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The influence of Positional Release Therapy on the myofascial trigger points of the upper trapezius muscle in computer users
Accepted Manuscript The Influence of Positional Release Therapy on the Myofascial Trigger Points of the Upper Trapezius Muscle in Computer Users M. Mohammadi Kojidi, MSc., PT Candidate, Student Research Committee, F. Okhovatian, PhD, PT, Professor, A. Rahimi, PhD, PT, Professor, A.A. Baghban, PhD in Biostatistics, Associate Professor, H. Azimi, PhD in English Language Teaching, Assistant Professor PII:
S1360-8592(16)30045-6
DOI:
10.1016/j.jbmt.2016.04.006
Reference:
YJBMT 1340
To appear in:
Journal of Bodywork & Movement Therapies
Received Date: 13 January 2016 Revised Date:
26 February 2016
Accepted Date: 21 March 2016
Please cite this article as: Mohammadi Kojidi, M, Okhovatian, F, Rahimi, A, Baghban, A., Azimi, H, The Influence of Positional Release Therapy on the Myofascial Trigger Points of the Upper Trapezius Muscle in Computer Users, Journal of Bodywork & Movement Therapies (2016), doi: 10.1016/ j.jbmt.2016.04.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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The Influence of Positional Release Therapy on the Myofascial Trigger Points of the Upper Trapezius Muscle in Computer Users
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Mohammadi Kojidi M1, Okhovatian F2*, Rahimi A3, Baghban AA4, Azimi H5 1
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MSc., PT Candidate, Student Research Committee, School of Rehabilitation Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2* PhD, PT, Professor, Physiotherapy Research Centre, School of Rehabilitation Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran 3 PhD, PT, Professor, Physiotherapy Research Centre, School of Rehabilitation Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran 4 PhD in Biostatistics, Associate Professor, Physiotherapy Research Centre, School of Rehabilitation Sciences , Shahid Beheshti University of Medical Sciences, Tehran, Iran 5 PhD in English Language Teaching, Assistant Professor, Department of English Language Teaching, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Corresponding Author*: Physiotherapy Research Centre, Shahid Beheshti University of Medical Sciences, Damavand St, Opposite Bou-ali Hospital, Tehran, Iran. Tel: 0098 21 77576268 E-mail: [email protected]
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Abbreviations: PRT; Positional Release Therapy, LTrPs ; Latent Trigger points , PPT; Pressure pain threshold ,VAS; Visual Analogue Scale
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Abstract Objective: The purpose of the present study was to investigate the effect of Positional Release Therapy (PRT) in computer users via latent trigger points (LTrPs) of the upper trapezius muscle. Materials and Methods: Twenty-eight women with the upper trapezius MTrPs participated in this study. Subjects were randomly classified into two groups (14 in each group): the subjects in the Group 1 received PRT in shortened position while those in the group 2 received sham control in the neutral position of the upper trapezius muscle. They received three therapy sessions every other day for one week. The local pain intensity and Pressure pain threshold (PPT) were measured via Visual Analogue Scale (VAS) and algometry, respectively, before interventions and repeated 5 minutes after the first and third treatment sessions in each group.
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Results: One-way ANOVA was used for data analysis. After treatment, between groups comparison revealed that for PPT and VAS, there were significant differences between the two groups (VAS and PPT; P< 0.05). Conclusion: Both groups (PRT and sham control) showed alleviation of pain and increase in PPT during three sessions of therapy although PRT showed to be more effective in these patients. Key Indexing Terms: Positional Release Therapy, Computer user, Trigger point, Upper Trapezius Muscle
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Introduction Work-related Musculoskeletal Disorders (WRMSDs) are also known as Repetitive Strain Injury (RSI) and Cumulative Trauma Disorder (CTD) (Yassi A., 1991; Yassi A., 2000). As witnessed in the literature, etiology for WRMSDs symptoms is complicated, yet researchers have named multiple factors that are significant in its development such as psychosocial, organizational, and individual aspects of job satisfaction and workplace climate (Ranasinghe et al., 2011; Piranveyseh et al., 2016), as well as gender. Work-related Musculoskeletal Disorders have high prevalence in women than in men, probably due to women’s musculoskeletal susceptibility (Yap, 2007; Hakala et al., 2012). The disorders related to computer-based activities can increase compressive loadings in the spine and create a creep response in the tissue and so subsequently cause pain symptoms and muscle strain in different parts of the body; in upper extremity the highest prevalence of MSDs was found in the neck and shoulder (49.0%) regions (Jensen et al., 2002; Wahlström, 2005; Trester et al., 2006; Tulder ,et al., 2007; Piranveyseh et al., 2016). These investigations are significant with regard to developing prevention strategies, as these problems can directly and/or indirectly affect individual lives and societies, for example, by affecting the quality of life, leading to increase in absences at work and consequently economic burdens (Szeto et al., 2002; Wahlström , 2005; Staal et al., 2007; Akrouf et al., 2010). Among MSDs related to neck and shoulder, the upper trapezius is the most involved muscle in office workers, especially intensive computer users. Fischer measured the PPT of eight different muscles using a pressure algometer and found that the upper trapezius was the most sensitive muscle tested (Fischer, 1987; Rempel et al., 2005; Trester et al., 2006). At work place, continuous exposure to Video display units together with inappropriate work stations (stressful environment) and prolonged static or awkward/non-neutral body posture while using computers accompanied by inadequate rest breaks lead to reduction of local blood ischemia, hypoxia, and subsequently fatigue in muscle tissues. This gradual activation of muscle might lead to developing trigger points in the trapezius muscles and can account for higher rates of musculoskeletal complaints even with low level static exertions (Trester et al., 2006; Hoyle et al., 2011; Chang et al., 2
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2011; Lari et al., 2016) ; therefore, it was hypothesized that both postural and visual demands may play roles in muscle activation patterns, and, perhaps development of stress on muscle fibers can be attributable to active or latent MTrPs, and resultant chronic musculoskeletal disorders (Buckle and Devereux, 2002; Trester et al., 2006). There are two categories of Trigger points (TPs): active and latent, the active trigger points feature local or referred pain away from the trigger point, while latent trigger points do not cause spontaneous pain unless evoked by an external stimulant (Simons and Travel, 1999). Ibarra et al., 2011, showed that LTrPs are associated with reduced efficiency of reciprocal inhibition, which may contribute to unbalanced muscle activation, so elimination of LTrPs and/or prevention of LTrPs to become active may improve motor unit functions and may prevent development of local pain and decreases central sensitization (Ibarra et al., 2011). So far, a variety of treatments have been introduced to relieve the musculoskeletal complaints and symptoms associated with MTrPs through noninvasive and invasive treatments such as Ischemic Compression, Manual Pressure Release, Strain Counter Strain, Muscle energy technique, Massage, Spray and Stretch, Electrical Stimulation, and injections with local anesthetics, corticosteroids, or botulism toxin or dry needling (Prentice, 2004; Richards , 2006; Yap, 2007; Chaitow , 2009; Okhovatian et al., 2012; Mehdikhani et al., 2012; Kamali Sarvestani et al, 2013; Cagnie et al., 2013 Lari et al., 2016 ). The previous systematic review studies have shown that one of the essential treatments in the management of LTrPs is Manual Therapy (MT) and several studies have shown that MT treatments make no significant difference in comparison with a placebo (Fernandez et al., 2005). However, MT techniques are less costly, with least side effects in treatment of MTrPs, but there is a lack of evidence about the efficacy of these methods or a comparison of treatment to suggest the best technique. The intervention used in the present study was PRT. It is an indirect and passive therapeutic technique that uses TrPs. The application of PRT is a safe and effective method to successfully treat elicited MTrPs. In this technique, in order to facilitate restoration of normal tissue length and to treat excessive muscle tension or spasm, tissues are placed in a Position of comfort for a brief period (90 sec) to resolve the associated dysfunction. PRT, in the shorten position, decreases gamma and alpha neuronal activities and resets the muscle spindle mechanism of the affected tissue, and thus helps improvement in vascular circulation and removal of the chemical mediators of inflammation (Speicher et al., 2006; Al-shawabka et al., 2013; Singh et L., 2014). Despite the high prevalence of MPS and all the research done on MPS, the clinical efficacy of PRT has not been well established. The aim of the present study was to investigate the effect of PRT on pain intensity and pain pressure threshold in computerusing females with latent trigger points in upper trapezius muscle at work place. 2. Methodology 3
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2.1. Design and subject selection In the present randomized, single-blind study, twenty-eight female office workers, aged between 19 to 45, with latent TrPs of upper trapezius muscle were selected from a clinic affiliated to Shahid Beheshti University of Medical Science, Tehran Iran. The study was conducted between June-Oct 2015. The research proposal was approved by the ethical committee of Physiotherapy Research Centre (PTRC), Shahid Beheshti University of Medical Sciences. A diagnosis of latent MTP was confirmed after manual palpation and patient feedback (Simons and Travel, 1999). Prior to randomization, the group allocation scheme was successfully concealed from the subjects. Once patients were determined to meet the requirements of the study and signed the informed consent form, after the first evaluation session, they were asked to pick one of the 28 papers from inside an envelope: 14 papers had number 1 printed on them and the other 14 had the number 2. The papers had previously been shuffled into the envelope. The paper picked determined each subject’s grouping: 1 for treatment group and 2 for sham control group. Both groups were assessed and treated by an experienced physiotherapist aware of the group type. The subjects were blind to the group type and were treated half an hour prior to starting the workday. All the subjects received a total of three treatment sessions every other day over one week. Table(1)and (2) lists patients' inclusion and exclusion criteria.
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2.1.1 Inclusion criteria: (Ruiz-Sáez et al., 2007; Aguilera et al., 2009; Okhovatian et al., 2012)
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Table1 Inclusion criteria Pain intensity of at least 3 on VAS and presence of at least 1 latent trigger point in a taut band on shoulder in response to 2.5kg/cm 2 of pressure Presence of palpable taut band in a skeletal Muscle Female computer users with latent trigger points, between 19 and 45 years At least 2 hours in sitting position and work via computers per day
2.1.2 Exclusion criteria: (Fernandez et al., 2006; Kelencz et al., 2011) Table 2 Exclusion criteria Diagnosis of fibromyalgia Diagnosis of cervical Radiculopathy or Myelopathy determined by their primary care physician History of a whiplash injury History of cervical spine and shoulder surgery 4
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Assessed for eligibility (N= 28)
Allocation
Randomized assignment
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Enrollment
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Having undergone Trigger point therapy within the past month prior to the study Drug intake ( anti-inflammatory medication during treatment sessions)
(1)PRT n= 14
First treatment session
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Evaluation before & after intervention
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Second treatment sessions
Third treatment sessions
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Evaluation after intervention Analysis (n= 28)
Fig1. Flow diagram of the control trial
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(2) Control n= 14
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2.2. Interventions
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2.2.1. Positional Release Therapy As for PRT, prior to starting the treatment, the therapist identified the LTrPs in the upper trapezius muscle using pincer palpation. Latent TrPs implicated in the condition were palpated and marked with a small dot on the skin at each treatment. The subject laid in supine position with the cervical spine in neutral position. Subjects were encouraged to relax as much as possible. The therapist applied gradually increasing pressure by her thumb over the TrPs of upper trapezius muscle until the sensation of pressure became one of pressure and pain. At the same time, the therapist created a new position with less tension resulting in a subjective reduction of pain of up to 70%. The position that led to reduced pain was cervical extension, ipsilateral side flexion of the cervical spine with slightly contra lateral rotation (5-8 degrees). The patient's upper extremity was positioned in passive abduction and maintained for 90s. Finally, the subject was slowly placed into a neutral position of the cervical spine (D'Armbrogio , 1997; Prentice, 2004; Al-shawabka et al., 2013). This technique was performed three times in each treatment session with 15 sec rest interval.
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2.2.2. Control group At the onset of the study, the therapist identified the LTrPs in the upper trapezius muscle using pincer palpation. Latent TrPs implicated in the condition were palpated and marked with a small dot on the skin at each treatment session for the control group, the subject sat on the chair with relaxed upper extremities. Once located, the therapist applied algometry disc on the trigger point for 60 sec ( Fryer et al., 2005).with the patient feeling no sensation of pain and algometry instrument showing no number. The procedure was repeated three times in each session with 15 sec rest interval. After the three sessions of the study, three free-of-charge treatment sessions were offered to the subjects in both groups, as well. PPT, VAS, were assessed and recorded prior to beginning the study and 5 minutes after the first and third sessions in both groups. 2.4. Outcome measures 2.4.1. Pain intensity: To evaluate local pain intensity a pressure of 2.5 kg/cm2 was exerted on the latent TrP of upper trapezius muscle using the algometer and the patients were asked to show their pain on the VAS. The VAS was a 10-cm horizontal line divided into 10 equal parts: Number "0" showing "no pain" and, at the other end, number 10, showing "maximum pain". The reliability and validity of the VAS as a measure of pain was previously established ( Price et al., 1983; Bijur et al., 2001).
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2.4.2. In the present study, an algometer (Taiwan model 5020,) was used to assess PRT. This device consists of a round rubber disk (area, 1 cm) attached to a pressure (force) gauge. The high reliability, reproducibility, and validity of the PPT have already been demonstrated in numerous studies (Fryer et al., 2005; Gemmell et al.,2008; Kinser et al., 2009). The intra-examiner reliability for the use of a pressure algometer ranges from 0.6 to 0.97 and the inter-examiner reliability ranges from 0.4 to 0.98 ( Robb et al., 2011). All the patients were placed in sitting position during the assessment.
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3. Analysis of data SPSS (version 16) was used to analyze the data. The normality of distribution was assessed by means of Shapiro-Wilk test (P>0.05). Baseline and after three treatment sessions features were compared between groups using one-way ANOVA. The statistical analysis was conducted at a 95% confidence level. The P-values less than 0.05 were considered as statistically significant. 4. Results
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Twenty-eight women were divided into two groups: PRT group (14 patients), and a Sham control group (14 patients). No significant difference was found for demographic data (age, weight, height, BMI, and working hours) for each group at the beginning of the study between groups (p>0.05) (Table 3). Moreover, there were no differences between groups for the VAS (P= 0.363) and the PPT (P= 0.404). Thus, it could be assumed that the groups were not different at the onset of the study. The VAS value measured after three treatment sessions was significantly lower than that before the treatment in the two groups (p<0.05). The VAS in the group receiving PRT showed significant improvement as compared with that in the group receiving sham control (p=0.001) (Table 4). PPT value increased significantly after three treatment sessions rather than before treatment in the two groups (p<0.05), but PPT in the group receiving PRT showed significantly more improvement than that in the groups receiving only sham control (p=0.000) (Table 5).
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P-value 0.865 0.812 0.723 0.552 0.327
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Table 3 Demographic data for each group at the beginning of the study Variables PRT Control Age (y) 27.86± 6.64 28.29± 6.58 Weight (Kg) 61.57±5.21 61.14 ±4.18 Height(Meter) 1.64±0.03 1.653± 0.04 BMI (Kg/m2) 22.68±1.41 22.39±1.18 Working hours 3±0.85 2.71 ±0.64 Values are expressed as Mean ± S.D
Table 4 Clinical intervention data for each group at the beginning of the study and after the first & third treatment sessions Variable PRT Control P-value VAS Comparison between groups 6.5± 0.80
After first session
5.01±0.73
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Before first session
0.363
5.88± 0.85
0.007
4.7±0.87
0.001
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After third session 3.4±0.90 Values are expressed as Mean ± S.D
6.2±0.82
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Table 5 Clinical intervention data for each group at the beginning of the study and after the first & third treatment sessions Variable PRT Control P-value PPT Comparison between groups Beforefirst session 0.404 1.54± 0.11 1.50±0.13 Afterfirst session
1.62±0.10
1.51±0.12
0.031
Afterthird session 1.74±0.08 Values are expressed as Mean ± S.D
1.55±0.12
0.000
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Discussion
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The current study was carried out to evaluate the effects of PRT and sham control in the management of trigger points in upper trapezius muscle in computer users as more susceptible workers among office workers. In so doing, pain intensity and PPT were measured and recorded by VAS and algometry, within three treatment sessions over one week. Subjects in all two groups were homogeneous in terms of demographic data, and the number of women in each group was the same (n=14). A total of 28 subjects participated in the study. According to the data presented in the results section, the effect of PRT and Sham control groups on latent TrPs of upper trapezius resulted in the increase of PPT (p=0) and decrease in VAS (p=0.001). According to the results, the PRT group received a significantly more effective treatment of the latent upper trapezius trigger points in computer users.
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In some studies, the effect of PRT has previously been reported. These findings are consistent with those reported in other studies, including Kelencz et al., 2011, who, based on the analysis of electromyography data, found that PRT reduced the muscle tension in the upper trapezius and decreased the musculoskeletal pain (Kelencz et al.,2011). In addition, the results came in agreement with those reported by Mohamed et al., 2014, who examined the effect of myofascial therapy treatments using PRT on chronic mechanical low back pain showing that PRT reduced pain and improved lumbar range of motion (Mohamed and Ahmad, 2014). Harlapur et al., 2010, compared myofascial release and PRT in chronic plantar fasciitis on pain. There were no significant differences between the two groups in terms of VAS (Harlapur et al., 2010). The effectiveness of PRT on myofascial pain is a controversial issue. For instance, it is shown that although PRT can reduce pain and increase range of motion, PPT, and flexibility, other treatments are comparatively more effective than PRT (Kelencz et al.,2011; Doley et al.,2013; Singh et al., 2014; Mohamed and Ahmad, 2014; Pattanshetty and Raikar, 2015), whereas in another study the PRT was not observed to differ from that of control group (Alagesan and S. Shah, 2012 ). The PRT is usually applied with the target muscle in an easy position (shortened position) by applying 90 sec of manual pressure in order to treat trigger point ( Saavedra et al., 2014). PRT is believed to achieve its benefits by means of an automatic resetting of muscle spindles, which would help to dictate the length and tone into the affected tissues and increase the length of Sarcomeres in contraction knot area, PPT and local pain intensity improvement after application of PRT can also be due to the manual contact component of the treatment and the stimulation of A∆ fibres; a process that can lead to blockage of the pain (Meseguer et al., 2006; Chaitow 2009; Saavedra et al., 2014 ). The PRT reduces local pain intensity and increases PPT. In this method, following the release of pressure on TrP, tissue blood and lymphatic circulation of that area increases 9
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which eliminates hypoxic conditions and results in cellular metabolism leading to the removal of inflammatory chemical substances such as prostaglandins, histamine, and bradykinin; therefore, reduction of sensitization of nociceptors occurs. Also, one of the advantages of PRT is breaking the cycle of pain-spasm-pain (Alagesan and S. Shah, 2012, Pattanshetty and Raikar, 2015). An advantage of our study was its novelty. So far, no study is reported on comparison of PRT and Sham control groups, and no study was observed to apply these two methods together for the treatment of latent trigger points of upper trapezius muscle in the computer users, as an example of office workers, either. Positional release therapy was found to be effective in reducing pain and increasing Pressure pain threshold.
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Limitations of the study Among the limitations of the study was the fact that the sample size was small and the assessor was not blind to the treatment type. Future studies can be carried out with broader dimension, long follow up, double blind procedure, and the use of other outcome measures such as range of motion and sonography for determining thickness of the upper trapezius muscle trigger points.
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Conclusion According to the present study, both groups (group1: PRT, group 2: Sham control group) were given suitable treatments for latent TrPs of upper trapezius muscle, but the PRT group showed significantly more improvement in increasing PPT and decreasing VAS in three treatment sessions in 19-45 year-old female computer users with at least 2 hours of work and with latent upper trapezius trigger points.
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Acknowledgement The present project was sponsored by Shahid Beheshti University of Medical Sciences, Physiotherapy Research Centre (Grant # IR.Sbmu.ram.Rec.1394.310), Tehran, Iran.
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Saavedra, FJ., Cordeiro, MT., Alves, JV., Fernande, HM., Reis, VM., Mont’Alverne, DGB. The influence of positional release therapy on the myofascial tension of the upper trapezius muscle. Revista Brasileria Cineantropometria e Desempenho Humano. 2014; 16(2): 191-199. Tulder, MV., Malmivaara, A., Koes, B. Repetitive strain injury. Lancet. 2007; 369: 1815–1822.
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DOI:
10.1016/j.jbmt.2016.04.006
Reference:
YJBMT 1340
To appear in:
Journal of Bodywork & Movement Therapies
Received Date: 13 January 2016 Revised Date:
26 February 2016
Accepted Date: 21 March 2016
Please cite this article as: Mohammadi Kojidi, M, Okhovatian, F, Rahimi, A, Baghban, A., Azimi, H, The Influence of Positional Release Therapy on the Myofascial Trigger Points of the Upper Trapezius Muscle in Computer Users, Journal of Bodywork & Movement Therapies (2016), doi: 10.1016/ j.jbmt.2016.04.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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The Influence of Positional Release Therapy on the Myofascial Trigger Points of the Upper Trapezius Muscle in Computer Users
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Mohammadi Kojidi M1, Okhovatian F2*, Rahimi A3, Baghban AA4, Azimi H5 1
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MSc., PT Candidate, Student Research Committee, School of Rehabilitation Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2* PhD, PT, Professor, Physiotherapy Research Centre, School of Rehabilitation Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran 3 PhD, PT, Professor, Physiotherapy Research Centre, School of Rehabilitation Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran 4 PhD in Biostatistics, Associate Professor, Physiotherapy Research Centre, School of Rehabilitation Sciences , Shahid Beheshti University of Medical Sciences, Tehran, Iran 5 PhD in English Language Teaching, Assistant Professor, Department of English Language Teaching, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Corresponding Author*: Physiotherapy Research Centre, Shahid Beheshti University of Medical Sciences, Damavand St, Opposite Bou-ali Hospital, Tehran, Iran. Tel: 0098 21 77576268 E-mail: [email protected]
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Abbreviations: PRT; Positional Release Therapy, LTrPs ; Latent Trigger points , PPT; Pressure pain threshold ,VAS; Visual Analogue Scale
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Abstract Objective: The purpose of the present study was to investigate the effect of Positional Release Therapy (PRT) in computer users via latent trigger points (LTrPs) of the upper trapezius muscle. Materials and Methods: Twenty-eight women with the upper trapezius MTrPs participated in this study. Subjects were randomly classified into two groups (14 in each group): the subjects in the Group 1 received PRT in shortened position while those in the group 2 received sham control in the neutral position of the upper trapezius muscle. They received three therapy sessions every other day for one week. The local pain intensity and Pressure pain threshold (PPT) were measured via Visual Analogue Scale (VAS) and algometry, respectively, before interventions and repeated 5 minutes after the first and third treatment sessions in each group.
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Results: One-way ANOVA was used for data analysis. After treatment, between groups comparison revealed that for PPT and VAS, there were significant differences between the two groups (VAS and PPT; P< 0.05). Conclusion: Both groups (PRT and sham control) showed alleviation of pain and increase in PPT during three sessions of therapy although PRT showed to be more effective in these patients. Key Indexing Terms: Positional Release Therapy, Computer user, Trigger point, Upper Trapezius Muscle
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Introduction Work-related Musculoskeletal Disorders (WRMSDs) are also known as Repetitive Strain Injury (RSI) and Cumulative Trauma Disorder (CTD) (Yassi A., 1991; Yassi A., 2000). As witnessed in the literature, etiology for WRMSDs symptoms is complicated, yet researchers have named multiple factors that are significant in its development such as psychosocial, organizational, and individual aspects of job satisfaction and workplace climate (Ranasinghe et al., 2011; Piranveyseh et al., 2016), as well as gender. Work-related Musculoskeletal Disorders have high prevalence in women than in men, probably due to women’s musculoskeletal susceptibility (Yap, 2007; Hakala et al., 2012). The disorders related to computer-based activities can increase compressive loadings in the spine and create a creep response in the tissue and so subsequently cause pain symptoms and muscle strain in different parts of the body; in upper extremity the highest prevalence of MSDs was found in the neck and shoulder (49.0%) regions (Jensen et al., 2002; Wahlström, 2005; Trester et al., 2006; Tulder ,et al., 2007; Piranveyseh et al., 2016). These investigations are significant with regard to developing prevention strategies, as these problems can directly and/or indirectly affect individual lives and societies, for example, by affecting the quality of life, leading to increase in absences at work and consequently economic burdens (Szeto et al., 2002; Wahlström , 2005; Staal et al., 2007; Akrouf et al., 2010). Among MSDs related to neck and shoulder, the upper trapezius is the most involved muscle in office workers, especially intensive computer users. Fischer measured the PPT of eight different muscles using a pressure algometer and found that the upper trapezius was the most sensitive muscle tested (Fischer, 1987; Rempel et al., 2005; Trester et al., 2006). At work place, continuous exposure to Video display units together with inappropriate work stations (stressful environment) and prolonged static or awkward/non-neutral body posture while using computers accompanied by inadequate rest breaks lead to reduction of local blood ischemia, hypoxia, and subsequently fatigue in muscle tissues. This gradual activation of muscle might lead to developing trigger points in the trapezius muscles and can account for higher rates of musculoskeletal complaints even with low level static exertions (Trester et al., 2006; Hoyle et al., 2011; Chang et al., 2
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2011; Lari et al., 2016) ; therefore, it was hypothesized that both postural and visual demands may play roles in muscle activation patterns, and, perhaps development of stress on muscle fibers can be attributable to active or latent MTrPs, and resultant chronic musculoskeletal disorders (Buckle and Devereux, 2002; Trester et al., 2006). There are two categories of Trigger points (TPs): active and latent, the active trigger points feature local or referred pain away from the trigger point, while latent trigger points do not cause spontaneous pain unless evoked by an external stimulant (Simons and Travel, 1999). Ibarra et al., 2011, showed that LTrPs are associated with reduced efficiency of reciprocal inhibition, which may contribute to unbalanced muscle activation, so elimination of LTrPs and/or prevention of LTrPs to become active may improve motor unit functions and may prevent development of local pain and decreases central sensitization (Ibarra et al., 2011). So far, a variety of treatments have been introduced to relieve the musculoskeletal complaints and symptoms associated with MTrPs through noninvasive and invasive treatments such as Ischemic Compression, Manual Pressure Release, Strain Counter Strain, Muscle energy technique, Massage, Spray and Stretch, Electrical Stimulation, and injections with local anesthetics, corticosteroids, or botulism toxin or dry needling (Prentice, 2004; Richards , 2006; Yap, 2007; Chaitow , 2009; Okhovatian et al., 2012; Mehdikhani et al., 2012; Kamali Sarvestani et al, 2013; Cagnie et al., 2013 Lari et al., 2016 ). The previous systematic review studies have shown that one of the essential treatments in the management of LTrPs is Manual Therapy (MT) and several studies have shown that MT treatments make no significant difference in comparison with a placebo (Fernandez et al., 2005). However, MT techniques are less costly, with least side effects in treatment of MTrPs, but there is a lack of evidence about the efficacy of these methods or a comparison of treatment to suggest the best technique. The intervention used in the present study was PRT. It is an indirect and passive therapeutic technique that uses TrPs. The application of PRT is a safe and effective method to successfully treat elicited MTrPs. In this technique, in order to facilitate restoration of normal tissue length and to treat excessive muscle tension or spasm, tissues are placed in a Position of comfort for a brief period (90 sec) to resolve the associated dysfunction. PRT, in the shorten position, decreases gamma and alpha neuronal activities and resets the muscle spindle mechanism of the affected tissue, and thus helps improvement in vascular circulation and removal of the chemical mediators of inflammation (Speicher et al., 2006; Al-shawabka et al., 2013; Singh et L., 2014). Despite the high prevalence of MPS and all the research done on MPS, the clinical efficacy of PRT has not been well established. The aim of the present study was to investigate the effect of PRT on pain intensity and pain pressure threshold in computerusing females with latent trigger points in upper trapezius muscle at work place. 2. Methodology 3
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2.1. Design and subject selection In the present randomized, single-blind study, twenty-eight female office workers, aged between 19 to 45, with latent TrPs of upper trapezius muscle were selected from a clinic affiliated to Shahid Beheshti University of Medical Science, Tehran Iran. The study was conducted between June-Oct 2015. The research proposal was approved by the ethical committee of Physiotherapy Research Centre (PTRC), Shahid Beheshti University of Medical Sciences. A diagnosis of latent MTP was confirmed after manual palpation and patient feedback (Simons and Travel, 1999). Prior to randomization, the group allocation scheme was successfully concealed from the subjects. Once patients were determined to meet the requirements of the study and signed the informed consent form, after the first evaluation session, they were asked to pick one of the 28 papers from inside an envelope: 14 papers had number 1 printed on them and the other 14 had the number 2. The papers had previously been shuffled into the envelope. The paper picked determined each subject’s grouping: 1 for treatment group and 2 for sham control group. Both groups were assessed and treated by an experienced physiotherapist aware of the group type. The subjects were blind to the group type and were treated half an hour prior to starting the workday. All the subjects received a total of three treatment sessions every other day over one week. Table(1)and (2) lists patients' inclusion and exclusion criteria.
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2.1.1 Inclusion criteria: (Ruiz-Sáez et al., 2007; Aguilera et al., 2009; Okhovatian et al., 2012)
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Table1 Inclusion criteria Pain intensity of at least 3 on VAS and presence of at least 1 latent trigger point in a taut band on shoulder in response to 2.5kg/cm 2 of pressure Presence of palpable taut band in a skeletal Muscle Female computer users with latent trigger points, between 19 and 45 years At least 2 hours in sitting position and work via computers per day
2.1.2 Exclusion criteria: (Fernandez et al., 2006; Kelencz et al., 2011) Table 2 Exclusion criteria Diagnosis of fibromyalgia Diagnosis of cervical Radiculopathy or Myelopathy determined by their primary care physician History of a whiplash injury History of cervical spine and shoulder surgery 4
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Assessed for eligibility (N= 28)
Allocation
Randomized assignment
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Enrollment
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Having undergone Trigger point therapy within the past month prior to the study Drug intake ( anti-inflammatory medication during treatment sessions)
(1)PRT n= 14
First treatment session
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Evaluation before & after intervention
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Second treatment sessions
Third treatment sessions
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Evaluation after intervention Analysis (n= 28)
Fig1. Flow diagram of the control trial
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(2) Control n= 14
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2.2. Interventions
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2.2.1. Positional Release Therapy As for PRT, prior to starting the treatment, the therapist identified the LTrPs in the upper trapezius muscle using pincer palpation. Latent TrPs implicated in the condition were palpated and marked with a small dot on the skin at each treatment. The subject laid in supine position with the cervical spine in neutral position. Subjects were encouraged to relax as much as possible. The therapist applied gradually increasing pressure by her thumb over the TrPs of upper trapezius muscle until the sensation of pressure became one of pressure and pain. At the same time, the therapist created a new position with less tension resulting in a subjective reduction of pain of up to 70%. The position that led to reduced pain was cervical extension, ipsilateral side flexion of the cervical spine with slightly contra lateral rotation (5-8 degrees). The patient's upper extremity was positioned in passive abduction and maintained for 90s. Finally, the subject was slowly placed into a neutral position of the cervical spine (D'Armbrogio , 1997; Prentice, 2004; Al-shawabka et al., 2013). This technique was performed three times in each treatment session with 15 sec rest interval.
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2.2.2. Control group At the onset of the study, the therapist identified the LTrPs in the upper trapezius muscle using pincer palpation. Latent TrPs implicated in the condition were palpated and marked with a small dot on the skin at each treatment session for the control group, the subject sat on the chair with relaxed upper extremities. Once located, the therapist applied algometry disc on the trigger point for 60 sec ( Fryer et al., 2005).with the patient feeling no sensation of pain and algometry instrument showing no number. The procedure was repeated three times in each session with 15 sec rest interval. After the three sessions of the study, three free-of-charge treatment sessions were offered to the subjects in both groups, as well. PPT, VAS, were assessed and recorded prior to beginning the study and 5 minutes after the first and third sessions in both groups. 2.4. Outcome measures 2.4.1. Pain intensity: To evaluate local pain intensity a pressure of 2.5 kg/cm2 was exerted on the latent TrP of upper trapezius muscle using the algometer and the patients were asked to show their pain on the VAS. The VAS was a 10-cm horizontal line divided into 10 equal parts: Number "0" showing "no pain" and, at the other end, number 10, showing "maximum pain". The reliability and validity of the VAS as a measure of pain was previously established ( Price et al., 1983; Bijur et al., 2001).
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2.4.2. In the present study, an algometer (Taiwan model 5020,) was used to assess PRT. This device consists of a round rubber disk (area, 1 cm) attached to a pressure (force) gauge. The high reliability, reproducibility, and validity of the PPT have already been demonstrated in numerous studies (Fryer et al., 2005; Gemmell et al.,2008; Kinser et al., 2009). The intra-examiner reliability for the use of a pressure algometer ranges from 0.6 to 0.97 and the inter-examiner reliability ranges from 0.4 to 0.98 ( Robb et al., 2011). All the patients were placed in sitting position during the assessment.
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3. Analysis of data SPSS (version 16) was used to analyze the data. The normality of distribution was assessed by means of Shapiro-Wilk test (P>0.05). Baseline and after three treatment sessions features were compared between groups using one-way ANOVA. The statistical analysis was conducted at a 95% confidence level. The P-values less than 0.05 were considered as statistically significant. 4. Results
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Twenty-eight women were divided into two groups: PRT group (14 patients), and a Sham control group (14 patients). No significant difference was found for demographic data (age, weight, height, BMI, and working hours) for each group at the beginning of the study between groups (p>0.05) (Table 3). Moreover, there were no differences between groups for the VAS (P= 0.363) and the PPT (P= 0.404). Thus, it could be assumed that the groups were not different at the onset of the study. The VAS value measured after three treatment sessions was significantly lower than that before the treatment in the two groups (p<0.05). The VAS in the group receiving PRT showed significant improvement as compared with that in the group receiving sham control (p=0.001) (Table 4). PPT value increased significantly after three treatment sessions rather than before treatment in the two groups (p<0.05), but PPT in the group receiving PRT showed significantly more improvement than that in the groups receiving only sham control (p=0.000) (Table 5).
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P-value 0.865 0.812 0.723 0.552 0.327
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Table 3 Demographic data for each group at the beginning of the study Variables PRT Control Age (y) 27.86± 6.64 28.29± 6.58 Weight (Kg) 61.57±5.21 61.14 ±4.18 Height(Meter) 1.64±0.03 1.653± 0.04 BMI (Kg/m2) 22.68±1.41 22.39±1.18 Working hours 3±0.85 2.71 ±0.64 Values are expressed as Mean ± S.D
Table 4 Clinical intervention data for each group at the beginning of the study and after the first & third treatment sessions Variable PRT Control P-value VAS Comparison between groups 6.5± 0.80
After first session
5.01±0.73
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0.363
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0.007
4.7±0.87
0.001
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After third session 3.4±0.90 Values are expressed as Mean ± S.D
6.2±0.82
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Table 5 Clinical intervention data for each group at the beginning of the study and after the first & third treatment sessions Variable PRT Control P-value PPT Comparison between groups Beforefirst session 0.404 1.54± 0.11 1.50±0.13 Afterfirst session
1.62±0.10
1.51±0.12
0.031
Afterthird session 1.74±0.08 Values are expressed as Mean ± S.D
1.55±0.12
0.000
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Discussion
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The current study was carried out to evaluate the effects of PRT and sham control in the management of trigger points in upper trapezius muscle in computer users as more susceptible workers among office workers. In so doing, pain intensity and PPT were measured and recorded by VAS and algometry, within three treatment sessions over one week. Subjects in all two groups were homogeneous in terms of demographic data, and the number of women in each group was the same (n=14). A total of 28 subjects participated in the study. According to the data presented in the results section, the effect of PRT and Sham control groups on latent TrPs of upper trapezius resulted in the increase of PPT (p=0) and decrease in VAS (p=0.001). According to the results, the PRT group received a significantly more effective treatment of the latent upper trapezius trigger points in computer users.
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In some studies, the effect of PRT has previously been reported. These findings are consistent with those reported in other studies, including Kelencz et al., 2011, who, based on the analysis of electromyography data, found that PRT reduced the muscle tension in the upper trapezius and decreased the musculoskeletal pain (Kelencz et al.,2011). In addition, the results came in agreement with those reported by Mohamed et al., 2014, who examined the effect of myofascial therapy treatments using PRT on chronic mechanical low back pain showing that PRT reduced pain and improved lumbar range of motion (Mohamed and Ahmad, 2014). Harlapur et al., 2010, compared myofascial release and PRT in chronic plantar fasciitis on pain. There were no significant differences between the two groups in terms of VAS (Harlapur et al., 2010). The effectiveness of PRT on myofascial pain is a controversial issue. For instance, it is shown that although PRT can reduce pain and increase range of motion, PPT, and flexibility, other treatments are comparatively more effective than PRT (Kelencz et al.,2011; Doley et al.,2013; Singh et al., 2014; Mohamed and Ahmad, 2014; Pattanshetty and Raikar, 2015), whereas in another study the PRT was not observed to differ from that of control group (Alagesan and S. Shah, 2012 ). The PRT is usually applied with the target muscle in an easy position (shortened position) by applying 90 sec of manual pressure in order to treat trigger point ( Saavedra et al., 2014). PRT is believed to achieve its benefits by means of an automatic resetting of muscle spindles, which would help to dictate the length and tone into the affected tissues and increase the length of Sarcomeres in contraction knot area, PPT and local pain intensity improvement after application of PRT can also be due to the manual contact component of the treatment and the stimulation of A∆ fibres; a process that can lead to blockage of the pain (Meseguer et al., 2006; Chaitow 2009; Saavedra et al., 2014 ). The PRT reduces local pain intensity and increases PPT. In this method, following the release of pressure on TrP, tissue blood and lymphatic circulation of that area increases 9
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which eliminates hypoxic conditions and results in cellular metabolism leading to the removal of inflammatory chemical substances such as prostaglandins, histamine, and bradykinin; therefore, reduction of sensitization of nociceptors occurs. Also, one of the advantages of PRT is breaking the cycle of pain-spasm-pain (Alagesan and S. Shah, 2012, Pattanshetty and Raikar, 2015). An advantage of our study was its novelty. So far, no study is reported on comparison of PRT and Sham control groups, and no study was observed to apply these two methods together for the treatment of latent trigger points of upper trapezius muscle in the computer users, as an example of office workers, either. Positional release therapy was found to be effective in reducing pain and increasing Pressure pain threshold.
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Limitations of the study Among the limitations of the study was the fact that the sample size was small and the assessor was not blind to the treatment type. Future studies can be carried out with broader dimension, long follow up, double blind procedure, and the use of other outcome measures such as range of motion and sonography for determining thickness of the upper trapezius muscle trigger points.
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Conclusion According to the present study, both groups (group1: PRT, group 2: Sham control group) were given suitable treatments for latent TrPs of upper trapezius muscle, but the PRT group showed significantly more improvement in increasing PPT and decreasing VAS in three treatment sessions in 19-45 year-old female computer users with at least 2 hours of work and with latent upper trapezius trigger points.
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Acknowledgement The present project was sponsored by Shahid Beheshti University of Medical Sciences, Physiotherapy Research Centre (Grant # IR.Sbmu.ram.Rec.1394.310), Tehran, Iran.
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