“A COMPARATIVE STUDY OF EFFECT OF PNF TECHNIQUE AND OF STATIC STRETCHING IN NECK PAIN”

By

Tanya Fatima Beryl Souza

Dissertation research proposal submitted to the

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

In partial fulfillment of the requirements for the Degree of

MASTER OF PHYSIOTHERAPY (M.P.T)

IN

MUSCULOSKELETAL DISORDERS & SPORTS

PHYSIOTHERAPY

Under the guidance of

Mr. Mrutyunjay Kumar

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE

ANNEXURE –II

PERFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. / Name of the Candidate
and Address / Tanya Fatima Beryl Souza
HOSMAT Girls Hostel, 33, 80 ft road, opposite laggere ring road bridge, Bangalore 560058
2. / Name of the Institution / HOSMAT COLLEGE OF PHYSIOTHERAPY
3. / Course of study and subject / Master of Physiotherapy (MPT)
Physiotherapy in Musculoskeletal Disorders and Sports Physiotherapy
4. / Date of admission to Course / 01-06-2013
5. / Title of the Topic
A COMPARATIVE STUDY OF EFFECT OF PNF TECHNIQUE AND OF STATIC STRETCHING IN NECK PAIN
6. / BRIEF RESUME OF THE INTENDED WORK
6.1NEED FOR THE STUDY
Pain is an "unpleasant sensory and emotional experience associated with actual or potential tissue damage."1 In chronic pain, the sensorial process becomes abnormal, leading to detectable changes in central nervous system data processing, motor control, and the experience of pain itself.2 Pain may lead a person to stop working or exercising.3
Chronic neck pain is a sensation of hyperalgia to skin palpation, ligaments, and muscles during both active and passive movement.4 Mechanical neck pain has been described as having no detectable or specific etiology (such as inflammation or infection), and it may be reproduced by provocative stimuli. It is usually located at the lower neck region between the occipital region and the first thoracic vertebra.5
Neck pain is a common complaint in the general population with the lifetime prevalence of approximately 50%.6,7 Most patients who present with chronic neck pain symptoms fit into the category of nonspecific neck pain, having postural or mechanical basis.8 Aetiological factors include poor posture, neck strain or occupational or sporting activities, anxiety, depression, but are often multifactorial and poorly understood,8 and its exact pathology remains obscure.9,10
Hanten et al.11 and Lee et al.12 observed that neck pain causes range of motion (ROM) reduction, which may be linked to mechanical restriction between two or more vertebrae. According to Barnsley,13 such restriction may be caused by pain, fiber contracture, bone ankylosis, or muscle spasm. A patient with neck pain may also present a posture imbalance resulting from shortening and increased activation of suboccipital, sternocleidomastoid, upper trapezius, pectoralis, and rotator cuff muscles.14
Pragmatic reviews have in the past extolled the virtues of a variety of treatments for neck pain.15,16,17These include education, rest, collars, posture control, exercises, physical modalities, traction, mobilization, massage, analgesics, tricyclic antidepressants, psychological interventions, trigger point injections, occipital nerve blocks, epidural steroid injections, neurectomy, discectomy, fusion, soft tissue technique, muscle energy technique, thrust technique, myofascial release, manipulation under anaesthesia and craniosacral manipulation. None of the reviews, however, provided any scientific evidence of efficacy of any of these traditional interventions.18
Physical therapies for treating chronic pain include different exercises. Conventional physical therapy uses static muscle stretching, which consists of stretching a muscle up to a tolerable point and sustaining the position for a certain period of time. In Brazil, France, Italy, and Spain, therapists are increasingly resorting to a method called global posture reeducation (GPR),19 which focuses on entire muscle groups instead of targeting individual muscles. Based on the existence of muscle chains - didactically divided into posterior and anterior chains20 - this method proposes global stretching of antigravity muscles. While static stretching of a single muscle or a small group of muscles usually lasts 30 seconds,21
Some studies have reported that muscle fatigue is associated with chronic neck pain8. Increase in pain and discomfort will decrease normal muscle performance via reflex inhibition9. The muscle weakness will be induced due to prolonged impairment in the function of proprioceptive receptors and motor control10.
Proprioceptive neuromuscular facilitation (PNF) exercise is based on movement patterns, which facilitate and correct sensory motor function and helps to decrease pain and increase muscle strength in patients with neck pain11.
At present, the common treatment for neck disorders focus on decreasing pain and disability. Though metaanalysis studies say that, there is insufficient information on how to use some modalities like traction, ultrasound, electrical stimulation and heat therapy12. On the other hand, few studies shows exercise therapy programs having positive effect on decreasing pain and improving strength in patients with neck pain, but not much studies stated individual effectiveness over other exercise therapy programmes13.
6.2 REVIEW OF LITERATURE
Isabelle Paulus et al (2008)28 reported that subjects with neck pain having altered head and neck postures due to impairment in proprioceptive receptors and motor control
Cunha et al compared the effect of conventional static stretching and muscle chain stretching, as proposed by the global posture reeducation method, along with manual therapy in patients with chronic neck pain. Results showed significant pain relief and improvement in ROM and Quality of life. They concluded that conventional stretching and muscle chain stretching in association with manual therapy were equally effective in reducing pain and improving the range of motion and quality of life of female patients with chronic neck pain, both immediately after treatment and at a six-week follow-up, suggesting that stretching exercises should be prescribed to chronic neck pain patients.23
A.Rezasoltani et al (2010)26 concluded that proprioceptive neuromuscular facilitation exercise for neck is a useful method to decrease pain and increase muscle strength in subjects with neck pain.
Mark Chan Ci En et al (2009)35reported that, Neck Disability Index is reliable and valid for measuring disability in patient with neck pain
Fozzatti conducted a prospective non-randomized clinical trial to evaluate the effect of global postural reeducation (GPR) on stress urinary incontinence (SUI) and quality of life in SUI female patients. Results showed a significant improvement in Quality of Life in all domains, with emphasis on General Perception of Health, Incontinence Impact and number of leaking episodes. The Functional Evaluation of the Pelvic Floor and Pad Use also presented significant improvement. They concluded that GPR is an efficient alternative for treatment of stress urinary incontinence.28
Gross et al in a systematic review to assess the effects of physical medicine modalities for pain in adults with mechanical neck disorders concluded that there is little information available from trials to support the use of physical medicine modalities for mechanical neck pain except electromagnetic therapy.29
Balogun et al evaluated the inter-and intra tester reliabilityof measuring six neck motions with tape measure (lM) and the Myrin gravity-reference goniometer (MG). Based on the results as well as its simplicity and low cost, the authors recommend the tape measuring method for wider clinical use. It could be used to assess gross limitation of motion of an individual suspected of having cervical dysfunction and for objectively monitoring the success of a therapeutic program.30
Hsieh and Yeung conducted a study to determine if the tape measuring method is a reliable method of measuring six active neck motions. This study indicated that the tape measuring method is a reliable means for clinicians to assess neck range of motion.31
Scrimshaw and Maher compared the responsiveness of the McGill Pain Questionnaire with the Visual Analogue Scale (VAS). The study found that the VAS was more responsive than the McGill Pain Questionnaire and VAS may be a better tool than the McGill Pain Questionnaire for measuring pain in clinical trials and clinical practice.32
Kelly conducted a study to determine the minimum clinically significant difference in visual analog scale (VAS) pain scores. Results revealed that the minimum clinically significant difference in VAS pain scores is 9 mm and there is no statistically significant difference in VAS pain scores based on gender, age, or cause of pain.33
6.3 OBJECTIVES OF THE STUDY
The main objective of the study is to find out the effects of Proprioceptive neuromuscular facilitation and static stretching on pain and range of motion in patients presenting with chronic mechanical neck pain. Specifically to determine the effects of
  1. Proprioceptive neuromuscular facilitation on pain and cervical range of motion in patients presenting with chronic mechanical neck pain
  2. Static stretching on pain and cervical range of motion in patients presenting with chronic mechanical neck pain
  3. Comparing the PNF and static stretching on pain and cervical range of motion in patients presenting with chronic mechanical neck pain
Hypothesis:
There will be a significant difference between the effects of PNF and static stretching on pain and range of motion in patients presenting with nonspecific chronic neck pain.
Null Hypothesis:
There will be no significant difference between the effects of PNF and static stretching on pain and range of motion in patients presenting with nonspecific chronic neck pain.
7. / MATERIALS AND METHODS
7.1 Source of data
Data will be collected from patients, who are referred to the outpatients Physiotherapy department of HOSMAT hospital, with diagnosis of nonspecific neck pain after obtaining informed consent
7.2 Method of collection of data
Research Design:
Experimental design will be used in this study.
Sampling method
Random sampling method
METHODOLOGY
Patients who are diagnosed to have nonspecific neck pain and fulfilling the following inclusion and exclusion criteria will be selected for the study after obtaining informed written consent.
Inclusion Criteria:
1. Clinically diagnosed primary mechanical, either myogenous or arthrogenous, neck pain and pain lasting for over 12 weeks
2. Symptoms primarily confined in the area between the superior nuchal line and the tip of the first thoracic spinous process and provoked by neck movements or by sustained neck postures
3. Age group 40-60
4. Both males and females
Exclusion Criteria:
1. History of a significant trauma to the cervical spine
2. History of fracture and dislocation of the cervical spine
3. Disease of the spinal cord or cauda eaqina
4. Inflammatory or infective arthropathies of the vertebral column
5. Vertigo
6. Neurological signs and symptoms
7. History of spinal surgery
8. Presence of malignancy
Study Design
The selected subjects will be randomly assigned into one of two groups. Each group will consist of 15 patients of both genders within the age group of 40-60 years.
Group I: This will consist of 15 patients and they will undergo PNF
Group II: This will consist of 15 patients and they will undergo static stretching.
Interventions
Patients will attend three weekly physical therapy sessions during a six-week period..
Group–I:
Subjects will be asked to lie on their back (supine) in a position that their heads and necks were out of bed. They will be asked to perform flexion, adduction and external rotation movement of the right shoulder and upper limb simultaneously with the extension and rotation of the head and back towards the opposite side. The exercise will perform in same pattern for the opposite side.
They will be also asked to perform extension, abduction and internal rotation movements of the right shoulder and upper limb with the head and neck flexion and rotation towards the same side. The subjects have to follow all patterns by their eyes. The each pattern of exercise will be repeated 10 times per set and repeated for 3 sets under supervision. Subjects will be given2-3 minutes of rest period between each set. The exercise protocol will be performed for 10 therapeutic sittings.
An additional home exercise programme will be prescribed to the subjects, which includes the above mentioned exercise with same dosage and it will be performed by the subjects at their homes. Hot water fermentation is also advised to the subjects.
GROUP-II
Subjectwill perform stretching of upper trapezius, suboccipitalis and back of the neck, pectoralis major and minor, rhomboids, finger and wrist flexors, forearm pronators, finger and wrist extensors, forearm supinators, and paravertebral muscles.34 Each exercise will be auto-passively repeated twice for 30 seconds and done slowly at normal breathing rhythm and with no compensations allowed. The total stretching time will be equivalent to that of the PNF group.
Evaluation: Before the beginning and after the 6 week intervention period, all patients will be evaluated in the following outcome measures.
1. Pain measured in a 10 cm Visual Analog scale. VAS is a 10 cm line with pain descriptors marked “no pain” at 1 end and “the worst pain imaginable” at the other. The patients will be asked to report their perceived pain level, both at rest and on most painful movement, by marking the VAS with a perpendicular line.
2. Cervical range of motion using a tape measure. Flexion and extension will be measured as the distance between the tip of the chin and sternal notch with subjects’ mouth closed. Side flexion will be measured as the distance between the mastoid process and the acromian process. Lateral rotation will be measure as the distance between the chin and acromian process.
STATISTICAL TESTS:
The following statistical tests will be used to analyze the collected data:
The pain score data collected using VAS will be analyzed using non-parametric tests as the data are ordinal in nature. The intra group pre and post-test data will be analyzed using Wilcoxon sign rank test, while the post-test inter group data will be analyzed with Mannwhitney U test.
The Cervical ROM data collected using tape measure will be analyzed using parametric tests as the data are interval in nature. The intra group pre and post-test data will be analyzed using Unpaired t-test, while the post-test inter group data will be analyzed with Paired t-test.
7.3 Nature of Investigations and Interventions:
The study requires non-invasive investigations and interventions to be conducted on patients. They include physical examination like inspection, palpation, and measurement of range of motion, etc. Treatment interventions include Proprioceptive neuromuscular facilitation and static stretching.
7.4 Ethical clearance:
Ethical clearance has been obtained from the ethical committee of our institutions to carry out the investigations and interventions on patients necessary for this study.
8. / REFERENCES
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  2. Farina S, Tinazzi M, Le Pera D, Valeriani M. Pain-related modulation of the human motor cortex. Neurol Res. 2003;25:130-42.
  3. Häkkinen A, Salo P, Tarvainen U, Wiren K, Ylinen J. Effect of manual therapy and stretching on neck muscle strength and mobility in chronic neck pain. J Rehabil Med. 2007;39:575-9.
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  11. Hanten WP, Olson SL, Russel JL, Lucio RM, Campbell AH. Total head excursion and resting head posture: normal and patient comparisons. Arch Phys Med Rehabil. 2000;81:62-6.
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9. / Signature of the candidate :
10. / Remarks of the Guide
11. / Name and Designation of
11.1 Guide : Mr. Mrutyunjay Kumar
11.2Signature :
11.3Co-Guide : Dr. Dipika Verma
11.4Signature : -
11.5Head of the Department :.Dr. Vikranth. G.R
11.6Signature :
12. / 12.1 Remarks of the Chairman : Satisfactory and recommended
and Principal
12.2 Signature :

APPENDIX- I