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Myofascial Pain Syndrome is characterized by sensory, motor, and autonomic symptoms caused by myofascial trigger points (TPs), resulting in quality of life, daily and social activities. The objective is to compare the levels of strength and pain tolerance before and after the use of Positional Release (TLP) and Myofascial Release (TLM) techniques. This is carried out as cross-sectional, quantitative, experimental study. Individuals with myofascial trigger points in the upper trapezius participated in the study and were randomly divided into three intervention groups (A, B, and C), where A corresponds to TLP, B corresponds to TLM, and C corresponds to the placebo group. Strength and pain tolerance levels were measured using a handheld isometric dynamometer and an algometer. The average of three pre- and post-intervention measurements was used as the reference value for the results. Groups A and B showed improvement in pain tolerance, compared to Group C, where pain tolerance worsened. As for the gain in strength, it cannot be said that there were significant changes, the three groups showed a slight increase in strength. The presented resources are easy to apply and low cost and prove to be auxiliary tools in the treatment of patients with neck pain.
Department of Physical Therapy, Catholic University of Pernambuco, Recife, PE, Brazil
Paulo Veiga
Department of Physical Therapy, Catholic University of Pernambuco, Recife, PE, Brazil
*Address all correspondence to: allyson.2018109899unicap.br
1. Introduction
Myofascial Pain Syndrome (MPS) is characterized by sensory, motor, and autonomic symptoms caused by myofascial trigger points (TPs). The myofascial trigger point is understood by a focal hyperirritability in the muscle that can strongly modulate the functions of the central nervous system [1, 2]. This trigger point can be identified by a palpable, hypersensitive nodule in a taut band of muscle. The site hurts when compressed and can produce characteristics, such as referred pain and sensitivity, motor dysfunctions, and autonomic phenomena, as TPs end up acting as persistent sources of nociceptive stimuli and contribute to peripheral and central sensitization [3]. The definition of pain was revised by the International Association for the Study of Pain (IASP) in 2020 and defines pain as “an unpleasant sensory and emotional experience associated, or similar to that associated, with actual or potential tissue damage”. Being a personal experience that can be influenced by biological, psychological, and social factors [4]. Referred pain, also known as secondary hyperalgesia, is when the pain site is different from the site of its cause, it is quite common and can be found in almost all myofascial pain problems. Referred muscle pain is generally described as deep, tingling, diffuse, compressing, or pressing, differentiating it from cutaneous neuropathic pain [5, 6]. Trigger points can be classified as active or latent. PGs are considered active when they are painful with or without movement, while latent PGs are only painful on palpation. Active PGs have larger areas of referred pain than latent trigger points [7].
It is observed in clinical practice that the trapezius is probably the muscle most affected by TPs, its upper fibers produce referred pain unilaterally in the cranial direction, reaching the temporal and orbital regions, mimicking a tension-type headache (TTH). Myofascial pain in the upper trapezius region can occur due to overload and excessive use of muscles, dysfunctions, and visceral imbalances, decreased nervous influx caused by compression of the intervertebral disc and spinal roots, with or without associated physical, emotional, and dietary factors [8, 9, 10].
Positional release therapy (PRT) has as its main feature the specific positioning of body segments in order to relieve pain in sensitive points, the objective of using the technique is to benefit the patient by relieving pain and muscle spasms [11, 12]. This technique works by restoring the balance of muscle tone; normalizing fascia tension resulting in tissue relaxation, decreasing joint hypomobility as a result of relaxation of affected muscles and fascial tissues; there is an improvement in circulation and reduction of edema; pain reduction, in response to the relief of muscle hyperactivity and strength is increased because the technique can restore the tone and normal function of the muscles involved [13, 14, 15]. It is a simple, low-cost, easy-to-learn technique that is well-accepted by patients. TLP has several benefits, and in recent years it has been widely discussed and used, but it still lacks scientific studies [16, 17].
Myofascial release therapy (MLT) is a technique that works with manual mobilization of the fascia [18, 19]. These techniques are performed to reduce pain, increase local blood circulation, increase range of motion, and restore normal exercise volume and quality [20]. Therefore, TLM can be an auxiliary intervention to obtain the desired results to improve the patient’s clinical symptoms [21, 22].
Given the situation presented, this research project was designed with the objective of comparing the level of pain and muscle strength in subjects with tension in the upper trapezius muscle fibers before and after the application of TLP and TLM, finally, comparing them with the effects generated by the placebo.
This project is linked to the Catholic University of Pernambuco, to the Health and Life Sciences Center, to the PHYSIOTHERAPY course. Linked to the project registered under No. 442930-FTA-045-2019/5–7 and approved by the UNICAP Human Research Ethics Committee, under CAAE: 03095918.9.0000.5206 and opinion number: 140918/2018. This is an experimental cross-sectional study of a quantitative nature.
2.1 Inclusion and exclusion criteria
Inclusion criteria: (1) individuals who are between 18 and 30 years old. (2) Individuals who have neck or trapezius pain. (3) Regardless of sex, education, and socioeconomic level. (4) Who have not had a history of previous muscle injury. (5) Who have accepted to sign the Free and Informed Consent Form (FICT).
Exclusion criteria: (1) Individuals who performed strength training (bodybuilding) in the last 3 days. (2) Individuals who have a history of anemia. (3) Patients with progressive neuromuscular diseases. (4) Subjects who will undergo a previous surgical procedure. (5) Subjects who did not find PGs in the upper fibers of the trapezius bilaterally.
2.2 Intervention description
The estimated sample size was 30 subjects, who would be divided into the three intervention groups, but only eight subjects participated in the research. The eight volunteers were divided into three groups in order of evaluation. Groups A and B were composed of three individuals in each group, and Group C contained two individuals. In Group A, the volunteers underwent myofascial release therapy (MLT); In Group B, the volunteers were submitted to positional release therapy (TLP) with the positional muscle inhibition method, and Group C corresponded to the placebo group, which was performed with the application of the positional release technique (TLP) on the contralateral biceps muscle to the trapezius that was evaluated and found the main trigger point.
In the first stage of collection, an individual evaluation questionnaire was applied, which contains name, age, weight, height, gender, marital status, profession, and presence of neck pain in recent months (yes/no if yes: hours; one day ago; one week ago; 1 month ago; > 1 month. The technique to be used (Group A, Group B, or Group C). Targeting of each volunteer for the group was randomly chosen in order of volunteer evaluation: Volunteer 1 was directed to Group A; Volunteer 2 was directed to Group B; Volunteer 3 was directed to Group C; Volunteer 4 was directed to Group A; and so on, with no interference in the order in which they were evaluated.
In the second stage, the participants of the three groups underwent an assessment of the strength of the upper fibers of the trapezius using a manual isometric dynamometer (MedEOR – medtech). Subsequently, the volunteer’s resistance to pain was evaluated with the Algometer (MedEOR – medtech), with pressure being applied specifically to the painful point (PG). Three measurements were performed, in which the average between them was used as a reference value (Figures 1 and 2).
Figure 1.
Assessment with isometric manual dynamometer (MedEOR - medtech) of trapezius strength (upper fibers) with shoulder shrug movement.
Figure 2.
Assessment of pain tolerance with digital Algometer (MedEOR - medtech) with pressure being exerted on the PG.
Initially, the three strength measurements were performed, with the volunteer sitting in a chair without arms, upper limbs freely positioned on the side of the body, the strap from the equipment itself was used, which must be attached to the seat of the chair, on the ipsilateral shoulder on the side that was identified the trigger point. The volunteer was asked to shrug the shoulder toward the ear on the same side, the equipment must resist the movement. Measurements are taken before and after performing the myofascial techniques, thus recording the three initial measurements, three post-intervention measurements, and the average of the initial and post-intervention measurements as a reference for obtaining the results.
For pain assessment, the equipment is configured in its algometer mode. With the individual sitting, three measurements were taken well above the trigger point located, applying pressure at a perpendicular angle, until the individual reports his maximum pain threshold, thus testing his pain tolerance. Algometry showed satisfactory reliability in the results of studies on different types of musculoskeletal pain [23, 24, 25].
Then, in Groups A, B, and C, the proposed approach was performed. In Group A, superficial manual myofascial release therapy was applied. To perform the technique, the volunteer is placed in dorsal decubitus and the therapist in a cranial position in relation to the volunteer. The therapist places one finger at the occipital origin of the upper fibers of the trapezius and the other at the insertion near the acromion. The therapist should maintain the position until PG inhibition. The technique was applied until its clinical objectives were achieved (Figure 3) [20, 21, 22, 23].
Figure 3.
Application position superficial of myofascial release therapy that was applied in group a.
In Group B, TLP was applied by positional inhibition. To perform the technique, the volunteer is positioned in dorsal decubitus, with the therapist in the cranial position. After identifying the trigger point, it should be monitored, maintaining pressure on the PG, and then the volunteer’s neck was passively placed in a position of inhibition, approaching the origin of the insertion of the upper trapezius muscle, passively performing an ipsilateral inclination, contralateral rotation, and neck extension. The pressure and positioning will be maintained for 90 seconds and after that time the volunteer’s head must be passively repositioned in a neutral position. The theory is that the muscle will go into active insufficiency, due to the approximation of the sarcomeres and having as a reaction the relaxation of the tissues in the region involved (Figures 4 and 5) [12, 17].
Figure 4.
Application position of positional myofascial release therapy that was applied in group B. localize the trigger point.
Figure 5.
Application position of positional myofascial release therapy that was applied in group B. position passively performing muscle action and hold for 90 seconds monitoring the trigger point.
In Group C, the control group, a TLP is performed on the biceps brachii muscle contralateral to the trapezius, where the PG was identified, in order to analyze whether the results of the previous groups are superior to the control group. To perform the technique, the volunteer is placed in dorsal decubitus, PGs must be identified in the biceps brachii muscle (contralateral to the PG identified in the trapezius) and perform their action passively, doing elbow flexion, shoulder flexion, and supination (Figures 6–8).
Figure 6.
Application placebo of positional myofascial release therapy that was applied in group C. localize the trigger point.
Figure 7.
Application placebo of positional myofascial release therapy that was applied in group C. position passively performing muscle action and hold for 90 seconds monitoring the trigger point.
Figure 8.
Application placebo of positional myofascial release therapy that was applied in group C. position passively performing muscle action and hold for 90 seconds monitoring the trigger point.
Finally, pain and muscle strength are tested again in the three groups, with the aim of comparing the results obtained before and after applying the myofascial release and positional release techniques. With this, verify if these results are superior to the control group.
Continuous variables were presented as mean and standard deviation (descriptive statistics techniques). To test the assumption of normality of the variables involved in the study, the Kolmogorov–Smirnov test was applied. Parametricity was verified in all study data. After confirming the parametricity, the data of the mean values of the Algometry in grams/force (g/f), and the results of the mean Peaks of Kg/force (Kg/f), of the tests before and after myofascial inhibition and positional release of the trapezius muscle of the study participants, the data were presented in a descriptive way. The results were entered into an Excel spreadsheet and the software used to obtain the statistical calculations was the GraphPad Prism 4®.
The sample of the present study consisted of eight individuals of both sexes, with a predominance of females, corresponding to 62.5% (i.e., 5) of the studied population.
According to the collected data, observe in Table 1 the characterization of the public studied, the weight, age, and height data were collected in the evaluation form itself. Data referring to age faced an average of 21 years with a standard deviation of ±1.309 under the total value. The age range of the population varied between 19 and 23 years; with regard to weight, there was an average of 65.5 with a standard deviation of ±11.29, the weight variation of the individuals was between 46 and 81 kgs; the height of the volunteers ranged from 1.56 to 1.81, obtaining an average of 1.680 with a standard deviation of ±0.077, confirming the homogeneity of the group.
Minimum
Maximum
Average/DP
Age (Years) Weight (kg) Weight (kg)
19 46,00 1560
23 81,00 1820
21/1309 65,5/11,29 1680/0,077
Table 1.
Comparison of age, weight, and height of study participants, demonstrating the homoscedasticity of the group.
T-test for paired samples; statistically significant difference p-value ≤. Minimum Maximum Average/DP.
In Figure 9, it is possible to identify the comparison of the means of pre- and post-intervention results of each group related to pain tolerance (maximum threshold of supported pain), measured with a pressure algometer. According to the data collected, there was an improvement in pain tolerance comparing the pre- and post-intervention means of Group A: Myofascial Release, starting from 16575.7 g/f to 21494.6 g/f or 29.68% and of Group B: Positional Release, which presented an average of 8405.9 g/f before the intervention and 8405.9 g/f or 79.56% compared to Group C: Control Group, in which there was a decrease in pain tolerance, that is, the mean of the maximum pain threshold supported by this group was lower, since the pre-intervention mean of the group was 15,903 g/f and the post-intervention mean was 14,910 g/f or − 6.24%, demonstrating that individuals in group C endured less pain compared to Groups A and B.
Figure 9.
Comparison of means of pain tolerance pre- and post-intervention of groups group a: Myofascial release, group B: Positional release, and group C: Control group in g/f.
Figure 10 shows the comparison of the means of the pre- and post-intervention results of each study group in relation to the strength of the trapezius muscle (upper fibers) in the movement of shrugging the shoulder, measured with a digital dynamometer. According to the data collected, there were no significant changes in Groups A and B, in relation to Group C: Control Group. However, there were gains in strength in the three groups, noting that in Group A the gain in strength was 22.16%, in Group B the gain was 6.03% and in Group C or the control group there was a gain of 9.79%, so these gains cannot be statistically significant in the present study.
Figure 10.
Comparison of isometric strength means pre- and post-intervention of groups group a: Myofascial release, group B: Positional release, and group C: Control Group in kg/f.
After low back pain, neck pain is one of the pain disorders that most affect the musculoskeletal system, when considered chronic, there is persistence of symptoms resulting in severe discomfort, absence from work, and reduced quality of life [26].
The present study was directed to investigate and compare the immediate effects of positional release therapy and superficial myofascial release therapy on the strength of the trapezius muscle (upper fibers) and on the maximum pain threshold of the same muscle. The results were satisfactory in terms of increased pain tolerance, that is, decreased pain as an immediate effect of positional release therapy (79.56%) and superficial myofascial release therapy (22.68%), but when related to strength there were no significant gains in relation to the control group.
The results of the study are physiologically justified by the study by Sain and Meena [27], it was demonstrated that positional release therapy obtains its benefits through an automatic redefinition of muscle spindles, helping to decrease muscle tone and increase the length of sarcomeres in the regions affected by trigger points. When performing the TLP technique, the muscle is positioned in its most comfortable position, resulting in tissue relaxation, improving vascular circulation, and reducing nociceptive stimuli, which are believed to be the originators of the inflammatory process. TLP also aids in peripheral and central desensitization.
Through the results, it is possible to see that they corroborate the data obtained by Namvar et al. [28], in which it was concluded that myofascial release proved to be an effective manual therapy technique in reducing pain and disability, in addition to improving isometric extension strength of the neck in patients with chronic nonspecific neck pain. In the present study, superficial myofascial release therapy (TLP) showed an increase of 22.16%, but this increase was not statistically significant because there was no significant change in relation to the control group.
In the study by Priyanka Rishi, Premlata, and Gurpreet Singh [29], it was concluded that the positional release therapy technique proved to be a favorable therapeutic instrument when the objectives to be achieved are the increase of the ROM and the improvement of the pain threshold levels in patients who suffer neck pain, in agreement with the present study.
Ravish et al. [30] compared the efficacy of the myofascial release technique with laser versus the positional release technique with laser in patients with unilateral trapezalgia. The total study sample consisted of 60 individuals divided into groups: A and B. Laser treatment was the same for both groups; Myofascial release technique was applied in Group A and Positional Release Therapy in Group B for 3 days alternately for 4 weeks. There was a significant improvement in the reduction of pain, functional limitation, and ROM., However, laser myofascial release therapy showed more satisfactory results than laser positional release therapy.
Given the situation studied, it was possible to conclude that positional release therapy and superficial myofascial release therapy were effective in increasing pain tolerance, that is, in reducing pain. However, the results did not show a significant difference in relation to strength gain when compared to the control group. The resources presented in this work are easy to apply, low cost, and prove to be tools that can help in the treatment of patients with neck pain and trapezalgia, and may precede kinesiotherapy by deconstructing kinesiophobic patterns generated by pain. Despite the numerous benefits, TLP and superficial TLM lack relevant studies and it is necessary to carry out more studies in the area, aiming at not only immediate effects but also in medium- and long-term benefits.
Thanks to the Catholic University of Pernambuco, the School of Health and Life Sciences and the university’s scientific initiation, which were important parts for carrying out the work.
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Written By
Allyson Cabral and Paulo Veiga
Submitted: 17 May 2023Reviewed: 17 May 2023Published: 02 October 2023
Open access peer-reviewed chapter
