. This

treatment addresses the muscle tightness and shortening that are closely associated with

pain in this disorder and permits gradual restoration of normal activity.15

In 1981, Travell and Simons stated that it should only be necessary to stretch the

shortened sarcomeres enough to separate the overlap of actin and myosin filaments and

thus to break the vicious cycle. Uncontrolled contractile activity would stop. This would

terminate uncontrolled metabolic activity, which in turn would permit accumulation of

ATP. The calcium pump of the sarcoplasmic reticulum could restart and return the

muscle to normal control. This apparently happens in the few seconds that the muscle is

held under full passive stretch during stretch and spray. They also said that treatment by

sustained firm pressure (ischemic compression) on the trigger point produces: local

stretch of the shortened sarcomeres due to pressure, a pressure (ischemic) nerve block,

emptying of capillaries, and afterwards, a rebound hyperemia. The transient nerve block

would tend to interrupt pain pathways and any sympathetically mediated local reflex

ischemia. Excessive metabolites and sensitizing substances would be flushed away by the

rebound hyperemia.13
33
Another study by Jaeger et al also supported the assumption that local tissue

responses to the stretch itself somehow result in decrease in trigger point sensitivity. In

this study, the pain intensity reduced and the pressure pain threshold increased

immediately after one treatment session of stretch and spray over the involved trapezius

muscle but the results were attributed to the stretching technique and not to the

vapocoolant spray.
 Lewit et al34 applied the procedure of post-isometric relaxation technique for

reducing trigger point sensitivity and pain intensity. The technique involved stretching

the muscle containing the trigger point, followed by an isometric contraction against

minimal resistance. After the contraction, the muscle was first allowed to relax, and then

it was stretched. The results showed immediate pain relief in 94%, lasting pain relief in

63% as well as lasting relief of point tenderness in 23% of sites treated. Thus indicating

that PNF stretching procedures may give better results than static stretching procedures

for the treatment of myofascial trigger points also as shown in other studies.46, 47, 48, 49

Studies have also shown that both the stretching procedures- static stretching and

contract relax PNF give an immediate increase in range of motion.50, 51

Soft Tissue Mobilization

It is said that massage is an excellent tool in the treatment of myofascial pain

syndromes and at times the sole treatment necessary. A reasonable course of therapeutic

massage along with other modalities may be tried before an invasive procedure such as

injection is pronounced necessary.35 A combination of massage techniques can be used

when treating trigger points.35

Some trigger points may become deactivated after only a few minutes of

treatment whereas others may take multiple treatments of 30 to 60 minutes. Regardless of

the time spent, post massage passive and active stretching of the involved muscle groups

is ideal to further increase the elasticity and normal length of the muscle fibers. 35

For the purpose of this study, effleurage and kneading have been included as

the components of soft tissue mobilization. The effects of these techniques involve:
Effleurage: Gradual compression reduces muscle tone and induces a general state of

relaxation that relieves muscle spasm and prepares the patients for more vigorous

treatment. Firm pressure accelerates blood and lymph flow, improves tissue drainage and

thus recent swelling.36

Its effectiveness may be accounted for by the massage producing elongation of

contractured sarcomeres in contraction knots to interrupt an essential link in the chain of

events postulated by the dysfunctional end plate hypothesis. Enough pressure to

mechanically disrupt the endplate can totally inactivate that endplate and eliminate the

cycle. Two experimental studies showed that vigorous massage of tender ‘fibrositis’

nodules did disrupt muscle fibers sufficiently to release intracellular myoglobin.

Comparable massage of normal muscle caused no such elevation of serum myoglobin. As

the tenderness and tension of the ‘nodule’ subsided with repeated treatments, the post

treatment increase in serum myoglobin became successively less and finally failed to

appear when symptoms had abated. This finding strongly supports the concept that

dysfunctional endplates may be more susceptible to mechanical trauma than are normal

endplates and that properly placed local tissue stretch can inactivate them. 17, 18
These

forms of local tissue manipulation apparently produce a localized stretch that lengthens

sarcomeres in the immediate vicinity of the applied pressure. The pressure itself may also

help by physically dispersing the sensitizing substances released because of the hypoxic

ischemia and by mechanical disruption of the dysfunctional endplate.14

Kneading: It consists of slow circular compression of soft tissues against underlying

bone. The greatest pressure is applied as the hands move proximally, although contact is

continuous. Small areas are usually treated using the fingertips alone. Kneading promotes
the flow of tissue fluid and causes reflex vasodilatation and marked hyperemia. This

reduces swelling and helps resolve inflammation. Vigorous kneading decreases muscle

spasm and can stretch tissues shortened by injury.36

Pain relief as a result of massage has a number of physiologic explanations.

Massage aids the body’s removal of metabolic waste products, which can be responsible

for cramping and soreness in muscles. The pressure and movement of the massage

stimulates the non-nociceptive nerve endings, thus reducing pain. Massage can also

contribute to the release of endorphins, a neurotransmitter that acts as a “central pain

suppressant”, and to increasing serotonin levels, which inhibit transmission of pain

signals to the brain.35

In a study massage therapy was found to be effective in immediately reducing

pain, improving trunk range of motion and increasing serotonin and dopamine levels, and

reducing symptoms associated with chronic low back pain; however, this study did not

specify the etiology of the pain.37

Other studies31, 38
have also shown immediate effects of soft tissue mobilization

technique in reducing pain due to myofascial trigger points.

In this study, the protocols chosen include ultrasound (1.5W/cm2; continuous

mode, 6 minutes), static stretching of upper fibers of trapezius for one group and

ultrasound (same parameters), contract relax for upper fibers of trapezius, soft tissue

mobilization for seven minutes for another group. These particular interventions were

selected because earlier studies have checked for the efficacy of ultrasound combined

with static stretching in producing long term effects in trigger points treatment but their

immediate effects have not been studied. Also, the soft tissue mobilization and PNF
interventions has been found to be effective in immediately reducing the trigger point

symptoms in case of subscapularis muscle but has not been applied for trigger points in

other muscles and moreover, has not been compared for effectiveness with any other

commonly used technique for their treatment. Thus, this study would yield a good

comparison between two treatment interventions used for the treatment of trigger points

in upper fibers of trapezius.

 Taping

Kinesiology Taping has an effect on kinematics, muscle activity and strength of the

scapular region in people with shoulder impingement. A study found that taping over the

upper trapezius muscle, resulted in positive changes in scapular motion and muscle

performance. .The results supported its use as a treatment aid in managing shoulder

impingement problems. Kinesiology Tape Application to the Upper Trapezius Reduces

Pain, Trigger Point Irritability and Increases Muscle Strength

COMPARING THE EFFICACY OF UPPER TRAPEZIUS KINESIOTAPING AND

STATIC STRETCHING EXERCISES IN PATIENTS WITH UPPER TRAPEZIUS
TRIGGER POINT PAIN.

BACKGROUND AND AIM

Globally, a large number of population is suffering from persistent trigger point pain of

upper trapezius. Several treatment protocols are available now a day to facilitate patient

recovery. Therefore, the aim of this study is to identify the effects of kinesiotaping in

improving upper trapezius trigger point pain, upper trapezius muscle strength and

functional disability.

STUDY DESIGN

Randomized controlled trial

SAMPLE SIZE

68 participants were recruited for the study.

METHODOLOGY

All participants of age 18-40 years were assessed using assessment Performa. Pain

intensity, upper trapezius muscle strength and Neck disability index were measured at

baseline and after treatment sessions. Group A comprised of 34 participant, received

Kinesiotaping and conventional physical therapy treatment whereas, equal number of

participants were recruited in Group B that received upper trapezius static stretching and

conventional physical therapy.

RESULT

The study revealed that both interventions (Kinesiotaping and stretching) were effective

i.e., <0.05 in improving pain intensity, muscle strength and functional disability in

patients with upper trapezius trigger point pain but significant improvement were

recorded in group treated with kinesiotaping.

CONCLUSION: The study concluded that both interventions are effective in improving

pain intensity, muscle strength and neck disability index but kinesiotaping is more

beneficial than static stretching among patient with upper trapezius trigger point pain.
 CHAPTER 3

METHODOLOGY
 This chapter deals with the methodology implemented to conduct this study. This

section provides detailed information on the sampling technique, study design and

procedure of data collection.

Sample

Subjects

A convenient sample of 30 subjects with myofascial trigger points in one side of

the upper trapezius muscle was included.

Subjects with neck pain referred for evaluation and intervention related to their

neck pathology were recruited consecutively from the OPD of kanchan advance

physiotherapy clinic.

All the subjects (n=30) who met the inclusion criteria were required to sign an

institutionally approved informed consent form (appendix B) prior to participation in the

study. Then they were randomly divided into two groups.

Inclusion Criteria

1) Clinically active, palpable trigger point on one side of the upper trapezius muscle

based on the mentioned criteria:

Essential Criteria

● Palpable tender spot in the upper trapezius fibers.

● Pain recognition upon palpation (time=10 sec)

● Taut band
Confirmatory Signs

● Atypical pattern of referred pain in the ipsilateral, postero-lateral cervical spine,

mastoid or temporal area.

● Palpable local twitch response on snapping palpation at the most sensitive spot in

the taut band.

2) Restricted range of motion in lateral bending of the cervical spine to the opposite

side.

3) Age between 20-45 years. A relatively young population of patients was recruited

to minimize pain that might be caused by accompanying degenerative disc and joint

diseases.

4) Patients with primary myofascial pain syndrome (no pain at any other area than the

corresponding trigger point. [(-) spurling sign]

5) No treatment of myofascial pain or trigger points at the time of the study.

6) No neck/ shoulder surgery within past year.

7) No clinical evidence of radiculopathy or myelopathy.

8) No history of disk disease, degenerative disease, fracture or dislocation in

the cervical vertebrae.

9) No cognitive defects.

10) Willingness to participate.

 Exclusion Criteria

1) Having signs and symptoms meeting the 1990 American College of Rheumatology

criteria for fibromyalgia. (Appendix A)

2) Having myofascial trigger point injections or receiving physical medicine in the

year preceding this study.

3) Having a history of acute trauma.

4) Having a history of inflammatory joint or muscle disease, infection, or malignancy.

5) Having an evidence of neurologic deficit.

6) Exhibiting inadequate co-operation.

Study Design

The study was a pre test post test (experimental) design to measure pain intensity

and cervical lateral flexion range of motion before and immediately after the treatment.

There were two equal groups.

GROUP I- Taping along with conventional physiotherapy treatment.

GROUP II- Static stretching along with conventional physiotherapy

treatment.
 Procedure

Ethical Approval

Ethical approval was obtained from the Institutional Ethical committee, Department of ITS

Institute Of Health & Allied Sciences, Muradnagar, Ghaziabad, Uttar Pradesh. Before data

collection vide letter number - IIEC/2022-24/PHYSIO/011

Measurement

1) Pain intensity: Scores on the visual analogue scale (VAS) were marked by the

patient pre intervention and immediately post intervention and the marked values

were taken to the nearest whole number.

2) Cervical lateral flexion was measured pre intervention and immediate post

intervention.

The same physical therapist performed all the measurements.

Instrumentation

1) Goniometer was used to measure ranges of cervical lateral flexion.

2) Ultrasound equipment with frequency 3 MHz.

3) Ultrasonic gel

4) Stop watch.

Pain intensity (VAS) was described by patients using a 10 cm line with 0

representing “no pain” and 10 representing “worst pain imaginable”.39

Cervical lateral flexion was measured as follows:

A transparent goniometer (full arc) was used to measure range of passive lateral

flexion at cervical spine.

 Patient’s position: Sitting with thoracic and lumbar spine well supported by the

back of the chair. The cervical spine was positioned in 0 degrees of flexion, extension and

rotation. The shoulder girdle was stabilized to prevent lateral flexion of the thoracic and

lumbar spine. The fulcrum of the goniometer was aligned over the spinous process of the

C7 vertebra and the proximal arm with the spinous process of the thoracic vertebrae so

that the arm was perpendicular to the ground. The distal arm was aligned with the dorsal

midline of the head, using the occipital protuberance for reference.

At the end of passive lateral flexion range of motion the alignment of the

proximal goniometer arm was maintained with the right hand and the subject’s head was

maintained in lateral flexion by other hand.40

Normal range of cervical lateral flexion is 0°-45°

Fig. 3.1 Instrumentation
Fig. 3.2 Application of ultrasound on trigger point of upper trapezius
Fig. 3.3 Position for static stretching of upper trapezius
Fig. 3.4 Application of soft tissue mobilization on trigger point of upper trapezius

Fig. 3.5 Application of contract – relax on trigger point of upper trapezius

Fig. 3.6 Application of PNF pattern of neck (end position)
Fig. 3.7 Upper Trapezius Kinesiotaping (1)
Fig. 3.8 Upper Trapezius Kinesiotaping (2)
Fig. 3.9 Upper Trapezius Kinesiotaping (3)
Fig. 3.10 Upper Trapezius Kinesiotaping (4)
To establish intrarater reliability- cervical lateral flexion measurements were taken three

times and the average of them was finally taken for calculation purposes.

Protocol

Independent Variable

Treatment regime:

● Taping along with conventional physiotherapy treatment.

● Static stretching along with conventional physiotherapy

treatment.

Dependent Variable

● Pain intensity as per VAS score.

● Range of motion of cervical lateral flexion.

Intervention

Subjects received verbal description of all the procedures and were included in the

study after informed consent form was signed. The PNF pattern for the neck was

demonstrated by the therapist

1) Group I: Patient was seated on a chair and upper fibers of trapezius were palpated

for the trigger point. The area was marked using a marker.

These patients were first treated with ultrasound (continuous) with the dosage of

1.5W/cm2, 3 MHz for 6 minutes at the trigger point or the taut band of upper fibers of

trapezius and at the referred pain area.

Then the patient was positioned in prone lying with head turned towards

uninvolved side and the identified restrictions were treated with soft tissue mobilization

utilizing a combination of effleurage and kneading to trapezius myofascia for 7 minutes

(starting with 10 seconds of effleurage then 20 seconds of kneading and then both

alternating for 30 seconds each, ending with effleurage).

The soft tissue mobilization was then followed by contract relax PNF to the

trapezius muscle.

Procedure of contract relax: (for left trapezius) 4

a) The subject was made to lie supine and rotated his head to the right as far as

possible without pain and then tucked his chin as far as possible. The therapist

stabilizes the left shoulder down away from the patient’s head. This starting

position lengthens the left upper trapezius to its pain free end range.

b) The therapist then crossed her arms and places the left hand at the subject’s occiput,

fingers pointing towards the ceiling and right hand on his left shoulder and then told

the subject to push against both of the therapist’s hand as if bringing the back of his

head and his left shoulder together. He was told not to lift or rotate his head, but

push straight back into the therapist’s hand. The therapist provided matching

resistance for this 7 second isometric contraction, being sure that subject pushes

equally from both ends and kept breathing normally throughout.

c) After the isometric push, the subject relaxed and breathed in. Then he actively

rotated his head farther to the right, tucked his chin more (if possible) and pulls his

left shoulder away from his head. This position was maintained for 15 seconds. This

deepened the upper trapezius stretch.

d) This procedure of contract relax was repeated 5 times with 20 seconds of rest period

between two contract relax cycles.57, 58

Subjects were then instructed to actively move through the PNF pattern of flexion

with rotation (D flexion, rotation) for 5 repetitions with manual facilitation.

 Procedure for PNF pattern: Flexion with rotation to the right (D fl, R)4 (for left

trapezius)

Antagonistic pattern: Extension with rotation to left.

Components of motion: Head rotates toward right (axis on atlas), mandible depresses

toward right, atlanto-occipital joint flexes towards right, and cervical spine flexes with

rotation towards right so that chin approximates right clavicle.

Normal timing:

Action occurs from distal to proximal, that is, head rotates toward right (atlas on axis),

mandible depresses as atlanto-occipital joint flexes towards right and cervical spine,

which has been convex to right, flexes with rotation to right and becomes convex to left.

Manual contacts:

Right hand: Pressure of medial palmar surface of hand and fingers under inferior surface

of mandible on right between symphysis and right angle.

Left hand: Palmar surface of hand and fingers on left postero-lateral aspect of skull to

control rotation.

Commands:

Preparatory: You are going to turn your head to the right and pull it down and over

toward the right, so that your chin touches your chest.”

Action: “Turn your head! Pull your chin down! Pull your head down!”

2) Group II: These patients were treated with ultrasound (continuous) with the dosage of

1.5W/cm2, 3 MHz for 6 minutes at the trigger point or the taut band of upper fibers of

trapezius followed by passive stretching of trapezius upper fibers. The end position was

maintained for 30 seconds and the procedure was repeated 4 times with a rest period of

15 seconds between two stretch cycles.

 Passive stretching for upper fibers of trapezius: 41

Patient’s position: supine lying

The stretch was a three movement stretch. The first component was a lateral bend

to stretch the side bend component of the muscle (the more anterior fibers). The second

position was forward, maintaining the lateral bend, to stretch the extension component of

the trapezius (the more posterior fibers). The final movement was rotation of the back of

the head away from the side being stretched, while maintaining the lateral-forward head

position, because the trapezius inserts in the back of the head on the inion.

After giving the treatment intervention, the data was collected immediately for the

pain intensity and cervical lateral flexion range of motion variables.

Data Acquisition

Data was collected in a quiet room, under similar conditions for each subject by

the same physical therapist.

Patients signed the consent form and then the data was collected in the data

collection form (appendix) along with other details of the patient. First baseline values for

pain intensity (VAS) and cervical lateral flexion range of motion were taken and then

post intervention readings were taken immediately after delivering the treatment

intervention.
 C

HAPTER 4

DATA ANALYSIS
This chapter includes the methods used for data analysis.

Statistically the characteristics of the groups and the results within and between

the groups were compared.

All the subjects performed two trials for both variables (VAS and cervical lateral

flexion range of motion), one at the baseline (pre-intervention) and second immediately

post intervention.

Data was managed on an excel spread sheet. This data was analyzed by means

of paired t-test for within group comparisons and by unpaired t-test for between group

comparisons through SPSS software. A significant level of p ≤ 0.05 was fixed.

CHAPTER 5

RESULTS
This section deals with the results obtained after the statistical analysis..

In the present study, the overall data analysis revealed significant

results.

Table 5.1 shows, the comparison of subjects of the groups for age, weight (kg),

height (cm) and duration of symptoms (months). A student t-test analyzed the two groups

for all these variables.

No significant differences were found between the groups for any of these variables

Group I

The immediate effects of Taping along with conventional physiotherapy treatment

procedures were determined by comparing the post intervention values of VAS (VAS2;

pain intensity) & cervical lateral flexion (CLF2) with the preintervention corresponding

values i.e., VAS 1 & CLF 1 (as shown in table 5.2) Paired t-test was used

to determine these effects.

Mean S.D.

VAS 1 6.00 1.51

VAS 2 2.20 1.78

CLF 29.03 4.80

1
CLF 39.24 5.53
2

Significant differences were found between the preintervention and post

intervention values for both the variables.

 Group II

Paired t-test was used to determine the Static stretching along with conventional

physiotherapy treatment procedure by comparing the preintervention and the post

intervention values for VAS (i.e. VAS 1 & VAS 2) & cervical lateral flexion (i.e. CLF 1

& CLF 2) (as shown in table

5.3) .
Mean S.D.

VAS 1 5.87 1.19

VAS 2 3.40 1.21

CLF 32.53 6.04

1
CLF 35.73 6.29
2

Significant differences existed between the preintervention and post intervention

values for both the variables (at 0.01 levels).

Comparison between Group I and Group II

The difference in the effectiveness, of Taping v/s Static stretching along with

conventional physiotherapy treatment, was determined by comparing the post

intervention improvement for pain intensity (i.e. VAS’) & cervical lateral flexion (i.e.

CLF), between the two groups. (As shown in table 5.4 & 5.5)

Both the groups did not differ significantly for the preintervention values of pain

intensity (VAS 1) & cervical lateral flexion (CLF 1)

 Group Group
I II
Mean S.D Mean S.
D
V AS’ 3.80 0.94 2.47 0.
64
CLF 10.21 2.67 3.22 0.6
0

A student t-test analyzed the two groups and showed that significant differences

existed between the post intervention reductions in pain levels between the two groups.

The range of cervical lateral flexion also improved significantly more than that of group

II.
Table 5.1: Baseline comparison of the two groups for Age, Height, Weight and Duration
of Symptoms (DOS)

Variable GROU GRO II

PI UP t- p value
( N=1 (N=1 value
5) 5)
Mean S.D. Mean S.D.
Age 32.27 7.68 36.6 5.24 1.8 0.082
(NS)
WT. (kgs) 59.87 6.57 64.07 5.70 1.87 0.72
(NS)
HT. (cms) 155.40 3.2 156.63 2.57 1.15 0.261
(NS)
DOS 26.27 14.61 21.73 12.5 0.91 0.370
(months) 8 (NS)

NS Not Significant
WT. Weight
HT. Height
DOS Duration of Symptoms
 Table 5.2: Comparison of VAS1 and VAS2; CLF1 and CLF2 in Group 1

Variable Me S. t-value p
an D. value
VAS1 6.0 1.
0 51 15.64* 0.000
VAS2
2.2 1.
0 78
CLF1 29. 4.
03 80 14.66* 0.000
CLF2
39. 5.
24 53

*Significant at 0.05 level

Table 5.3: Comparison of VAS1 and VAS2; CLF1 and CLF2 in Group 2

Variable Me S. t-Value p
an D. value
VAS1 5.8 1.
7 19 14.93* 0.000
VAS2
3.4 1.
0 21
CLF1 32. 6.
53 04 19.88* 0.000
CLF2
35. 6.
73 29

*Significant at 0.05 level

 Table 5.4: Comparison for VAS1, VAS2, VAS’ (VAS1-VAS2) between two Groups

Variab GROU GROUP

le PI II (N- t-value p value
(N=1 =15)
5)
Mean S.D. Mean S.D.
VAS1 6.00 1.51 5.87 1.19 0.27 0.790
(NS)
VAS2 2.20 1.78 3.40 1.21 2.21* 0.036

V9 3.80 0.94 2.47 0.64 4.54* 0.000

NS Not Significant
* Significant at 0.05 level

Table 5.5: Comparison for CLF1, CLF2, CLF (Difference) between two Groups

Variab GRO I GROUP

le UP II t-value p
(N=15 (N=15) value
)
Mean S.D. Mean S.D.
CLF1 29.0 4.80 32.53 6.03 1.76 (NS) 0.090
CLF2 39.24 5.53 35.73 6.28 1.62 (NS) 0.115
CLF 10.21 2.67 3.22 0.60 9.80* 0.000

*Significant at 0.05 level

 Pretreatment Post treatment Pretreatment Post
7

6
6 5

5
V
A
S 4
3

(
3
P
a 2

i 2

0
1

Grou Grou
p1

Fig. 5.6 Graphical representation of pre and post treatment VAS scores for group 1 and
group 2.
 Pretreatment Post treatment Pretreatment Post
4
5

3
R 3
O 3

M 3 2

( 2
5
C
e
r 2
0
v
i
c 1
5
a

1
0
1

Grou Grou

Fig. 5.7 Graphical representation of pre and post cervical lateral flexion ranges for
group1 and group 2.
 Group 1
Difference
4 in pre
3
and post treatment
pain3 intensity (VAS)

2
2

Fig. 5.8 Comparison of V9 (VAS 1- VAS 2) between two groups.

 Group 1

12

G
a
i 0
1

n .
2
1
i 10

R
O 8
M

(
C
e 6

Fig 5.9 Comparison for gain in ROM (Cervical lateral flexion) between two groups.
CHAPTER 6

DISCUSSION
 The purpose of this study was to determine whether Taping along with

conventional physiotherapy treatment and Static stretching along with conventional

physiotherapy treatment directed to trigger point in upper fibers of trapezius have an

immediate effect on pain and cervical lateral flexion range of motion. Also, the effects of

the treatment interventions were compared in this study.

In this section, the results of this study will be discussed in view of the possible

rational involved & the findings will be compared with the previously available literature.

This study indicates that both the chosen protocols yield significant immediate

improvement in the symptoms (in terms of pain intensity & cervical lateral flexion range

of motion) of trigger point in the upper fibers of trapezius.

As shown in table 5.4 & 5.5, a mean reduction of 2.47 in pain intensity & a mean

gain of 3.22 degrees in cervical lateral flexion is noted immediately post treatment for

group 2 subjects. The differences between the pre & post treatment values for both the

measured variables are significant (table 5.3), thus, indicating the effectiveness of Taping

protocol in immediately reducing the symptoms of trigger point in upper fibers of

trapezius.

These results have come in accordance with the previous studies which have
1, 30, 31, 42, 43
earlier also shown the effectiveness of these two protocols . The results

produced can be attributed to the thermal effects of ultrasound (dosage used was 1.5

W/cm2; continuous mode) & the changes brought up by the Taping at the trigger point

level. The thermal effects of ultrasound include acceleration of metabolic rate, decrease

or control of pain or muscle spasm, alteration in nerve conduction velocity, increased

circulation & increased soft tissue extensibility. These effects are used
 44, 45
primarily prior to stretching the shortened soft tissues and for reduction of pain . The

effects have also been explained by Mense stating that ultrasound heats the tissues which

if continued long enough at sufficient intensity might dominate the local energy crisis.

The increased heat & molecular excitation might augment the energy crisis patho-

physiology to the point of self destruction.14

The Taping techniques are effective by equalizing sarcomere length throughout

the affected muscle fibers and by breaking the feedback cycle (as in integrated hypothesis

of trigger point formation) 15. Other studies 13, 32, 33

have also explained the effectiveness

of Taping procedures in reducing symptoms of trigger points.

The result of this study have also been supported by another study done by

Wessling et al43,who had shown the immediate effectiveness of ultrasound combined with

Taping in improving the muscle extensibility. They also showed that the combination of

these two procedures yielded better results thanTaping alone. Whereas in static

stretching, a protocol of 30 second passive stretch is used. This particular protocol was

chosen because its effectiveness has been shown in bringing immediate flexibility in joint

range of motion52. Moreover, when compared to static stretching for 60 seconds, no

significant differences were found in the gain in range but it

was still found to more effective than a passive stretch of 15 seconds duration52.

For group 1, the results obtained show, a mean reduction of 3.80 in pain intensity

& mean gain of 10.21 degrees in cervical lateral flexion range of motion immediately

after the treatment (as shown in table 5.4 & 5.5), thus indicating significant improvement,

in symptoms (table 5.3). Moreover, it has also been shown that significant differences
exist between the post interventions improvements (VAS’ and CLF) for the two groups

(as shown in table 5.4 & 5.5). It has clearly been indicated that the treatment intervention

combining Taping with ultrasound, soft tissue mobilization and PNF yielded better

results than the intervention combining static stretching with ultrasound, soft tissue

mobilization and PNF. The better results obtained for group 1 subjects could be due to

the addition of Taping along with soft tissue mobilization for treating the trigger point &

using contract-relax PNF procedure for the upper fibers of trapezius.

Studies done by many authors previously have shown that the contract relax PNF
34,46,47,48,49,50,51
procedure yield immediate effects in terms of gain in range of motion .

Moreover, it has also been shown that the gains by contract relax PNF procedures are
46,47,48,49
larger than those by static stretching procedures. But none of these studies have

compared the two stretching protocols for myofascial trigger points.

These larger gains in range achieved by PNF group might be explained by the

phenomenon of autogenic inhibition and active mobilization of connective tissue. 47,49, 50

Along with the alteration in neural properties (brought about by autogenic inhibition),

changes in visco-elastic and thixotropic properties of the muscles being stretched have

also been reported, 50 bringing about better results. Autogenic inhibition has been defined

by Knott and Voss4, 50

as the inhibition of the homonymous muscle alpha-motor neurons

by the stimulation of the golgi tendon organ. This inhibitory effect is thought to diminish

muscle activity and therefore, allow for relaxation so that the muscle can be stretched. 50

Motor pool excitability, as measured by Hoffman reflex during different muscle

stretching techniques, was shown to be significantly diminished in cases of PNF

stretching techniques than in static stretching. 50 This inhibitory effect has been suggested

to increase muscle compliance, allowing for increased length during a stretch without

stimulation of stretch reflex.

 Musculotendinous units function in a viscoelastic manner and therefore, have the

properties of creep and stress relaxation.50 The unit deforms or lengthens as it is being

stretched and goes through elastic and then plastic deformation before completely

rupturing.50 The changes in viscoelastic properties of the muscle by a single session of

stretching protocol are attributed to the changes in elastic region. 50 Thixotropy is the

property of a tissue to become more liquid after motion and return to a stiffer, gel like

state at rest. Based on thixotropic properties, temporary increases in muscle flexibility are

expected.50

In addition to all this, the soft tissue mobilization procedure too has contributed in

the results obtained for group 1. A seven minute soft tissue mobilization procedure

compromising of effleurage & kneading was utilized in this study. The effectiveness of

this procedure has previously been shown in a study on trigger points of subscapularis

muscle bringing about significant improvement when combined with PNF technique.2

Gam et al54 also reported that massage and exercise reduces the numbers &

intensity of myofascial trigger points. The results are also supported by previous findings

indicating immediate improvement in symptoms caused due to myofascial trigger points,

by the use of massage therapy protocols31, 38

The effects can be attributed to the physiological effects 35, 36, 37

being brought up

by used soft tissue mobilization techniques and to the earlier shown increase in plasma

myoglobin concentrations immediately after one treatment session17, 18. Repeated massage

treatment is followed by a gradual decline in the post treatment increase in plasma

myoglobin to a level not differing significantly from that registered before massage. This

increase in the plasma myoglobin seemed to be the result of leakage of myoglobin from

the tense muscle fiber17, 18 and this level successively becomes less as the tenderness and

tension of the “nodule” subsides with repeated treatments.14

 Thus the inclusion of Taping, contract relax PNF & soft tissue mobilization in the

treatment protocol led to better results than those of static stretching protocol & that is

why, the subjects of group 1 would have shown better improvement than those of group

2.

Clinical Implications

This study showed that depending upon patients stage of healing and severity of

symptoms, the procedures used in this study could be repeated in subsequent sessions to

further improve the patient’s condition.

It also provides useful treatment options for treating trigger point in upper fibers

of trapezius wherein the invasive procedures (like injection therapy) are not desired

Both these treatment interventions can be included in the rehabilitation

programme along with other treatment protocols for the management of trigger points.

These treatment interventions can also be used in decreasing the frequency and

intensity of tension type headaches caused by trigger points in various muscles.

Future Research

This study utilized the two treatment interventions for producing immediate

improvement in symptoms of trigger point in upper trapezius. The long term effects of

these interventions should be studied.

Also, the effects of these interventions on trigger points in other muscles should also be

studied.
CHAPTER 7

CONCLUSION
 The result showed that a combination of Taping along with ultrasound, soft tissue

mobilization and PNF is more efficacious than a combination of static stretching along

with ultrasound, soft tissue mobilization and PNF when applied on trigger point of upper

fibers of trapezius. Thus, the hypothesis holds true.

CHAPTER 8

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APPENDICES
 APPENDIX A

CRITERIA FOR FIBROMYALGIA

 The American College of Rheumatology 1990 Criteria for the Classification of

Fibromyalgia* 53

1) History of widespread pain.

Definition: Pain is considered widespread when all of the following are present:

pain in the left side of the body, pain in the right side of the body, pain above the

waist and pain below the waist. In addition, axial skeletal pain (cervical spine or

anterior chest or thoracic spine or low back) must be present. In this definition,

shoulder and buttock pain is considered as pain for each involved side. “Low back”

pain is considered lower segment pain.

2) Pain in 11 of 18 tender sites on digital palpation.

Definition: Pain, on digital palpation, must be present in at least 11 of the following

18 tender point sites:

Occiput: bilateral, at the suboccipital muscle insertions.

Low cervical: bilateral, at the anterior aspects of the intertransverse spaces at C5-

C7.

Trapezius: bilateral, at the midpoint of the upper border.

Supraspinatus: bilateral, at origins, above the scapula spine near the medial

border.

Second rib: bilateral, at the second costochondral junctions, just lateral to the

junctions on upper surfaces.

Lateral epicondyle: bilateral, 2 cm distal to the epicondyles.

Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle.

Greater trochanter: bilateral, posterior to the trochanteric prominence.

 Knee: bilateral, at the medial fat pad proximal to the joint line.

Digital palpation should be performed with an approximate force of 4 kg.

For a tender point to be considered “positive” the subject must state that palpation

was painful. “Tender” is not to be considered “painful”.

* For classification purposes, patients will be said to have fibromyalgia if both

criteria are satisfied. Wide spread pain must have been present for at least 3 months. The

presence of a second clinical disorder does not exclude the diagnosis of fibromyalgia.
 APPENDIX B

CONSENT FORM
 APPENDIX 1: CONSENT FORM
TITTLE OF THE STUDY: “COMPARISON OF STATIC STRETCHING VERSUS TAPING
ALONG WITH CONVENTIONAL PHYSIOTHERAPY TREATMENT FOR TRIGGER
POINT OF UPPER TRAPEZIUS”
I have been informed by Gaurav Guleria; pursuing MPT, is conducting above mentioned research
under the guidance of research guide “DR. DEEPALI PAL, Assistant professor”, Department of
physiotherapy, Ras Bihari Bose Subharti University, Dehradun.
I have no objection and will be part of that group and will be regular in sessions designed and described
to me. I also understand that the study does not have any object which has negative implication on my
health. I understand that the medical information produced by the study will become part of institute
record and will be treated as per confidentiality regulations of the institute. I have been informed that
the data is used for medical literature and teaching purpose, name and other identities (photograph)
will not be used without my permission. I understand that my consent is voluntary and I reserve the
right to withdraw it and discontinue my participation from the study at any point of time during the
study.
I confirm that MR. Gaurav Guleria (Investigator) has explained to me, the purpose of the study and
procedure in the language I can understand. Therefore, I agree and wishfully grant my consent to
become a participant in the study and I will be accountable for the decision in case any.

Signature: Signature of Researcher

Participant Name: (Gaurav Guleria)
Date of Participation: (MPT Final Year)
RBBSU, DEHRADUN

GUIDE Signature CO-GUIDE Signature

 APPE

NDIX C

MAST

ER CHART
 C.L
S.NO GRO AG WT. HT. DOS VAS VAS VAS . C.L.F. C.L.F.
. UP E 1 2 ' F 2 '
.
1
1 1 24 50 158 12 4 0 4 30 37 6.4
.6
2 1 24 62 160 24 3 0 3 30 38.6 8
.6
3 1 25 48 156 36 5 0 5 29 45 15.7
.3
4 1 23 52 157 24 7 3 4 35 45 9.4
.6
5 1 43 69 157.5 48 6 3 3 21 33.6 12
.6
6 1 45 65 150 60 8 5 3 25 31.3 6
.3
7 1 40 62 152.5 36 7 5 2 26 34.3 8
.3
8 1 41 69 160 18 6 1 5 24 38.6 14
.6
9 1 38 68 155 8 7 2 5 31 42.6 11
.6
10 1 35 60 157.5 18 6 2 4 33 45.6 12
.6
11 1 29 58 152.5 24 5 2 3 21 31.6 10
.6
12 1 24 62 150 8 7 2 5 34 45.6 11.3
.3
13 1 28 60 154 18 4 0 4 30 42.3 11.7
.6
14 1 33 55 158 36 8 4 4 24 32.6 8.3
.3
15 1 32 58 153 24 7 4 3 35 45 9.4
.6
16 2 25 48 156 36 4 2 2 31 34 2.7
.3
17 2 38 60 155 24 5 3 2 39 42.6 3.3
.3
18 2 41 69 160 18 5 3 2 30 33.3 2.7
.6
19 2 43 70 160 24 7 4 3 42 46.6 4.3
.3
20 2 33 62 155.5 8 7 5 2 24 26.6 2.3
.3
21 2 32 60 154 10 6 4 2 27 31.6 4.3
.3
22 2 36 62 156 18 8 5 3 25 28.6 3.3
.3
23 2 40 64 153.5 36 5 3 2 35 39 3.7
.3
24 2 35 66 152.5 24 6 2 4 35 38.3 2.7
.6
25 2 28 64 157 6 6 3 3 32 34.6 2.6
.3
26 2 38 65 160 48 7 5 2 31 34.6 3.3
.3
27 2 42 69 160 36 7 4 3 21 24.3 3
.3
28 2 39 72 158.5 12 5 2 3 35 39 3.4
.6
29 2 42 66 157 18 6 4 2 37 40.6 3
.6
30 2 37 64 154.5 8 4 2 2 38 42.3 3.7
.6
Key:
AGE (In years)
WT ( Weight in kgs)
HT (Height in cms)

DOS Duration of symptoms (in

months
VAS 1 Pre intervention VAS
scores
VAS 2 Post intervention VAS scores

VAS’ (VAS 1-VAS 2)

Difference in VAS scores after

intervention.

CLF 1 Pre intervention range of

cervical lateral flexion.
CLF 2 Posr intervention range of
cervical lateral flexion.

CLF (CLF 2-CLF1)

Gain in cervical lateral flexion range of
motion
 APPENDIX D

EVALUATION PERFORMA
 Evaluation Performa

Date of Examination

1. Demographic

Data Name

Age

Gender

Height

Weight

Address

Occupation

Time since Problem (Duration of Symptoms)

2. History

a) Area of Pain

b) Any history of trauma

c) Any other region of Pain

d) Medical and Surgical history

3. On trigger point Examination

a) On Palpation

(i) Tenderness

(ii) Pain Recognition (on palpation for 10 sec.)

(iii) Taut Band

(iv) Referred Pain

(v) Local Twitch Response

b) Passive Range of Motion (Cervical)

(i) Flexion
(ii) Extension
Left
(iii) Lateral Flexion
Right
(iv) Rotation
 APPENDIX E

DATA COLLECTION FORM

 Data Collection Form

Number of Group

Variable Variable value Result

Patient number 1-15

Age In years

Weight In kgs

Height In cms

VAS Score Pretreatme Post

nt treatment

Passive Cervical In degrees Pre Post

Lateral Flexion through treatment
goniometer treatment
1 2 3 1 2 3

Average= 1+2+3/3