Background: Neck pain is a common disorder with a reported six-month prevalence rate of 54%. Strain/counter-strain technique and stretching are passive positional intervention aimed at relieving musculoskeletal pain and related dysfunction. The study aimed to find the effect of strain counter strain technique and to stretch on tenderness over upper trapezium of neck and neck function.


Methods: This is an experimental study with comparative pre-post study design. The subjects for the study selected from KPJ University College, Nilai, Malaysia. The study conducted in the Physiotherapy department of the University College. Total 70 with 53 female and 17 male patients were selected for this study as per sample size calculation. Thirty- five (35) samples were allocated to each group. Purposive sampling method adapted to select the samples. The study samples selected based on inclusion and exclusion criteria included exhibits with a tender point over upper trapezius. Dependant ‘t’ test was used to find the outcome of the study.


Results: Paired t-test on the visual analogue scale (VAS) and Neck Disability Index (NDI) among stretching group found significant (P< .0001) improvement in the outcome with a mean difference of 3.23 and 12.2 respectively. A paired t-test on VAS and NDI among strain counter strain group found significant (P<.0001) improvement in the outcome with a mean difference of 3.829 and 22.686 respectively.


Conclusion: This study concluded that both stretching and strain counter strain technique could reduce pain in the upper trapezius of the neck and improve neck function among the patients

Jibi  Paul

Pradeep  Balakrishnan

International Journal of Physiotherapy

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 Int J Physiother 2018; 5(4)              Page | 141ORIGINAL ARTICLEIJPHYABSTRACTBackground: Neck pain is a common disorder with a reported six-month prevalence rate of 54%. Strain/counter-strain technique and stretching are passive positional intervention aimed at relieving musculoskeletal pain and related dys-function. The study aimed to find the effect of strain counter strain technique and to stretch on tenderness over upper trapezium of neck and neck function. Methods:  This is an experimental study with comparative pre-post study design. The subjects for the study selected from KPJ University College, Nilai, Malaysia. The study conducted in the Physiotherapy department of the University College. Total 70 with 53 female and 17 male patients were selected for this study as per sample size calculation. Thir-ty-five (35) samples were allocated to each group. Purposive sampling method adapted to select the samples. The study samples selected based on inclusion and exclusion criteria included exhibits with a tender point over upper trapezius. Dependant‘t’ test was used to find the outcome of the study. Results: Paired t-test on the visual analogue scale (VAS) and Neck Disability Index (NDI) among stretching group found significant (P< .0001) improvement in the outcome with a mean difference of 3.23 and 12.2 respectively. A paired t-test on VAS and NDI among strain counter strain group found significant (P<.0001) improvement in the outcome with a mean difference of 3.829 and 22.686 respectively. Conclusion: This study concluded that both stretching and strain counter strain technique could reduce pain in the upper trapezius of the neck and improve neck function among the patients. Keywords: Stretching, strain counter strain, neck pain, visual analogue scale, Neck Disability Index.Received 02nd March 2018, accepted 18th June 2018, published 09th August 2018www.ijphy.org10.15621/ijphy/2018/v5i4/175695CORRESPONDING AUTHORInt J Physiother. Vol 5(4), 141-144, August (2018)                                                                          ISSN: 2348 - 8336EFFECT OF STRAIN COUNTER STRAIN TECHNIQUE AND STRETCHING IN TREATMENT OF PATIENTS WITH UPPER TRAPEZIUS TENDERNESS IN NECK PAIN*1Jibi Paul²Pradeep Balakrishnan*1Dr. Jibi Paul, MPT, PhD,Professor in Faculty of Physiotherapy, Dr. M.G.R. Educational and Research Institute,Chennai, India.E-Mail: jibipaul74@gmail.com²Lecturer in Physiotherapy, School of Health Sciences, KPJ Healthcare University College, Nilai, Malaysia.This article is licensed under a Creative Commons Attribution-Non Commercial 4.0 International License. Copyright © 2018 Author(s) retain the copyright of this article. Int J Physiother 2018; 5(4)              Page | 142INTRODUCTIONNeck pain is very common among officers specifically on computer workers with a prevalence rate of more than 50% [1-3]. Strain/counter-strain technique is applied passively on muscles to reduce pain and increase joint functions in different regions of the body tender points [4].Strain/counter strain is found effective to decrease hyper-sensitivity of muscular tissues on palpation thereby sub-jects can perform muscle strengthening programs to im-prove functions5. Many subjects with fibromyalgia have reported the effects of stretching and strain counter strain technique on pain and function of different joints [6]. Pathomechanism of neck pain in most of the cases are not identified in individuals, therefore, it is referred to as non-specific [7].  There are many factors contributing to non-specific neck pain, trigger point (TrP) is one of which has a scientific emphasis on that, stretching improve the flexibility of muscles thereby can increase the range of movement for the joints and can reduce neck pain [8-10].Effect of myofascial release on pain was reported by Si-mons et al. in 1999. Break down the strategy of the pain-spasm-pain cycle can affect the treatment of muscle pain. McHugh et al. 1992, has reported the effect of passive sus-tained stretching to promote muscle relaxation and reduc-tion of pain in tight muscles. The manual technique Strain counter-strain is useful in the reduction of pain and pro-moting muscle relaxation has been stated by Kisner C,1990. The concepts behind the treatment of sustained stretching and strain couter strain techniques are different, but both can promote muscle relaxation and reduce muscle pain by the break down the pain-spasm-pain cycle. The phys-iological effect of these techniques include an autogenic inhibition of tendon reflex and induce muscle relaxation. This improves the viscoelasticity of shortened muscles and surrounding tissues. The comparative effect of sustained stretching and strain counter strain technique is still con-troversial. The objective of this study is to find out the effect of strain counter strain over sustained stretching technique on neck pain and function. METHODOLOGYThis is an experimental study with subjects selected from all students and staff of KPJ University College, Nilai, Ma-laysia.  Study setting as did in the Physiotherapy depart-ment of the University College. Purposive sampling meth-od adapted to select the samples. Subjects selected based on inclusion and exclusion criteria.Inclusion criteria: Both genders with age Group between 18 to 50yrs, subjects who exhibit a tender point over upper trapezius, Unilateral and Bilateral tender points were in-cluded for the study.Exclusion criteria: Subjects with the traumatic and neuro-logical condition, Subjects with an open wound, subjects which don’t sign the informed consent were excluded from the study.Sample size and allocation: Total 70 patients were select-ed for this study as per sample size calculation. Thirty-five (35) samples were allocated to each group.Study Materials/Measurement Tools:Personal assessment form, Couch, Informed consent, VAS (Visual Analogue Scale): This is a valid and reliable tool to evaluate pain intensity among subjects suffering from musculoskeletal ailments [11]. Neck disability index scoring interpretation: Raw Score Relative Impairment; 0-4 none, 5-14 mild, 15-24 moderate, 25-34 severe, > 35 complete.Intervention:Both techniques were performed on alternate days for two weeks. Stretching done actively 3 times. Each time hold for 30 seconds followed by 10 seconds rest. Neck Disability In-dex, a reliable and valid tool used to collect the data from the samples [12,13].Stretching Procedure:Stretching as performed in sitting position with feet com-fortably placed on the ground. The neck is bend to forward and sideways slowly in a pain-free range of movement and rotate to opposite side, apply an inferior pressure on same side shoulder.  Hold this stretching for 30 seconds and re-lease gradually to return position then repeat it for three times. Data collection: All subjects were physically examined by the physiotherapist to screen for the presence of palpable tender points over upper trapezius. The pre-intervention process took approximately 5 minutes. Following the physical examination, the subjects were moved to a separate assessment cubicle where initial VAS score and neck disability index data was collected. The ob-tained data was documented as a pre and post-test score.Strain counter strain Procedure:Strain counter-strain technique can perform in the upright sitting position. Locate tender points in upper trapezius muscle and apply pressure till get the sensation of pain af-ter that perform neck ipsilateral side flexion with contra-lateral rotation, the shoulder in the same side need to be maintained abducted position.Statistical Analysis: From the dependent variables, sum-mary measures were evaluated and analyzed the differenc-es. Descriptive data analysis of demographic data. Depen-dent ‘t’ test used to find the effect of stretching and strain counter strain on the reduction of neck pain and neck function among the patients. The study was considered as significant with P <0.05.RESULTSDescriptive data analysis: Total 70 patients participated in the study with 53 females and 17 males and range of age 18 to 43 years (Table 1).Table 1: Descriptive data analysis of Group A and GroupGroup Sex Frequency Age groupStrain Counter Strain Technique-  Group AF 3219-40M 3Stretching TechniqueGroup BF 21 18-43M 14Total  70   Int J Physiother 2018; 5(4)              Page | 143Table 2: Paired t test within the Group APaired Samples TestGroup APaired Differencest dfSig.        (2- tailed)MeanStd. Devia-tionStd. Error Mean95% Confidence Interval of the DifferenceLower UpperPRE  VAS STRETCH -            POST  VAS STRETCH 3.229 1.573 .266 2.69 3.769 12.14 34 .000PRE NDI STRETCH - POST NDI STRETCH 12.200 7.654 1.294 9.57 14.83 9.43 34 .000Table 3: Paired t test within the Group BGroup BPaired Samples Testt df Sig.       (2- tailed)MeanStd. Devia-tionStd. Error Mean95% Confidence Interval of the DifferenceLower UpperPRE VAS  SCS-POST VAS SCS3.829 1.361 .230 3.36 4.296 16.64 34 .000 PRE NDI SCS   -POST NDI SCS 22.686 6.825 1.154 20.34 25.03 19.67 34 .000Table 2 and 3 show the outcome of stretching and strain counter strain technique on neck pain and function in Group A and Group B respectively.DISCUSSION Total seventy (70), patients of both genders with nonspe-cific neck pain participated in the study. Fifty-three (53) patients were female and seventeen (17) males with age group of eighteen (18) to forty-three (43). Paired t-test (Dependent) on the visual analogue scale (VAS) and Neck Disability Index (NDI) among stretching group found significant (P< .0001) improvement in the outcome with a mean difference of 3.23 and 12.2 respec-tively. A paired t-test on VAS and NDI among strain count-er strain group found significant (P<.0001) improvement in the outcome with a mean difference of 3.829 and 22.686 respectively.Mean difference in neck pain and function are 3.82 and 22.69 among patients undergone strain counter strain treatment, which is more effective than stretching exercise 3.23 and 12.2 respectively on neck pain and function.Sirikarn Sompra Song et al. (2011) has reported the ef-fect was not a significant difference on VAS in STR group, whereas, the SCS group indicated a significant difference of VAS with (P= 0.04). The study also reported that there was a tendency of decrease of symptoms immediately after the treatment of SCS with (P= 0.06) which remained until the next day.Studies have reported strain counter strain has a good effect on tender points of upper trapezius muscles. This technique is very effective for immediate reduction of pain in muscular tender points. Modified application of strain counter strain technique has proved a significant effect on pain (P < 0.001), Albert Atienza (2006) [14]. Strain counter-strain technique can reduce pain thereby increase the function of the neck. Reduced pain in muscu-lature can increase the range of movement of the neck. A reduction of pain and an increase in neck function of 50%-100% occurred in 19 of 20 patients immediately after SCS therapy. The partial improvement was maintained for six months in 11 of 20 patients, and four were still pain-free. This technique has been recommended for physical ther-apy for treatment of pain in tender points of musculature, Dardzinski J A (2000) [15].This study has reported that there is an improvement in neck function, reduction of pain and tenderness over up-per trapezius after the intervention with stretching and strain counter strain.The outcome measure was analyzed between the group and found strain counter strain has more effect over stretching treatment technique.Ethical Clearance of the Study: This study has got ethical clearance from the research and development committee of KPJ Healthcare University College, Nilai, Malaysia.Conflict of interest: No conflict of interest on the outcome of this study.CONCLUSIONThis study concluded that both stretching and strain count-er strain technique could reduce pain in the upper trape-zius of the neck and improve neck function. The neck is stretching, and strain counter strain technique can induce relaxation of upper neck muscles thereby increased neck muscle flexibility and function among the patients.Acknowledgment: The investigators would like to express their gratitude to the management and research and devel-opment of KPJ Healthcare University College for their sup-port and motivation to conduct this study. The researchers are thankful to all the participants to conduct this study successfully.REFERENCE [1] Douglass AB, Bope ET.  Evaluation and treatment of posterior neck pain in family practice.  J Am Board Fam Pract. 2004; 17: S13–22 [PubMed].[2] Bovim G, Schrader H, Sand T. Neck pain in general population. Spine (Phila PA 1976). 1994; 19: 1307e9.[3] Fejer R, Kyvik KO, Hartvigsen J. The prevalence of neck pain in the world population: a systematic critical review of the literature. Eur Spine J. 2006; 15: 834 e48.[4] Chaitow L. Positional release techniques. Singapore: Longman Aingapur Publishers; 1996.[5] Jones LN. Strain and counter strain. Newark, Ohio: American Academy of Osteopathy; 1981.[6] Wong CK, Schauer-Alvarez C. Effect of strain/counter strain on pain and strength in hip musculature. J Man Manip Ther. 2004; 12:215—23.[7] Borghouts JA, Koes BW, Bouter LM. The clinical course and prognostic factors of non-specific neck pain: a sys-tematic review. Pain. 1998; 77: 1–13 [PubMed]. [8] Jibi Paul, Pradeep Balakrishnan. Comparative effect of static and dynamic stretching exercise to improve flexibility of hamstring muscles among male adults. IJ- Int J Physiother 2018; 5(4)              Page | 144MAES.2015; 1(2):53-58.[9] Srinivas M, Jibi Paul. Effectiveness of stretching and modified footwear on reducing pain and function-al ability in athletes suffering from shin splint. IJ-MAES.2015;1(1):16-21.[10] Jibi Paul, Pradeep Balakrishnan. Comparative effect of static and dynamic stretching exercise to improve flexibility of hamstring muscles among non-athletes. International journal of physiotherapy.2014;1 (4):195-199.[11] Misailidou V, Malliou P, Beneka A, Karagiannidis A, Godolias G. Assessment of patients with neck pain: a review of definitions, selection criteria, and measure-ment tools. J Chiropr Med. 2010; 9: 49e59. [12] Vernon H, Mior S. The neck disability index – a study of reliability and validity.  J Manipulative Physiol Ther. 1991; 14: 409–15 [PubMed].[13] Macdermid JC, Walton DM, Avery S, Blanchard A, Etruw E, Mc Alpine C, Goldsmith CH. Measurement properties of the neck disability index a systematic re-view. Journal of Orthopedic and Sports Physical Ther-apy. 2009 May; 39(5):400-17.[14] Albert Atienza Meseguer, et al. Immediate effects of the strain/counter strain technique in local pain evoked by tender points in the upper trapezius mus-cle. Clinical chiropractic. 2006; 6(3): 112-118. [15] Dardzinski J A, Ostrov B E, Hamann L S. Myofascial Pain Unresponsive to Standard Treatment: Success-ful Use of a Strain and Counterstrain Technique with Physical Therapy. Journal of clinical rheumatology: practical reports on rheumatic & musculoskeletal dis-eases September. 2000; 6(4):169-74.  CitationPaul, J., & Balakrishnan, P. (2018). EFFECT OF STRAIN COUNTER STRAIN TECHNIQUE AND STRETCHING IN TREATMENT OF PATIENTS WITH UPPER TRAPEZIUS TENDERNESS IN NECK PAIN.  International Journal of Physiotherapy, 5(4), 141-144.

EFFECT OF STRAIN COUNTER STRAIN TECHNIQUE AND STRETCHING IN TREATMENT OF PATIENTS WITH UPPER TRAPEZIUS TENDERNESS IN NECK PAIN

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EFFECT OF STRAIN COUNTER STRAIN TECHNIQUE AND STRETCHING IN TREATMENT OF PATIENTS WITH UPPER TRAPEZIUS TENDERNESS IN NECK PAIN

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