INTRODUCTION:

Neck pain is the most common chief complaints among working men and women¹. Etiological factors are usually multifactorial, including poor posture, anxiety, depression, neck strain, occupational injuries or sports injuries². Trapezius muscle is an inverted triangle starts at the base of the skull, spreads over the shoulders and down to the mid back³. It is used to Elevates, Depresses, rotates and retracts the scapula⁴.

Trapezitis is defined as inflammation of the Trapezius muscle leading to stress pain which is known as neck pain or stiffness around the neck or shoulder, it is present even at rest and it is aggravated by activity⁶. Patient usually complaints of pain which limits activity of daily living. Pain lasts for 3 to 5 days⁷. Trapezitis is mainly caused due to repetitive movements, forward head posture, sitting without back support, working without arm support, prolonged forward bending activity⁸. Passive range of motion may be painful and restricted due to pain and protective spasm in antagonist groups of muscle. People who working at desks and computers or an individual who drive for a longer period of time are more prone for this condition, as the upper Trapezius muscle becomes painful and spasmodic⁹. Upper Trapezius muscle is designated as postural muscles of the neck and it is highly susceptible to overuse¹⁰. About two thirds of people experiencing neck pain at some point of their lives. Prevalence is highest in females with middle age are affected more than males. The overall prevalence of neck pain in the general population ranges between 0.4% and 86.8% (mean 23.1%) and point prevalence ranges from 0.4% to 41.5% (mean 14.4%)⁹. Recent study by Alagesan J, Shah US(2012) have hypothesized that the trapezitis Pathogenesis results from the overloading and injury of the muscle tissue, leading to involuntary shortening of localized fibers. The areas of stressed soft tissue receive less oxygen, glucose and nutrients supply, it leads to accumulation of high level of metabolic wastes, it results in pain and development of Trigger points^11,12. Trigger points has potential to create pain, limits range of motion and restrict Functional Ability¹³. In long standing cases there can be entrapments of spinal accessory nerve leading neck and shoulder pain as spinal accessory nerve (SAN) is the major motor supply to the trapezius and sternocleidomastoid muscles. This creates potential restriction in the functional activities and limited Range of Motion¹³.

Physical therapy has proven effective in trapezitis pain. Physical therapy may include treatment such as massage or ultrasound therapy, laser therapy, TENS, IFT and active treatment such as exercise therapies. METS are a commonly utilized method for achieving tonus release (inhibition) in a muscle before stretching. The approach involves the introduction of isometric contraction to the affected muscle producing post isometric relaxation through the influence of the Golgi tendon organ (autogenic inhibition). It may also be applied to antagonistic muscle group producing reciprocal inhibition in the offending muscle groups^1,14. Fryer and Fossum have hypothesized that sequence of muscle and joint mechanoreceptors activation evokes firing of local somatic efferent’s. This in turn leads to sympatho-excitation and activation of the peri-aqueductal gray matter, which plays a role in descending modulation of pain⁵. Beneficial effects of Laser Therapy on tissues and cells includes accelerated tissue repair, reduced fibrous tissue formation, improve blood circulation, improve cell metabolism, faster wound healing, relieve acute and chronic pain, anti-inflammatory and anti-edematous effects¹⁵. Laser therapy helps to reduce pain and inflammation and enhance tissue healing¹⁶. Ultrasound is a deep heating modality which has been shown to enhance collagen synthesis by Fibroblast¹². Physiological effects of therapeutic ultrasound include tissue temperature, increased in blood flow, increased extensibility of the tissue and reduced viscosity of the fluid elements in the tissue¹⁷. Further mechanical effects accelerate tissue metabolism by promoting cellular permeability and ion transport¹⁸.

METHODOLOGY:

The subjects were selected from the Saveetha physiotherapy, outpatient department of Saveetha medical college and hospital. 30 subjects with trapezitis were selected based on the inclusion and exclusion criteria. Detailed procedure was explained to the subjects in the colloquial terms about the safety and simplicity of the procedure. Informed concern was given to those who were interested to participate in this study and they were asked to fill the NDI (Neck Disability Index). Selected subjects were randomly assigned in to two groups 15 in each group by using lottery system. The outcome measure used in this study is Neck disability index (NDI). For all subjects pre and post-test values were calculated.

Procedure:

Group A subjects were treated with muscle energy technique with laser therapy. Group B subjects were treated with muscle energy technique with therapeutic ultrasound.

All the 30 subjects were received muscle energy technique. Muscle Energy Technique was given with the hold time for 10 seconds. This was repeated for three times for three sessions per week for four consecutive weeks.

For group A Probe method laser therapy was used given to the subjects. Safety precautions was taken to reduce the risk of exposure of laser light to the eyes. Laser therapy was given in painful area for 4 days/week for 4 weeks with the frequency of 10 Hz, Dosage 7j/cm², Area covered 1 cm², duration of 4 mins.

For group B Therapeutic Ultrasound was given to the subjects in the frequency of 1 MHZ in the continuous mode for 8 minutes with the intensity of 0.5W/cm² for 4 weeks (4days/week).

RESULTS:

The collected data was tabulated and analyzed using descriptive and inferential statistics. To all parameters mean and standard deviation (SD) was used. Paired t-test was used to analyze significant changes between pre and post-test measurements. Unpaired t test was used to analyze significant difference between the groups. P value <0.05 was considered as statistically significant.

Table 1 represents pre and post-test values of NDI scores for group A. The group A Pre-test mean value is 42.93% (SD 14.30%) and post-test mean value is 17.73% (SD 9.32%). There is a statistically significant difference with the P-value of 0.0001.

Table 2 represents pre and post-test values of NDI scores for group B. The group B pre-test mean value is 45.06% (SD 14.20%) and post-test mean value is 26.46% (SD 8.54%). There is a statistically significant difference with the P-value of 0.0001.

Table 3 represents post values of NDI score for group A and B. The group A post-test mean value is 17.73% (SD 9.32%) and for group B post-test mean value is 26.46% (SD 8.54%). This shows that NPRS score values are gradually decreasing in the group A than group B, which is statistically significant.

Table 1: Pre test and post test values of group-A

Parameter

Test

Mean

S.D.

Paired T-test

P-Values

Neck

Disability

Index (%)

Pre-test

42.93

14.30

10.4109

0.0001

Post test

17.73

9.32

Graph 1: Pre and post test values of group A

Graph 2: Pre and Post test values of group B

Graph 3: Comparison of post-test values of NDI scores for group A and B

Table 2: Pre and Post test values of group-B

Parameter

Test

Mean

S.D.

Paired T-test

P-values

Neck Disability Index (%)

Pre-test

45.06

14.20

10.0760

0.0001

Post test

26.46

8.54

DISCUSSION:

This study was conducted to compare the effects of Laser therapy and Ultrasound therapy along with muscle energy technique in subjects with Trapezitis. This study was conducted on 30 subjects with the age group of 18-35 according to the inclusion criteria and was randomly divided into two groups (i.e) group-A and group-B. Subjects of group A was treated with laser therapy with METS and group B was treated with ultrasound therapy with METS. NDI was used as a tool for analysis, outcome measures were taken at the end of 4^th week. Based on statistical analysis, both group A and group B showed improvement in NDI. However, subjects in group A who received laser with METS showed better improvement in NDI than the subjects in group B who received ultrasound therapy with METS, when both the groups are compared at the end of 4 weeks. Trapezius is functionally important during day-to-day activities. Since the Trapezius muscle works to move the neck in several directions, its degree of tightness or looseness affects the neck flexibility. Trapezitis is caused due to faulty ergonomics postures that are maintained for prolonged periods causing muscle imbalance¹⁹. The possible mechanism of pain reduction in METS can be attributed by hypoalgesic effects by inhibitory golgi tendon reflex activated during isometric contraction that leads to reflex relaxation of muscles. They involved central and peripheral modulatory mechanisms such as, activation of muscles and joints mechanoreceptors, that leads to sympatho-excitation evoked by somatic efferents and localized activation of pre-aqueductal gray matter plays a role in descending modulation of pain²⁰. Physiological mechanism in METS such as changes in muscle extensibility, changes in visco-elasticity and changes in stretch tolerance. METS mainly works on decreasing the spasm or tightness of muscle by first resetting the muscle spindle and inhibiting the muscles by activating the golgi tendon organ. This phenomenon is called post isometric relaxation²¹. A study by Gupta et al., on effects of post isometric relaxation versus isometric exercise in neck pain concluded that MET showed significant improvement on pain and functional status after 4 weeks of treatment.²¹ Physiological effects of therapeutic ultrasound includes increased in blood flow, increased extensibility of the tissue and reduced viscosity of the fluid elements in the tissue. Further mechanical effects accelerate tissue metabolism by promoting cellular permeability and ion transport. Draper do et al., in his study put forward the beneficial effects of therapeutic ultrasound can reduce muscle stiffness.²² RCT by Gam et al., in his study, ultrasound in treatment of myofacial trigger point in neck and shoulder, shown evidence for the positive effect of therapeutic ultrasound in improvement in ROM and reduction in pain.²³

Laser therapy is effective as analgesics and to accelerate the healing of injured tissues. Laser therapy promotes blood circulation to the affected area, faster wound healing, alleviating muscle tension, improves range of motion of the neck, relieving pain and inflammation.²⁴ Therapeutically significant benefit of Laser’s ability to stimulate protein synthesis, soft tissue repair and subsequent tissue regeneration. Mechanism of pain relief using laser includes secretion of endogenous opioids leading to clearance of analgesic substances via stimulation of micro-circulatory system. On application of laser, there is a change in biochemical markers of inflammation, distribution of inflammatory cells and reduction in the occurrence of edema and hemorrhage after the laser irradiation of laser beams of wavelength of 830nm.²⁴ Sibby et.al., reported that laser with stretching is effective in managing patients with neck pain than the INIT. They found that NDI scores are decreased significantly in the group that received laser therapy.²⁵ Beneficial effects of Laser therapy promotes pain relief within minutes of application than the ultrasound therapy, also as a result of neural blockade of the peripheral and sympathetic nerves and release of neuromuscular contractions leading to reduction of muscle spasms. There is a decrease of local edema and reduction of inflammation within hours to days. The patients treated with laser therapy had less pain, less secondary weakness, less tenderness than the patients treated with ultrasound therapy. As a result, Laser treatment can be considered as more effective than ultrasound treatment.

CONCLUSION:

From the result, it has been concluded that Laser therapy with muscle energy technique (Group A) was more effective than Ultrasound therapy with muscle energy technique (Group B) on improving functional ability in subjects with Trapezitis.

ETHICAL APPROVAL:

This research project was reviewed and approved by institutional ethics committee by department of research, Saveetha College of physiotherapy, Saveetha institute of medical and technical science, all procedures performed in this study were in accordance with the 1964 Helsinki Declaration.

ACKNOWLEDGEMENT:

The authors are grateful to the faculties of Saveetha College of physiotherapy, Saveetha institute of medical and technical science, for the facilities.

CONFLICT OF INTEREST:

The authors declare no conflict of interest.

REFERENCE:

1. Ujwal L Yeole., Neha P Diwakar and Pornima P Pawar. Effects of muscle energy technique and positional release therapy on neck pain in computer users a randomized control trial. International journal of recent research. 2017, Vol 8.

2. Gupta S, Jaiswal P, Chhabra D. A comparative study between postisometric relaxation and isometric exercises in non-specific neck pain. Journal of exercise science and physiotherapy. 2008 Dec 1; 4(2): 88-94.

3. Phadke A, Bedekar N, Shyam A, Sancheti P. Effect of muscle energy technique and static stretching on pain and functional disability in patients with mechanical neck pain: A randomized controlled trial. Hong Kong Physiotherapy Journal. 2016 Dec 1; 35: 5-11

4. Ravish VN, Helen S. To compare the effectiveness of myofascial release technique versus positional release technique with laser in patients with unilateral trapezitis. Journal of Evolution of Medical and Dental Sciences. 2014 Mar 3; 3(9): 2161-7.

5. Mahajan R, Kataria C, Bansal K. Comparative effectiveness of muscle energy technique and static stretching for treatment of subacute mechanical neck pain. Int J Health Rehabil Sci. 2012; 1(1): 16-21.

6. Swathi s, Hiral r, Priyanshu v. Immediate effect of ultrasound on pain management for healthy individuals with trapezitis. 2015

7. Santhosh Metgad, Ramya Kapilla. Comparative effect of therapeutic ultrasound using extract of ilex paraguariensis and diclofenac sodium gel in acute trapezitis, a randomized control trial;. International journals of therapies and rehabilitation research 2015; (4): 137-141.

8. Ashwini, Bulbuli, Archana, Methi. Immediate effect of spray and stretch technique on trapezitis. An experimental study; Journal of medical science and clinical research, 2017 vol 5 20591-20596.

9. Varun Naik, Junisha Mascarenhas, Namrata Mutkekar, Shibani Forgueri Comparative study to evaluate the effectiveness of therapeutic ultrasound and elastic resistance band exercises versus therapeutic ultrasound and conventional exercises in acute trapezitis: a randomized control trial;. International journals of therapies and rehabilitation research, 2015; 4(2): 18-22.

10. Pooja, Depak (2016). Effectiveness of neuro muscular inhibitory technique in sub-acute trapezitis; International journal of case report.

11. Vijay kage and gayatri gurav, Effect of neural flossing technique on pain, cervical range of motion and functional ability in subjects with acute, sub-acute trapezitis: An Experimental study; International journals of applied science.

12. J Alagesan, US Shah, Effect of positional release technique and taping on unilateral upper trapezius trigger points; International journal of health and pharmaceutical sciences 1 2012; (2): 13-17.

13. Carvalho SC, Vinod Babu K, Sai Kumar N, Ayyappan VR. Effect of positional release technique in subjects with subacute trapezitis. Int J Physiother. 2014; 1(2): 91-9.

14. Yathendra Kumar, Sneha, Effectiveness of muscle energy technique, ischemic compression and strain counter strain in upper trapezius trigger points;. International journal of physical, sports and health 2015; 22-26.

15. Kitchen SS, Partridge CJ. A review of low-level laser therapy: Part I: background, physiological effects and hazards. Physiotherapy. 1991 Mar 10; 77(3): 161-8.

16. Brosseau L, Welch V, Wells G, Tugwell P, De Bie R, Gam A, Harman K, Shea B, Morin M. Low level laser therapy for osteoarthritis and rheumatoid arthritis: a metaanalysis. The Journal of rheumatology. 2000 Aug 1; 27(8): 1961-9.

17. Morishita K, Karasuno H, Yokoi Y, Morozumi K, Ogihara H, Ito T, Hanaoka M, Fujiwara T, Fujimoto T, Abe K. Effects of therapeutic ultrasound on range of motion and stretch pain. Journal of physical therapy science. 2014; 26(5): 711-5.

18. Ruiz-Molinero C, Jimenez-Rejano JJ, Chillon-Martinez R, Suarez-Serrano C, Rebollo-Roldan J, Perez-Cabezas V. Efficacy of therapeutic ultrasound in pain and joint mobility in whiplash traumatic acute and subacute phases. Ultrasound in medicine and biology. 2014 Sep 1; 40(9): 2089-95.

19. Benjaboonyanupap D, Paungmali A, Pirunsan U. Effect of therapeutic sequence of hot pack and ultrasound on physiological response over trigger point of upper trapezius. Asian journal of sports medicine. 2015 Sep; 6(3).

20. Haritha, Shanthi, Madhavi, Efficacy of post isometric relaxation versus isometric exercise with chronic non-specific neck pain; International journal of physiotherapy, 2015 vol 2 1097-1102.

21. Rana DP, Brahmbhatt B. Effect of muscle energy technique versus positional release technique in computer workers with upper trapezius muscle spasm: A comparative study. International journal of multidisciplinary Research and development. 2017: 2349-5979.

22. Rashidi S. A review of mechanism of actions of ultrasound waves for treatment of soft tissue injuries. International Journal of Green Pharmacy (IJGP). 2017 Apr 17; 11(01).

23. 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. International Journal of Health and Allied Sciences. 2013 Jan 1; 2(1): 17.

24. Konstantinovic LM, Cutovic MR, Milovanovic AN, Jovic SJ, Dragin AS, Letic MD, Miler VM. Low-level laser therapy for acute neck pain with radiculopathy: a double-blind placebo-controlled randomized study. Pain Medicine. 2010 Aug 1; 11(8): 1169-78.

25. Schenk R, Adelman K, Rousselle J. The effects of muscle energy technique on cervical range of motion. Journal of manual and manipulative therapy. 1994 Jan 1; 2(4): 149-55.

Received on 16.12.2020 Modified on 08.02.2021

Asian Journal of Pharmacy and Technology. 2021; 11(2):116-120.

DOI: 10.52711/2231-5713.2021.00019

Parameter	Post test values				‘t’ test	P-value
	Group a		Group b
	Mean	Standard deviation	Mean	Standard deviation
Neck Disability Index (%)	17.7300	9.3200	26.4600	8.5400	2.6747	0.0123