Sport and Fitness Journal

Volume 8, No.2, Mei 2020: 91-98

E-ISSN: 2654-9182

THE EFFICACY OF MUSCLE ENERGY TECHNIQUE IN INDIVIDUALS WITH MECHANICAL NECK PAIN: A SYSTEMATIC REVIEW

Nugraha, Made Hendra Satria.1 Antari, Ni Komang Ayu Juni.2 Saraswati, Ni Luh Putu Gita Karunia3

  • 1,2,3 Physiotherapy Department, Faculty of Medicine, Udayana University

Correspondent email: [email protected]

ABSTRACT

Introduction: Mechanical neck pain is a condition that includes minor strain / sprain in the muscles, ligaments, or facet joint dysfunction. Objective: This systematic review is aimed to find out the effectiveness of the muscle energy technique in mechanical neck pain. Method: The systematic review access to journal databases such as: PubMed, PEDro, and the Cochrane Library. Results: Based on inclusion and exclusion criteria 5 articles were used in this systematic review. The application of the muscle energy techniques was applied ranging from 1 time to 4 weeks of intervention. From the 5 reviewed studies concluded that muscle energy technique was effective in improving neck motion and function in mechanical neck pain. Conclusion: Based on the results of systematic review it can be concluded that the application of MET improve neck movement through The International Classification of Functioning, Disability, and Health (ICF) criteria evaluated by pain score, pain threshold, range of motion, functional performance, and muscle thickness. The appropriate articles are still limited to 5 studies, but have good to strong qualities. In addition, the application of intervention does not have the same standard.

Key words: mechanical neck pain, muscle energy technique, systematic review

EFEKTIVITAS MUSCLE ENERGY TECHNIQUE PADA PENDERITA MECHANICAL NECK PAIN: SYSTEMATIC REVIEW

ABSTRAK

Pendahuluan: Mechanical neck pain merupakan tipe nyeri leher yang berkaitan dengan keadaan minor sprain atau strain pada otot dan ligamen dan disertai adanya disfungsi sendi facet. Tujuan Penelitian: Systematic review ini bertujuan untuk mengetahui efektivitas muscle energy technique pada mechanical neck pain. Metode: Penyusunan systematic review menggunakan akses database jurnal seperti: PubMed, PEDro, dan the Cochrane Library. Hasil: Berdasarkan kriteria inklusi dan eksklusi digunakan 5 artikel dalam systematic review ini. Aplikasi penerapan muscle energy technique diaplikasikan berkisar dari 1x intervensi sampai penerapan aplikasi selama 4 minggu. Dari 5 jurnal yang dikaji menyimpulkan bahwa muscle energy technique efektif dalam memperbaiki gerak dan fungsi leher pada mechanical neck pain. Simpulan: Berdasarkan hasil dari systematic review dapat disimpulkan bahwa penerapan MET dapat memperbaiki pergerakan leher berdasarkan kriteria The International Classification of Functioning, Disability, and Health (ICF) yang dievluasi melalui skor nyeri, ambang rangsang nyeri, kinerja fungsional, dan ketebalan otot.Jurnal yang sesuai masih terbatas pada 5 jurnal saja, tetapi memiliki kualitas dari baik sampai kuat. Selain itu, pemberian intervensi belum memiliki standar yang sama.

Kata kunci: mechanical neck pain, muscle energy technique, systematic review

BACKGROUND

Neck is the most mobile region in human body. Indirect cervical biomechanical changes affect the structure of the cervical spine. It causes neck pain.1 The incidence of neck pain is around 15%. Neck pain is the second most common disease after low back pain that occurs in general population and musculoskeletal practices.2 Neck pain occurs in approximately 67% of adults aged around 20-69 years.3 In Indonesia, the incidence of neck pain has increased. Approximately 16.6% of adults complain of cervical discomfort and 0.6% clinically manifesting into severe neck pain. The incidence of cervical neck pain increases with age and is more often experienced by women compared to men in a ratio of 1.67: 1.4

Mechanical neck pain (MNP) can originate from lesions on the zygapophyseal joint (facet joint) or the condition of muscle spasm in the cervical region. The source of symptoms of mechanical neck pain originates in the cervical, particularly in the uncovertebral joint or zygapophyseal joint. It causes the limitation of range of motion in all directions of cervical region, especially in the movements of rotation, extension, and cervical lateral flexion. Pain followed by a minor positional fault in muscle guarding of the levator scapulae, cervical paravertebral, and upper trapezius is closely related to the limitation of the range of motion of the cervical joint in mechanical neck pain.1

Muscle energy technique is a soft tissue mobilization technique that is applied by combining isometric contractions. The application of this method is intended to restore soft tissue structure to normal and provide indirect effect on the joint that is associated with a dysfunctional muscle and can be used to normalize joint mobility in dysfunctional soft tissue structures.1

Several studies have proven that the application of MET can reduce pain,

improve the range of motion, and reduce the degree of neck disability.5,6,7,8,9 However, the recommendation of application method and dosage have not been widely discussed by some previous studies.

METHOD

  • A.    Search strategy

The systematic review access to journal databases such as: Physiotherapy Evidence Database (PEDro), MEDLINE via PubMed, and the Cochrane Controlled Trials Register in the Cochrane Library. Search strategy using keywords: ‘mechanical neck pain’ and ‘muscle energy technique’.

  • B.    Inclusion/exclusion criteria

Inclusion criteria include: (1) Journal articles with randomized controlled trial (RCT) research designs, (2) Article must be in English, (3) Articles published in the last 10 years (May 2009 - May 2019). While the exclusion criteria include: (1) If there is the same article, then other articles are excluded, (2) case reports, abstracts, conference proceedings, or thesis.

  • C.    Study selection

Three    reviewers     (M.H.S.N.,

N.K.A.J.A and L.P.G.K.S) conducted screening and identification through a journal database, such as PEDro, Pubmed, and Cochrane library. The reviewers then screened the full text and adjust to the inclusion and exclusion criteria.

  • D.    Study quality assessment

In assessing the quality of studies, reviewers use the Standard Quality Assessment Criteria for Evaluating Primary Research Paper from a Variety of Fields. This criterion consists of a 14-item assessment checklist in which points were awarded to each criterion (no=0, partial=1, and yes=2). This criterion is a validated standard.10 Article quality assessment was assessed by dividing the total assessment score by 28 then categorized into: limited (<50%), adequate (50% - 69%), good

(70% - 80%), or strong (score of>80%).

Studied with percentage scores under 50% were excluded from this review.11

  • E.    Data extraction

Data were extracted by summarizing data on description of participants, intervention, control/comparison, outcome measure, results, and quality rating of the study.

RESULTS

  • A.    Study selection

The initial search in 3 databases found a total of 32 articles. Then the selection using inclusion and exclusion criteria obtained 10 articles. The same article was then excluded. The total articles used in this study amounted to 5 articles. Explanation regarding study selection, described in Figure 1.


Figure 1. A flow chart of search strategy


  • B.    Methodological quality and risk of bias of reviewed studies

After assessing the quality of the study, there is no article was excluded because they had a score of <50%. The

articles obtained have a strong category for 3 and good for 2 studies. Explanation regarding the quality assessment of journals, described in table 1.

Table 1. Methodological quality of included studies

Article

Items on standard quality assessment checklist

1    2    3    4    5    6   7    8    9   10  11   12  13   14

Nagrale et al., 2010

Oliveira-Campelo et al., 2013

Phadke et al., 2016

Sadria et al., 2017

Kashyap et al., 2018

+   +  +   +  +   +   -   +   +  +   +   ±   +   +

  • +   +  +   +  +   +   -   +   +  +   ±   +   +   +

  • +   +   +   +   +   -   -   +   +  +   ±   ±   +   +

  • +   +  +   +  +   ±   -   +   +  +   ±   ±   +   +

  • +   +   +   +   +   -   -   +   ±  +   ±   +   +   +

+ = yes; - = no; ± = partial


C. Study characteristics

The 5 reviewed studies had a total of 393 participants. The age of participants ranged between 18-50 years old. The


sample sizes of studies ranged from 15 to 37 subjects. The characteristics of the summary of the study results used in this review are summarized in table 2.


Table 2. Characteristics of reviewed studies describing the efficacy of muscle energy technique

Author

Sample

Intervention

Control/co mparison

Outcome measures

Results

Quality rating

Nagrale

N = 60

Integrated

Muscle

- Outcome

The results

Strong

et al.,

Age range:

Neuromuscular

energy

measure was

showed

25/28

2010 (5)

19 – 38.

Inhibition Technique/INIT (consist of MET, straincounterstrain, and ischemic compression/IC) (n=30)

Dosage: 3 session per week for 4 weeks.

technique/ MET (n=30)

assessed at pretreatment, 2 weeks after treatment, and 4 weeks after treatment.

- Neck pain: VAS.

Functional performance: NDI.

Cervical ROM: CROM goniometer.

significantly improvements in pain, lateral flexion ROM of cervical, and neck disability were detected in the INIT group.

89,28%

Oliveira-

N = 164

Muscle Energy

Placebo

- Outcome

MET group

Strong

Campelo

Age range:

Technique (MET)

(n=31)

measure was

had similar

25/28

et al., 2013 (6)

18 – 20

(n=32)

IC (n=37)

Passive stretching (PS) (n=29)

Dosage: 1 session

Wait and see group (n=35)

assessed at pretreatment, immediately, 24 hours after the intervention, and 1 week later.

-   Cervical

spine range of movement: cervical active range of motion (CAROM) Pressure pain sensitivity: algometer dan VAS.

result to the PS group, but with a lower immediate effect size. Only IC maintained the effect size after 24 hours and 1 week later.

89,28%

Phadke et

N = 60

MET (n=30)

PS (n=30)

- Outcome

MET and PS

Good

al., 2016

Age range:

measure was

had shown a

22/28

(7)

18 – 50      Dosage: 1 session

per day for 6 days

assessed at pretreatment and on the day 6.

- Neck pain: Visual analogue scale Functional performance: neck disability index

significant improvement in both NDI and VAS score.

However, MET showed a better improvement than PS group.

78,57%

Sadria et

N = 64      Muscle energy    Active

- Outcome

Both manual

Strong

al., 2017

Age range:   technique (n=30)   Release

measure was

techniques of

23/28

(8)

18 – 50.                        Technique

Dosage: 1 session (ART)

(n=30)

assessed at pretreatment and 24 hours after intervention.

-  Range of

motion: active range of movement cervical lateral flexion Neck pain: VAS Thickness of upper trapezius muscle: algometer

MET and ART can reduce the symptoms of latent trigger points equally.

82,14%

Kashyap

N = 45      Manual pressure   Postural

- Outcome

There were

Good

et al.,

Age range:   release + postural  advice +

measure was

significant

22/28

2018 (9)

18 – 30      advice + active     active

exercise +          exercises

conventional       +conventio

exercise            nal exercise

(isometric neck    (n=15)

exercise, stretching, gentle

assessed at

pretreatment

(day 0), day 1, day 5 postintervention,

improvement in all outcome measures at days 1 and 5 postinterventi on and at days 10 and 15

78,57%

conditioning

10 and 15

during the

exercises for neck

days follow-

follow-up for

and shoulder

up.

all groups.

girdle)

The between

(n=15)

- Neck pain:

group

Muscle energy

Visual

analyses

technique+

Analog

confirmed

postural advice +

Scale (VAS)

nonsignificant

active exercise +

Muscle

differences for

conventional

tenderness:

all variables.

exercise

pressure pain

(n=15)

threshold

Functional

Dosage:

performance:

conventional

Neck

exercise was

Disability

carried out

Index (NDI)

independently at

Range of

home for 15 days

neck

rotation:

standardized

measuring

tape

Table 3. Outcome measure used in the study

Study

Treatment Outcomes

Pain

Pain Threshold

Range of motion

Functional performance

Muscle thickness

Nagrale et al., 2010 (5)

√

√

√

√

Oliveira-Campelo et al., 2013 (6)

√

Phadke et al., 2016 (7)

√

√

Sadria et al., 2017 (8)

√

√

√

Kashyap, et al., 2018 (9)

√

√

√

√

DISCUSSION

The application of the muscle energy techniques was applied ranging from 1 time to 4 weeks of intervention. From the 5 reviewed articles concluded that muscle energy technique was effective in improving neck motion and function in mechanical neck pain. Evaluated


measurements included: pain, range of motion, neck disability, and the thickness of the upper trapezius muscle. Table 3 describes the outcome measure used in this study to evaluate the limitations of body function and movement in mechanical neck pain based on The International Classification of Functioning, Disability and Health (ICF) criteria.


MNP originates from lesions on the zygapophyseal joint (facet joint) or the condition of muscle spasm in the cervical region. MET is effective in increasing the range of motion due to the presence of post isometric relaxation (PIR) and RI (reciprocal inhibition) mechanisms.12

PIR refers to the assumed effect of reduced muscle tone after isometric contraction. Hypertonia muscle will be stretched of the new range of motion. The therapist give the resistance from the opposite direction and the patient is asked to do isometric contractions by resisting the therapist's force for 5-10 seconds. After isometric contractions, the muscles will be stretched gently to increase muscle flexibility to the new range of motion. This procedure could be repeated 2 or 3 times.12

In contrast to PIR, RI involves the physiological response of the antagonistic muscle that has been contracted isometrically. When muscles are contracted isometrically, the antagonist muscles will be blocked, and experience a decrease in muscle tone. The application of RI is done by utilizing antagonist muscle contractions. Muscles that experience lesions are positioned in the middle of the total degree of range of motion. The patient is asked to contract in a limited direction while the therapist gives resistance in the opposite direction (isometric) or even allows movement toward it (isotonic). This is followed by relaxation of the patient and also exhalation. At the same time, therapists passively stretch the muscle in a limited direction with new range of motion. This procedure is repeated 3-5 times.12

Based on the systematic review, it was found that the application of MET on mechanical neck pain can reduce pain evaluated through visual analogue scale. Fryer and Fossum at (Nagrale, et al., 2010) stated that the sequence of muscle and joint mechanoreceptor activation stimulates the

local somatic efferents. It turn leads to sympatho-excitation and activation of the periaqueductal gray matter, which play role in the descending modulation of pain.5 Frontera at (Phadke, et al., 2016) stated that the reduction in pain could be due to the inhibitory effects of golgi tendon organs (GTO), which reduces the motor neuron discharges. It is causing relaxation of the musculotendinous unit by resetting its resting length and pacinian corpuscle modification. These reflexes allow relaxation in musculotendinous and 7

decreased pain perception.

In other words (Sadria, et al., 2017) summarize that the application of MET could stretch and increase the myofascial tissue extensibility and affect the viscoelastic tissue properties and mediate the changes of extracellular fluid dynamics and fibroblast mechano-transduction.8 Because of this mechanism, there is also an improvement of the range of motion and a reduction of the muscle spasm. Therefore, there is improvement in neck disability.5,6,7,8,9

CONCLUSION

It can be concluded that the application of MET improve neck movement through The International Classification of Functioning, Disability, and Health (ICF) criteria evaluated by pain score, pain threshold, range of motion, functional performance, and muscle thickness.

RESEARCH LIMITATIONS

The appropriate articles are still limited to 5 studies, but have good to strong qualities. In addition, the application of intervention does not have the same standard.

REFERENCES

  • 1.    Sudaryanto, Sutjana DP, Irfan M. Pemberian teknik mulligan dan soft tissue mobilization lebih baik daripada hanya soft tissue mobilization dalam meningkatkan lingkup gerak sendi ekstensi, rotasi, lateral fleksi cervical pada mechanical neck pain. Sport Fitn J. 2013:1(2):54-69.

  • 2.    Yadav H, Goyal M. Efficiacy of muscle energy technique and deep neck flexors training in mechanical neck pain - a randomized clinical trial. Int J Therap Rehab Research. 2015:4(1): 52-66.

  • 3.    Wadee An. Efficacy of muscle energy techniques versus myofascial release in management of patients with cervical myofascial pain. Int J Chemtch Research. 2017:10(2):468-76.

  • 4.    Juliastuti.    Perbedaan pengaruh

pemberian  auto stretching dan

kinesio taping terhadap penurunan nyeri pada sindroma nyeri servikal et causa mechanical neck pain. Desember 2017;5(2):432-44.

  • 5.    Nagrale, AV., Glynn, P., and Joshi, A. The Efficacy of an Integrated Neuromuscular Inhibition Technique on Upper Trapezius Trigger Points in Subjects with Non-specific Neck Pain:  A Randomized Controlled

Trial, Journal of Manual and Manipulative Therapy 2010: 18(1).

  • 6.    Oliveira-Campelo, NM., de Melo, CA., Alburquerque-Sendιι'n, F., Machado, JP. Short- and MediumTerm Effects of Manual Therapy on Cervical Active Range of Motion and Pressure Pain Sensitivity in Latent Myofascial Pain of the Upper Trapezius Muscle: A Randomized Controlled Trial. Journal of

Manipulative and Physiological Therapeutics. 2013:36(5).

  • 7.    Phadke, A. Bedekar, N. Shyam, A., and 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. 2016:35:5-11.

  • 8.    Sadria, G., Hosseini, M., Rezasoltani, A., Bagheban, AA., Davari, AR., and Seifolahi, A. A Comparison of the Effect of the Active Release and Muscle Energy Techniques on the Latent Trigger Points of the upper Trapezius. Journal of Bodywork & Movement Therapies. 2017:21(4):920-25.

  • 9.    Kashyap, R., Iqbal, A., and Alghadir, AH. 2018. Controlled Intervention to Compare the Efficacies of Manual Pressure Release and the Muscle Energy Technique for Treating Mechanical Neck Pain due to Upper Trapezius Trigger Points. Journal of Pain Research 2018:11:3151-60.

  • 10.    Kmet LM, Lee RC, Cook LS. Standard quality assessment criteria for evaluating primary research papers from a variety of fields. Edmonton:    Alberta Heritage

Foundation for Medical Research (AHFMR); 2004.

  • 11.    Lim, YL., Chee, DY., and Girdler, S. Median    Nerve    Mobilization

Techniques in the Treatment of Carpal Tunnel Syndrome:   A

Systematic Review. Journal of Hand Therapy. 2017:xxx:1-9

  • 12.    Chaitow L, Crenshaw K. Fritz S, Fryer G,  Liebenson C, Muscle

energy techniques. 3rd ed. Wolfaard  S, editor. Elsevier

Health Sciences; 2006

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