The Effects of Deep Tissue Manipulation in Person With Neck Pain D

THE EFFECTS OF DEEP TISSUE MANIPULATION IN PERSON
WITH NECK PAIN

A dissertation submitted
TO
Shri Guru Ram Rai University in the Partial
Fulfilment of the Requirement fordegree of
Master of Physiotherapy
With Specialization
IN
MUSCULOSKELETAL PHYSIOTHERAPY
BY
DEBADUTTA DIBYAJYOTI DEY

Enrollment No.–R190316003
Guide Co. Guide
Dr. ANIRBAN PATRA PT, Dr. NIRAJ KUMAR PT,

ASSOCIATE PROFESSOR, SGRRU HOD/ASSOCIATE
PROFESSOR, SGRRU
Department of Physiotherapy Department of Physiotherapy
SHRI GURU RAM RAI UNIVERSITY
COLLEGE OF PARAMEDICAL SCIENCES
Department of Physiotherapy
Patel Nagar, Dehradun- 248001, Uttarakhand, India
[Estd. by Govt. of Uttarakhand, vide Shri Guru Ram Rai University Act no. 03
0f 2017 & recognized by UGC u/s (2f) of UGC Act 1956]
2019-2021
Pathribag, Dehradun-248001, Uttarakhand, India
(Estd. by Govt. of Uttarakhand, vide Shri Guru Ram Rai University Act no. 03 of 2017)
CERTIFICATE BY THE CANDIDATE
I hereby declare that the dissertation work entitled “To study the effects of
deep tissue manipulation in person with neck” embodies the work done by
me at Shri Guru Ram Rai University, Patel Nagar, Dehradun. The dissertation
work in part of full has not been submitted to any other university.
(Signature of student)
DATE: Debadutta Dibyajyoti Dey

MPT 2nd Year (Musculoskeletal)
1
CERTIFICATE BY THE GUIDE
This is to certify that the dissertation work entitled “To study the effects of deep
tissue manipulation in person with neck.” submitted by “Debadutta Dibyajyoti
Dey” in partial fulfillment of the requirement for the award of degree of Master
of Physiotherapy of the Shri Guru Ram Rai University, Dehradun, Uttarakhand is
a bona fide work carried out by her under my supervision and guidance during
the academic year 2019-2021, Neither this project nor the part of it has been
submitted for any Degree or Diploma.
(Signature of guide)
Date:
Place: Dr. Anirban Patra (PT)

Associate Professor
Shri Guru Ram Rai University
2
ENDORSEMENT BY THE HEAD OF THE

DEPARTMENT
This is certificate that the dissertation entitled “To study the effects of deep
tissue manipulation in person with neck.” is a Bonafide dissertation work
done by “Debadutta Dibyajyoti Dey” under the guidance of Dr. Anirban
Patra (PT) (Musculoskeletal) in the partial fulfillment of requirement for the
degree of Master of Physiotherapy.
DATE: (Seal and Signature of HOD)
Dr. Niraj Kumar (PT)

PLACE: HOD/Associate professor,
Department of Physiotherapy
Shri Guru Ram Rai University
3
CERTIFICATE BY THE EXAMINER
This is to certify that the dissertation work entitled “To study the effects of
deep tissue manipulation in person with neck.” submitted by “Debadutta
Dibyajyoti Dey” in partial fulfillment of the requirement for the award of
degree of Master of Physiotherapy of the Shri Guru Ram Rai University,
Dehradun, Uttarakhand has been thoroughly examined and approved by us.
Accepted /Not Accepted Accepted/Not accepted
(Signature of Internal Examiner) (Signature of External Examiner)
Place: Place:
Date: Date:
4
DECLARATATION BY THE CANDIDATE
I hereby declare that the Shri Guru Ram Rai University Patel Nagar,
Dehradun (Uttarakhand) shall have the right to preserve, use and disseminate
this dissertation/thesis in print of electronic format for academic research
purpose.
DATE: Debadutta Dibyajyoti Dey
PLACE: MPT 2nd Year (Musculoskeletal)
5
ACKNOWLEDGEMENT
I humbly and whole heartedly dedicate this thesis to “The Almighty” who
blessed me with the opportunity that I was able to do work upon it.
First of all, I feel immense pleasure to record my regards and to maintain

my heartfelt gratitude to my parents who helped me throughout whenever I need
the strength and support.
I would like to thanks Honourable Chairman “Shri Devendra Das

Maharaj Ji” and Principal Dr. Malvika Singh for providing all the facilities to
carry out the work, constant encouragement, kind suggestion and allowed me to
avail the opportunity to work for this prestigious degree. I owe my deep sense of
gratitude of HOD of physiotherapy department Dr. Niraj Kumar (PT) (MPT-
Musculoskeletal) who provided me good infrastructure for our thesis work.
It gives immense pleasure and satisfaction to place my sincere thanks and

appreciation with the respect and regards for an adorable personDr. Anirban
Patra PT, MPT (Musculoskeletal), Department of Physiotherapy,
SGRRIM&HS, Patel Nagar Dehradun (U.K), it was his blessing, guidance,
valuable suggestion and encouragement which helped me to greatly ease the task
of completing this project a reality.
I humbly thanks to all the teaching membersDr. Tarang Srivastava PT,

MPT (Musculoskeletal), Dr. P. Nandita (PT) MPT (Sports Rehab.), Dr.Nishu
Sharma (PT) MPT (Neuro), Dr. VichitraBaliwan (PT) MPT (Cardio), Dr.
Karishma Chauhan (PT) MPT (Neuro) & other staff of the Department for the
support and assistant during the work.
With great regard I knowledge my sincere thanks to my siblings, friends,

senior,colleague and juniors for their help throughout the course of the study.
Debadutta Dibyajyoti Dey
MPT 2nd year (Musculoskeletal)
6
DEDICATION
Every challenging work needs self-efforts as well as guidance of elders especially

those who are very much closer to our heart.
To almighty God
humble effort I dedicate to my sweet and loving
Father and Mother
Whose affection, love, my encouragement and prays of day and night make me able
to
get such Success and honour
Hard Working and Respected
Teachers
Who guided me to the right path and light me with the beauty of
Knowledge
Along with Generous and humble
Family, Friends and Colleagues.
7
TABLE OF CONTENT
Sl.no Chapter Page no.
1 Introduction 2-5
2 Literature review 6-14
3. Aim and hypothesis 15-16
4. Methodology 17-20
5. Data collection 21-22
6. Data analysis 23-24
7. Result 25-27
8. Discussion 28-38
9. Conclusion 39-40
10. Limitation, future suggestion 41-42
11. Reference 43-50
12. Appendices 51-75
Apendix-1(Consent form) 52
Apendix-2(Assessment preform) 53-54
Appendix-3(Measurement procedures) 55-59
Appendix-4(Data entry sheet) 60
Appendix-5(Control group treatment) 61
Appendix-6(Experimental group treatment) 62-63
Appendix-7(Statistical result table) 64-67
Appendix-8(Graphs) 68-71
Appendix-9(Photographs and instruments used) 72-75
1
CHAPTER 1
INTRODUCTION
2
The aetiology of injury to the cervical spine and the causes of cervical spine
pathology are numerous. They can be myogenic,mechanical, neurogenic, or
psychosomatic in origin and can be further divided into acute and chronic state. Acute
injuries may be due to trauma, unaccustomed activity, or a poor working or
sleepingposition. Chronic pathology usually is due to poor working or sleeping
position. Chronic pathology usually is due to poor posture, poor muscle tone, or
illness. In ayoung child, it may be the result of an idiopathic torticollis.
The International Association for the study of pain (IASP) in its classification of
chronic pain define cervical spinal pain perceived anywhere in the posterior region of
the cervical spine, from the superior nuchal line to the first thoracic spinous process.
(2). Neck pain is located in the anatomical region of the neck with or without
radiation to the head, truck, and upper limbs. It defines the posterior neck region
down to the superior border of the clavicle and the suprasternal notch.
Chronic neck pain is described as an often-widespread sensation with hyperalgesia in

the skin, ligaments, and muscles, on palpation and in both passive and active
movements in neck. Another type of classification proposed by IASP is based on the
duration of Neck pain. Acute neck pain usually lasts less than 7days,sub-acute neck
pain lasts more than 7days but less than 3 months, and chronic neck pain has duration
of 3months or more.
For a structure to be a potential source of pain, it must be innervated. The posterior

neck muscles and the cervical zygapophysial joints are innervated by the cervical
dorsal ramie. The atlanto-occipital joint is supplied by the C1 ventral ramus, lateral
atlanto-axial joint is innervated by the C2 ventral ramus the median atlanto-axial joint
and its ligaments are supplied by the sinuvertebral nerves of C1-3. These nerves also
supply the Dura mater cervical spinal cord. The innervations of the prevertebral and
lateral muscles of the neck are innervated by branches of the cervical Duramater and
the vertebral artery. It has been shown that noxious stimulation of the cervical
zygapophyseal joints causes neck pain and perceived in the same location as pain
from articular structure innervated by the same segment.
Chronic neck pain is a common disease in general population and employees. Chronic
neck pain can occur one year after the initial episodes and it has been found in 60% to
80% of employees. The incidence of chronic neck pain was higher in women (15%)
the men (9%). women have the highest incidence at the age of 45 and men at the age
of 60.
The causes for chronic neck pain: -
 Poor posture
 High physical workload
 Intermediate and high work-related emotional exhaustion
 Experiencing and having earlier experienced bullying at work
 Common mental disorders
3
 Rare to occasional and frequent sleep problem
 Overweight and obesity
Posture is not a position, but a dynamic pattern of reflexes, habits, and adaptive
responses to anything that resist you being more or less upright and functional. If the
alignment of the head and spine is not optimal, the neck can be predisposed to injury
and / or degenerative effects of wear and tear over time. The most common condition
that contributes to neck pain is forward head posture. Forward head posture is when
the neck slants forward in front of shoulder. Forward head posture is when the neck
slants forward in front of shoulder. Forward head posture causes the muscles of upper
back to continually over work to counter balance the pull of gravity on forward head.
Prolong undue stress over back muscles leads to tightness in particular muscles such
as: -
 Scalene muscles (three pairs of muscles that help rotate the neck).
 Sub occipital muscles (four pairs of muscles used to rotate the head).
 Pectoralis minor muscles (a pairs of thin triangular muscles at the upper part
of the chest) Subscapularis muscles (a pair of large triangular muscles in
anterior part of scapula).
 Levator scapulae muscles (a pair of muscles located at the back and side of the
neck).
Thoracic spine is relatively hypo mobile than cervical and lumbar spine due to
attachment of ribs and downward spinous process. The above muscle tightness further
impairs the mobility.Hyper mobility occurs in cervical spine, which will give more
undue stress over the above muscles. In long termprolonged shearing of the vertebrae
from forward head posture eventually irritates the small facet joints in the neck as
well as the ligaments and soft issues. Soft tissue injuries often occur when muscles are
abnormally tense. Muscles work by tensing, contracting, and then relaxing. They get
shorter when they contract, which moves the part of the skeletal system they are
attached to. If they don’t relax completely, it can lead to problem, including pain,
muscles weakness, a restricted range of motionand misalignment of your skeletal
system. This irritation can result in neck pain that radiates down to the shoulder
blades and upper back, this can also cause trigger points in the muscles, which is
characterised by point of exquisite tenderness that are painful to touch, along with
limited range of motion.
Research on soft-tissue mobilization therapy is limited. 198 who had been diagnosed
with tennis elbow for at least six weeks were divided into three treatment groups. The
people in the first group received mobilization with movement therapy, the people in
the second group received corticosteroid injections, and the people in the third
groupreceived no treatment. The group that received mobilization with movement
treatment saw the most improvement overall. Hayes explains that “the benefits of soft
tissue release instead may lie in psychological and neurological mechanism, “the
4
sensation of touch that occurs in the key actually’’. “The sensation or pressure
provides a neural input to the brain which subsequently may result in a decrease in
neural activity to the muscle”.
Soft tissue techniques are used to improve circulation, reduce nerve entrapments, and
release adhesion within myofascial Structures. Soft tissue manipulations can stretch
connective tissue, fascia and muscles to enhance mobility resulting in a decrease in
pain. Soft-tissue technique includes trigger point therapy to allow muscles to return to
optimal length, myofascial release designed to restore mobility and length within
connective tissue.
Thoracic spines have higher correlation with neck pain. Thoracic spine treatments
grade 1-4 mobilization to the thoracic spine as selected by the physical therapist for
cervical spine pain. The immediate effects of thoracic spine mobilization have been
shown to facilitate greater range of motion increases in the cervical spine and greater
pain decreases within a treatment session and follow-up visits. Thoracic spine thrust
mobilization is used for pain relief and to mobilize restricted areas within the
musculoskeletal system. These techniques are used to improve circulation, restore
muscle length, improve mobility of the joints, balance the neurological system, and
reduce strain on the muscles, tendons, ligaments, joint surface.
In Deep Tissue Manipulation the pressure is adequately deep that it can manipulate
the underlying facet joint of Cervicothoracic spine and simultaneously release the soft
tissues of peri scapular muscles, which is thought to give combine effect of soft tissue
release and facet joint mobilization in neck region. Considering these facts and
incidents of chronic neck pain, purpose of this study to see effect of Deep Tissue
Manipulation to reduce the symptoms in subjects with chronic neck pain.
5
CHAPTER 2
LITRETURE REVIEW
6
The literature presented here, related to the research topic has been collected from
various sources including book, journals and web sources like pub med, Google,
scholar, research gate, ebscohost etc.
INTRODUCTION
Neck pain is a common musculoskeletal disorder, but little is known about which
individuals develop neck pain. (McLean 2010). Non-specific neck pain has a postural
or mechanical basis and affects about two thirds of people at some stage, especially or
mechanical basis and affects about two thirds of people at some stage, especially in
middle age. Acute neck pain resolves within days or weeks, but may become chronic
in about 10% of people.
EPIDEMIOLOGY
Neck pain is one of the four most commonly reported musculoskeletal disorders. It is
estimated that in the adult ‘world population’ there is a mean lifetime prevalence of
50%, year prevalence of 37%, month prevalence of 25%, and point prevalence of
10%, About one-fifth of adults who were previously pain free report a new episode of
neck pain in a 1-year period.
Neck pain is becoming increasingly common throughout the world. It has a

considerable impact on individuals and their families, communities, health-care
systems, and business. There is substantial heterogeneity between neck pain
epidemiological studies, which makes it difficult to compare or pool data from
different studies. The estimate 1year incidence noted in office and computer workers.
While some studies report that between 33% and 65% of people have recovered from
an episode of neck pain at 1year, most cases run an episodic course over a person’s
lifetimeand, thus, relapses are common. The overall prevalence of neck pain in the
general population ranges between 0.4% and 86.8% (means: 23.1%); point prevalence
ranges from 0.4% to 41.5% (mean: 14.4%); and 1year prevalence ranges from 4.8%
to 79.5 % (mean: 25.8%). Prevalence is generally higher in women, higher in high
income countries compared with lowand middle-income countries and higher in urban
areas compared with rural areas. Many environmental and personal factors influence
the onset and course of neck pain. Most studies indicate a higher incidence of neck
pain among women and an increased risk of developing neck pain until the 35–49-
year age group, after which the risk begins to decline. The global burden of disease is
currently making estimates of the global burden of neck pain in relation to impairment
and activity limitation.
Neck pain is a common symptom is the population. The prevalence increases with
longer prevalence period and generally women have more neck pain than men. At
7
least for 1year prevalence period and generally women have more neck pain than
men. At least for 1year prevalence, Scandinavian countries report higher mean
estimates than in the rest of Europe and Asia.
Neck pain is a frequent complaint in healthcare with a prevalence ranging from 5.9%
to 38.7% in the general population (badly 1992, march 1998) [15], reaching a
prevalence of 19.5% in Spain and a prevalence of 13.8% in the USA. Each year 0.6%
of the general population develops disabling neck pain, leading to persistent pain in
67% of cases. The literature suggests that the main long-term consequences of neck
pain are individual disability and job absenteeism, which are recognized as significant
public health and socioeconomic problems. musculoskeletal injuries and disorders are
the most common medical causes the majority of illness-related work absenteeism of
more than 2weeks in Spain, Norwayand Germany in the United States back pain is the
most common reason for filing workers’ compensation claims and often causes lost
workdays (Guo 1999) [23]. In Spain, workers with chronic pain are more likely to be
absent from work and the duration of this absenteeism involving neck pain in Ontario,
Canada, is 14.4%in women and 10.1% in men (cote 2008) [25].Lost of these studies
described traumatic or neurological chronic neck pain, classified according to its
origin. When the aetiology of chronic neckpain, also referred to as mechanical neck
pain, is diagnosed as cervical pain with or without radiation without a known
pathological basis as the underlying cause of the complaints (Borg outs 1997,
Schellingerhout2008) [26,27]
Bandied et al 2017[28] reviewed the literature and found that:
 30% of patients with neck pain will develop chronic symptoms, with neck
pain of greater than 6months in duration affecting 14% of individual who
experience an episode of neck pain.
 37% of individual who experience neck pain will persistent problems for at
least 12months. Five percent of the adult population with neck painwill be
disabled by the pain, representing a serious health concern.
 Five percent of the adult population with neck pain will be disabled by the
pain, representing a serious health concern.
 The economic burden due to disorders of the neck is high, and includes costs
of treatment, lost wages, and compensation expenditure.
 Individuals with chronic neck pain are largely middle aged and the majority
are female. Clinicians should consider age greater than 40, coexisting low
back pain, a long history of neck pain, cycling as a regular activity, loss of
strength in the hand, worrisome attitude, poor quality of life, and less vitality
as predisposing factors for the development of chronic neck pain.
8
AETIOLOGY
Neck pain may result from overuse of muscles in the neck and shoulder (many
shoulder muscles also attach to the neck), strain on the joints in the neck, or a pinched
nerve in neck or shoulder area. One of the biggest contributors to neck pain is poor
posture during an activity. “Instead of pulling the chin down for a neutral posture,
some people keep the chin forward and shoulders slouched. That makes the chin stick
out and creates tension in the neck and surrounding muscles.
According to GarvinMorrison 2011 the most common condition that contributes to

neck pain is forward head and shoulder posture. Forward head posture is when the
neck slants forward head and shoulders. This head position leads to several problems.
The forward pull of weight of the head puts undue stress on the vertebrae of the lower
neck, contributing to degenerative disc disease and other degenerative neck problems.
Similarly, this posture causes the muscles of the upper back to continually overwork
to counterbalance the pull of the gravity on the forward head. This position is often
accompanied by forward shoulders and a rounded upper back, which not only feeds
into the neck problems. The lower cervical vertebrae (C5 and C6) may slightly slide
or shear forward relatives to one another as a result of presidents with jobs that
require them to look down or forward all day, such as pharmacists who spend many
hours counting pills or data entry workers who look at a computer screen.
Prolonged shearing of the vertebrae from forward head posture eventually irritates the
small facet joints in the neck as well as the ligament and soft tissues. This irritation
can result in neck pain that radiates down to the shoulder blades and upper back,
potentially causing a variety of conditions, including:
 Trigger points in the muscles, which are points of exquisite tenderness that are
painful to touch, along with limited range of motion.
 Disc degeneration problems, which may potentially lead to cervical
degenerative disc disease, cervical osteoarthritis, or a cervical herniated disc.
Cervical disc herniation results from the displacement of the nucleus pulpous of the
inter-vertebral disc at the cervical level, which may result in direct compression of the
spinal cord or impingement of nerve roots. Herniation of the nucleus pulpous (HNP)
at the cervical level often results in radiculopathy, marked by compression and
inflammation if the cervical nerve roots near the neural foramen. Cervical HNP can be
generally classified into four types: disc bulge, protrusion, extrusion, and
sequestration. Herniation in general is considered to be the result of poster lateral
annular stress compounded by natural degenerationof the disc.
The symptoms of poster lateral cervical herniation present as ipsilateral pain in the
neck, or pain radiating down the ipsilateral arm to the finger. The pain can be dull or
sharp in quality. Number or tingling may also replace pain as the primary
presentation. Neck flexion and arm abduction over the top of the head may yield the
9
same effect. Furthermore, decreased sensation to pain, touch, or vibration may be
present in the ipsilateral arm. Although not absolute, the ipsilateral nature of the
above symptoms is a hallmark of cervical herniation disrupting the nerve roots on the
same side.
Trigger points are commonly thought to be a sensitive area within muscle or

connective tissue (fascia) that becomes painful when touched or overworked, and
sometimes they can refer pain to other parts of the body. Trigger point is thought to
result from nodules or tight “knots” that develop in a taut muscle fibre. There could be
numerous possible causes for a trigger point, such as an acute injury, repetitive
overuse, or irritation of facet joints in the spine, strain, injury to muscle fibres,
repetitive overuse or irritation of facet joints in the results in lack of muscle activity
for a period of the time, computer working intensely.
RISK FACTORS
The studyprovides strong evidence that older age, female gender, high job demands,
low social/work support, being an ex-smoker, a history of neck disorders predicts the
future onset of neck pain.
Having the computer monitor located not in front (i.e., on the left or right side) of the
operator and cold office temperature are modifiable occupation risk factors for non-
specific NP and LBP in computer-using office workers. Additionally, a history of
neck injury, longer office work year, female sex and married status were also
identified as important occupational or individual factors associated with Neck pain.
PATHOPHYSIOLOGY
Despite considerable research efforts, chronic neck pain remains a poorly understood
condition causing substantial disability, work absenteeism and health care costs. It is
generally recognized that chronic neck pain is a dynamic, fluctuating condition with
multifactorial aetiology and complex pathogenesis.
The pathophysiology for the majority of neck pain condition is not clarified. There is
evidence for disturbed oxidative metabolism and elevated levels of pain-generating
substances in neck muscles, suggesting that impaired local muscle circulation or
metabolism can of the pathophysiology.
IASP 2008 Neck pain may be spontaneous or traumatic in origin. Soft tissues and
cervical spine disease are the most common causes of neck pain. Soft tissue structures
include fascia, ligaments, tendons, and muscles. Disorders of the synovial joints and
intervertebral disc of the cervical spine may contribute to neck pain as well as refer
pain into the posterior head, shoulder, and distally into the arm.
10
Myofascial Trigger Point (MTrPs) are main characteristic feature presented in
myofascial pain syndrome. MTrPs are classified into active and latent trigger points:
An active trigger point is one with spontaneous pain or pain in response to movement.
The pain is continual, with reduced muscular elasticity, muscle weakness and referred
pain is continual, with reduced muscular elasticity, muscle weakness and referred pain
in the degree of irritability of the TrPs.
Latent trigger point is sensitive spot that causes discomfort only in response to
compression. These exhibits the same clinical characteristic are active TrPs, although
they tend to be less severe. Moreover, in the latent forms, the pain is induced rather
than constant, both in zone of origin of the pain and in that of the referred pain. Some
authors have even considered that the presence of latent TrPs may be connected with
the genesis of muscle cramps.
According to Travell and Simons, the formation of an active trigger point may be due
to acute and micro trauma to the muscle. This stress creates a disruption of
sarcoplasmic reticulum and releases of free calcium ions. The calcium ions stimulate
actin and myosin interaction and also metabolic activity increased metabolic activity
causes an increase in the release of histamine, serotonin, kinin, prostaglandins, which
raises the sensitivity and firing of group III and IV muscle nociceptors which
converge with other visceral and somatic input creating perception of local and
referred pain. The TrPs is a site of functional pathology where increased energy
consumption in combined with decreased energy supply this termed as Enemy crises
hypothesis (Bengrsson et al.1986; Hong, 1996; Simons et al..., 1998).
This pain in turn stimulates motor unit inducing muscle spasm and splinting causing
decrease of blood flow to muscle and decrease ATP, and calcium pump action, which
in turns create pan spasm cycle. This repeated pain – spasm cycle leads to sustained
noxious metabolites in the area that build up in connective tissue, creating localized
fibrosis nothing but trigger point. The formation of an active trigger point is due to
multiple dysfunctional motor end plate, creating abnormal environment and
interruption at neuromuscular junction due to excessive release of acetylcholine is
another proposed pathophysiology by (David Simon). Recent in-vivo examinations of
human tissue have revealed increased levels of Vaso neuroactive substance in the
immediate vicinity of trigger point, which can be considered to confirm the trigger
point hypothesis.
Clinical Relationship between Muscle Trigger Point and Joint Hypo

mobility:
A clinical relationship between TrPs and joint impairments has been suggested by
several authors.
Lewit (1991) emphasized the importance of the treatment of TrPs and joint
dysfunction when both were present. In clinical practice, therapists commonly use a
11
treatment approach that includes different techniques directed at both muscle and joint
dysfunction. It is clinically suggested that manual treatment of an inter-vertebral joint
dysfunction may provoke a therapeutic effect in TrPs located in those muscles
innervated by the manipulated segment. Two clinical studies have investigated the
relationship between the presence of muscle TrPs and joint hypo mobility in patients
with neck pain. In the first study, a significant relationship was found between TrPs in
the upper fibres of the trapezius muscle and the presence of joint hypo mobility
(considered when an abnormal end-feel, an increased resistance, and a deceased joint
gliding were found) at the C3-C4 segment. In a second study with participants, all
patients exhibited posterior-anterior (PA) joint hypo mobility at C3-C4 zygapophyseal
joint and TrPs in the upper trapezius, sternocleidomastoid, and Levator scapulae
muscles; although a statically significant correlation did not exist between the
identified muscle TrP and PA joint hypomobility in the midcervical spine. Both
studies confirm clinical finding related to the relationship between muscle TrPs and
joint hypomobility. Several theories have discussed the relationship betweenTrPs and
joint hypomobility.
Perhaps the increased tension of the taut muscular bands and facilitation of motor
activity can maintain displacement stress on the joint, such that a TrP provokes the
joint dysfunction. In the way, it may be may be that muscle shortening and increased
tension caused by muscle TrP aggravate and/or maintain abnormal joint tension in the
vertebra levels crossed by these muscles.
An alternative explanation would be that an abnormal sensory input from the joint
hypomobility reflexively activates TrPs (Gerwin1993) [36]. This hypothesis has been
preliminarily confirmed but Lowe (1993), who found that joint dysfunctions can
increase the responsiveness of motor neutrons of adjacent muscles to nociceptive
input from TrPs. It is also conceivable that muscle TrPs provide a nociceptive barrage
to the dorsal horn neurons and there by facilitate segmental hypomobility. The dorsal
horn neural afferences connection may explain the neurophysiologic mechanism of
manipulative therapy by which spinal manipulative provokes an afferent
bombardment from the articular and myofascial receptors, which produce pre-
synaptic inhibition of segmental pain pathways and possibly activation of endogenous
system (Wall 2006). There is preliminary evidence investigating changes in muscle
sensitivity after the spinal manipulation. Reported that cervical manipulation
produced significant increases in pressure pain threshold levels over tender point
surrounding a cervical dysfunction.
(Kauan et al 1997) found that spinal manipulation at C3-C4 and C4-C5 level s was
effective in reducing pain and tightness from trapezius muscle TrPs in the upper
trapezius muscle. These results suggest that pain may benefit from manual treatment
of joint hypomobility in the management of TrPs.
Myofascial Pain Syndrome is the presentation of sensory, motor and autonomic

symptoms caused by MTrPs (Simons 1999). It is a regional pain problem
12
characterized by MTrPs is palpable taut bands of skeletal muscle that refer pain to a
distance from the area where the point is located, and that can cause distant motor and
autonomic effects. An MTrPs is a hyperirritable nodule within a taut band of a muscle
that is thought to be caused by motor endplate dysfunction. The MTrPs area is painful
on compression and autonomic phenomena (Simons 1999).
MTrPs were categorized by Travell and Simons as either active or latent. While active
MTrPs produce a spontaneous clinical complaint of pain, latent MTrPs are clinically
silent, and they are painful only when properly stimulated by different stimuli, such as
pressure or needling. Both active and latent MTrPs may cause restricted range of
motion and weakness of the muscles harbouring the MTrPs (Simons 1999).
MANAGEMENT OF CHRONIC NECK PAIN

Cervical retraction in chronic neck pain
(Diab 2016) conducted a study, the purpose of this study was to investigate the effect
of McKenzie protocol on cervical ROM, pain and function in patients with
nonspecific neck pain. According to the result of the current study, McKenzie
protocol of treatment had significant improvement in cervical ROM, pain intensity
level and neck functional activity level when compared to the control group which
had only traditional treatment.
Cervicothoracic mobilization in increasing extension range of motion

Central PA mobilization of the thoracic hypo mobile segment, which reproduces the
original back pain and/ or radiating pain, increases thoracic extension. (Lee & Evans
1994, 1997), (Harms &Baders, 1997), (Latimer & Maher,2002), (Fritz et al. 2005),
(Johansson 2006). Restoration if uniform spinal extension movement may be helpful
in LBP.
Ischemic compression to trigger points

Gemmell 2008 conducted a study; the purpose of this study was to determine the
immediate effect of ischemic compression, trigger point pressure release and placebo
ultrasound on pain, degree of cervical lateral flexion and pressure pain threshold of
upper trapezius trigger points in subjects with non-specific neck pain. Results showed
that ischemic compression in superior to sham ultrasound, it immediately reduced
pain in patients with non-specific neck pain and upper trapezius trigger point.
13
Muscle Energy Technique to tight muscles
The aim of this study was to compare the effect of MET with passive stretching on
pain and functional disability in people with mechanical neck pain. VAS and NDI
scores showed a significant improvement in both MET and stretching groups on the
6th day postintervention (p< 0.05). However, both VAS and NDI scores showed better
improvement in the MET group as compared to the stretching group (p<0.025). So,
the study concluded that muscle energy technique was better than stretching technique
in improving pain and functional disability in people with mechanical neck pain.
DEEP TISSUE MANIPULATION

Deep Tissue Manipulation is a technique which was used to affect the sub-layer of
musculature the deeper layers of muscle along with fascia and the under lying facet
joints. The muscles must be relaxed in order for the practitioner to each deeper
musculature through more superficial muscles. Deep Tissue manipulation might have
an effect of stretching over soft tissue, mobilizing effect over underlying facet joint
and remodelling effect over fascia. In Deep Tissue Manipulation the pressure is
adequately deep that it can manipulate the underlying facet joints of Cervicothoracic
spine and simultaneously release the soft tissues of periscapular and Para spinal
muscles, which is thought to give combine effect of soft tissue release and ipsilateral
facet joint mobilization, which tends to increase the ROM in spine. Application of
deep tissue manipulation was described in appendix VI.
14
CHAPTER 3
AIM AND HYPOTHESIS
15
Aim of the study: To know the effectiveness of deep manipulation in persons with
Neck pain.
Null hypothesis: There would be no effect of deep tissue manipulation when it is

applied on persons with Neck pain.
Alternative hypothesis: Deep tissue manipulation would have better effect than
conventional exercise in person with neck pain.
16
CHAPTER 4
METHODOLOGY
17
RESEARCH DESIGN: Experiment two groups, pre-test structure study design.
SUBJECTS/PARTICIPANTS: A total of 50 subjects having non- specific

neck pain with without radiation will be recruited randomly.
Group 1- experimental group (Deep tissue manipulation group) - 25 subjects.
Group 2- conventional treatment group (disease specific treatment group) - 25

subjects.
RESEARCH SETTING: The study will be conducted in physiotherapy

Department of SimpleCare and DP&RC, Cuttack.
SAMPLE AND SAMPLING TECHINQUES:

Since the study is experimental in nature, Randomized sampling with random
assignment to subgroup was done to select the subjects who all attended the
physiotherapy Department in SimpleCare and DP&RC, Cuttack.
Total sample consists of 50 subjects with neck pain (30 males and 20females), (age
range 20-50 years with mean age was 42) with without radiation to the upper
extremity.
Characterized by:
 A chief complaint on Neck pain with or without radiation, above 3months or
more.
 Application of stretching or pressure over periscapular muscles reproduces
original symptom.
 Head forward posture is characterised by anterior positioning of mastoid
process in relation to the acromioclavicular joint, therapist observe this from
side. Central P-A pressure suggestive of hypomobility that is confirmed by
reduced amplitude of glide over C8- T1 spinal segments.
INCLUSION CRITERIA: Subjects having nonspecific neck pain with without

radiation for more than 3 months. Both male and female. Age between 20-50 year.
Application of stretching or pressure over periscapular muscles reproduces original
symptom.
18
EXCLUSION CRITERIA: Age above 50 years, age below 20years, rheumatoid
arthritis, neurological deficit, recent fracture, dislocation, infective arthritis, spinal
cord lesion, Sing of vertebral artery disease, active bone disease or malignancy,
Osteoporosis.
VARIABLES:
Independent: Deep Tissue Manipulation to peri scapular and Para Spinal muscle,
MET, Posterior to Anterior glides.
Dependent: Neck Disability Index, Cervical Range of Motion, Pressure Pain

Threshold.
OUTCOME MEASURE:
1. NECK DISABILITY INDEX:The Neck Disability questionnaire to

asses neck pain complaints. It was developed from Oswestry index for Back
Pain and the Pain Disability Index. The authors are from the Canadian
Memorial Chiropractic College in Toronto Canada. (Vernon H. &Mior S.
1991). It is the only specific scale reported in literature for cervical spine
disorder. Its scores range from0 to 50, 0 is the most desirable health status. It
is a self-administered scale, which takes only few minutes to complete. This
test has been shown to reliable and valid and responsive functional outcome
measure for evaluation.
2. GONIOMETER: Goniometer is a protractor with an extended stationary arm

and fulcrum mounted moveable arm holding a protector is placed parallel with
stationary body segment and a moveable arm moves along a moveable body
segment. The axis is placed over the joint when anatomical land-marks are
well defines; the accuracy of measurement is greater. Goniometry was
performing using a universal Goniometer with a measuring scale marked out
at one degree interval. For cervical spine ROM measurements by goniometry,
the measuring system developed by (Cripriano j, William, 1985) will be
followed. Goniometric measurement has been found to have greater intra
tester reliability than estimation by observation.
19
3. SYRING ALGOMETER: Pressure Pain Threshold (PPT) is defined as the
minimal amount of pressure that produces pain (Fischer 1990). A simple hand-
held pressure algometer (PA) with a spring is commonly used, although more
sophisticated electrical devices with a strain or pneumatic pressure gauge have
been developed. Handled pressure algometer have also been found to be
highly reliable with repeated measure over time, when tested in pain-free
muscles of either the hand or other body region.
PROCEDURE:
30 subjects both male and females will be evaluated with the age between 30-50 years
and duration of years and duration of neck pain is 3 months, recruited from
Department of Physiotherapy in Simple care & DR&PC based on the fulfilment of the
inclusion and exclusion criteria, through an informed consent and assessment
Performa. The subjects were randomly assigned into 2 groups (Group 1/ Experimental
treatment group/Deep tissue Manipulation Group & Group 2/ Conventional group).
The entire procedure was explained to them. They were given verbal instructions for
the study and informed, consent was taken from every subject before their
participation in the study. Before initiating the treatment, subjects were assessed for
baseline values of all the dependent variables i.e., cervical spine side flexion and
extension range of motion &NDI. Therapy will be started on the same day on the
same day after the measurement will be taken.
INTERVENTION:
Group 1. (Experimental): 20 subjects will receive Deep tissue Manipulation including
5days in a week for 4 weeks.
Group2. (Conventional treatment group): 25 subjects will receive disease specific

treatment, for 5days in a week for 4 weeks.
Then at end of 4 weeks recording of changes in pain by PPT and function by NDI
score and Neck extension and slide flexion ROM by Goniometer were taken.
20
CHAPTER- 5
DATA COLLLECTION
21
PRE-TEST AFTER 2 POST TEST I
WEEKS
AFTER 4
WEEKS
POST TEST
II
22
CHAPTER – 6
DATA ANALYSIS
23
Statistical analysis was performed using SPSS version 25.0
The dependent variables were analysed using measurement ANOVA.
There was one between factor (Group) with two levels (Group: Deep soft tissue
manipulation and conventional therapy) and one with three levels (pre-test, Post-test-
I, Post-test-II).
All pair wise post-hoe comparisons were analysed using a 0.05 level of significance.
24
CHAPTER 7
RESULTS
25
NECK DISABILITY INDEX: -
Group 1 illustrated that there were decreases in NDI in both the group from pre-
treatment to post-treatment.The experimental group showed greater improvement in
the post- treatment measurements as control group at the end of 4 week of treatment
session.
There was main effect for time F (1538.716), DF (2), p= 0.000
There was also a main effect for group F (28.324), DF (1), p = 0.000
The main effects were qualified into time X group interaction F (94,608), DF (2), p =
0.000
Tukey’s Post Hoc analysis shows that there was a significant improvement in score
for both the group. However, the experimental group showed significantly greater
improvement than control group at the end of 4 weeks.
Neck Extension Range of Motion: -

Group 1 illustrates that there was increase in ROM in both from pre-treatment to post-
treatment. The experimental group showed lesser improvement in the post-treatment
measurement as compared to the control group at the end of 4 weeks of treatment
session.
There were main effects for time F (1317, 499), DF (2), p = 0.000
There was also a main effect for group F (7.297), DF (1), p= 0.000
The main effects were qualified into time X group interaction F (44.345), DF (2), p=
0.000
Tukey’s Post Hoc analysis shows that there was a significant in score for both the
group. However, the experimental group showed significantly greater improvement
than control group at the end of 4 weeks.
Side Flexion Range of Motion toward affected side: -

Graph 1 illustrates that there was decrease in side flexion towards affected side in
both the group from pre-treatment to post-treatment group showed greater
improvement in the post-treatment measurement as compared to the control group at
the end of 4 weeks of treatment session.
There was main effect for time F (22245.596), DF (2), p = 0.000
26
There were no main effects for group F (1.847), DF (1), p = .178
The main effects were qualified into time X group interaction F (1O6.860), DF (2), p=
0.000
Tukey’s Post Hoc analysis shows that there was a significant improvement in score
for both the group. However, the experimental group showed significantly greater
improvement that control group at the end of 4 weeks.
Side Flexion Range of Motion toward unaffected side: -
Graph 1 illustrates that there was decrease in Side flexion toward unaffected side in
both the groups from pre-treatment to post-treatment. The experimental group showed
greater improvement in the post-treatment measurement as compared to the control
group at the end of 4 weeks of treatment session.
There was main effect for time F (3132.317), DF (2), p = 0.000
There was no main effect for group F (2.705), DF (1), p =.104
The main effects were qualified into time X group interaction F (140.038), DF (2), p
= 0.000
Tukey’s Post Hoc analysis shows that was a significant improvement in score for both
the group. However, the experimental group showed significantly greater
improvement than control group at the end of 4 weeks.
27
CHAPTER 8
DISCUSSION
28
Out of 50 patients, 20 were diagnosed as derangement syndrome characterised by
centralisation of pain with chin tucking followed by cervical extension as per
McKenzie concept, 30were diagnosed as cervico-thoracic extension
dysfunction.Dysfunction characterised by head forward posture, ROM is limited
towards neck extension and P-A pressure over C-T1 and above suggest hypomobility.
20 were diagnosed as muscular dysfunction of periscapular muscle such as Levator
Scapulae, Rhomboids, upper fibres of Trapezius and sub-Occipital muscles,
characterised by pain in end range of motion due to stretching of tightened muscles as
per McKenzie concept. All of them had trigger points present in at least one of the
above specifiedmuscles (periscapular muscles) characterised by hyper irritable focus
in a taut band of a muscle. Treatment administration in the conventional group is as
per diagnosis. Patients with derangement syndrome had received chin tucking then
progressed to neck extension. Patient with cervico-thoracic extension dysfunction had
undergone P-A mobilization in hypo mobile segment of the spine. Patient suffering
from muscular dysfunctions had taken Muscle Energy Technique over involved
muscles followed by Ischemic compression for trigger points. Treatment
administration to the experimental group was Deep Tissue Manipulation irrespective
of diagnosis. In deep that it can manipulate the underlying facet joints of
Cervicothoracic spine and simultaneously release that soft tissue soft periscapular and
Para spinal muscles, which is thought to give combine effects of soft tissues release
and PA mobilization, which tends to increase the ROM at neck in Experimental
group.
Myofascial release/soft tissue release in the three-dimensional application of sustained

pressure and movement into fascial system in order to eliminate fascia restriction to
facilitate the release of restrictions that are impeding progress. Restricted fascia will
not allow muscle it encases to relax into proper function. Upon locating an area of
fascial tension, pressure is applied in the direction of the restriction. Often the
therapist will pin at one point and stretch away from the pin, other times the stretch
will occur in both directions away from the central restriction. This can be gentle
stretch, upon which layer of muscular is being targeted. Deep-tissue manipulation
often uses more pressure or technique to address problems that are not on the surface
of the body. Deep Tissue Manipulation was used to affect the sub-layer of
musculature the deeper layers of muscle along with fascia and the underlying facet
joints. The muscles must be relaxed in order for the practitioner to each deeper
musculature through more superficial muscles. This is how deep tissue manipulation
is different from myofascial release. Deep tissue manipulation, might had an effect of
stretching over soft tissue, mobilizing effect over underlying effect over underlying
facet joint and remodelling effect over fascia.
The reasons for change in dependent variable were describes below with
appropriate evidences:
29
The overall result of this study shows that there was significant decrease in NDI,
improvement in Pain Threshold and increase in contra lateral neck side flexion ROM
along with neck extension in both the group i.e., Deep Tissue Manipulation Group
and conventional group from pre to post-1 (10 days) as well as from post-1 to post-2
(10 days). however experimental group improved significantly more in all variable
than controlgroup.
1. PRESSURE PAIN THRESHOLD

In this study Pressure pain threshold of muscles were measured after complained of
2nd week and 4th weeks of the study. Both the group showed increase in PPT, but after
completion of the study, experimental group showed increase in PPT than
conventional group. The means change of muscle sensitivity expressed in percentage
from pre to post in experimental group after 2nd week and 4th weeks of the study were
41.4%, 51.1%, 51.3%,60.5% and in conventional group were 24.3%, 23.6%,
21.7%,28.1% for Levator scapula. Trapezius Rhomboids and Sub Occipitals
respectively.
In Conventional Group: -
The effect of ischemic compression therapy in increasing the PPT and ROM may be
attributed to the reactive hyperaemia caused by the temporarily occlusion of blood
supply (Hou et al. 2002). This helps in flushing out the muscle of inflammatory
exudates & pain metabolites, breaking down scar tissue & reducing muscle tone.
Direct ischemic compression reduces the sensitivity of nodules and may equalize the
length of sarcomeres in the muscle housing trigger point (Simons 2002). These
changes may result in normal resting length of muscles.
The increase in PPT as experienced by the participants may by the effect of

mobilization on mechanoreceptors and the sympathetic activity. Spinal dysfunction or
restriction leads to alteration of the normal pattern of discharge of the proprioceptors
and brings about a modification in the tone of the muscles. The effect of mobilization
on a particular vertebral level stretches the corresponding segmental muscles by its
action on spindle and Golgi tendon reflexes thereby leading to normalization of
muscle tone and increasing the PPT. As upper trapezius is innervated by nerves from
C2 through C4 level, it may be possible that the mobilization procedure directed at
these segments could have a positive effect on mobilization procedure directed at
these segments could have a positive effect on upper trapezius MTrPs sensitivity.
Further the increase in PPT may also be hypothesized t the effect of mobilization in
triggering central hypoalgesia by activating sympathetic nervous system and
periaqueductal Gray matter. The results are in accordance with the Ruiz-Saez et
al..2007 study that showed cervical spine manipulation directed at the C3 through C4
30
segment induced changes in pressure pain sensitivity in latent MTrPs in upper
trapezius muscle.
MET is applied to target muscles as they are lengthening and strengthening, leading to
decreased local oedema and increased lymphatic fluid movement. MET has been
shown to improve in strength and pain in chronic lateral epicondylitis. MET inhibits
the motor activation of Golgi tendon organ and isometric contraction cases
lengthening of viscoelastic and plastic changes in myofascial connective tissue.
A neurological explanation for the analgesic effects of MET is increased tolerance to

stretch, that results from MET are now considered to be to a combination of
nociceptive inhibition of dorsal horn of spinal cord.(i.e. gating via mechanoreceptor
stimulation during MET) and/or up regulation of analgesic endocannabinoids and/or
up regulation of analgesic endocannabinoids and/or altered fluid content of connective
tissue due to sponge-like behaviour during contractions associated with MET
isometric contractions and/or viscoelastic changes.
In Experimental Group: -
During this study it was examined that almost all the patients had at least any one
periscapular muscles tightness. On palpation, there was taut band with hyper irritable
spot and the muscle were relatively firm than normal individual. Probably this is due
to the pain in acute stage which resulted in protective spasm. This spasm normally
subsides after resolution of acute phase but out of fear the individual makes a habit to
remain in that particular posture which leads to sustain contraction of muscles and
gives rise to trigger points. The reduction in PPT in experimental group may be due to
application of Deep Tissue Manipulation which is thought to reduce the pain by
inhibiting the sympathetic tone, increasing the circulation and by reducing the hyper
irritable spot.
Postulated that patients with neck pain demonstrated greater activation of accessory
neck muscles during a repetitive upper limb task compared to asymptomatic controls.
Greater activation of the cervical muscles in patients with neck pain may represent
altered pattern of motor control to compensate for reduced activation of painful
muscles. Greater perceived disability among patients with neck pain accounted for the
greater electromyography amplitude of the superficial cervical muscles during
performance of the functional task.
Restrictions in motion and the cause of pain can also occur as a result of a muscle
strain. A muscle strain can lead to chronic issues and inflammation. Treatment of
these types of pain has no real plan like the treatment of an acute injury has. This pain
begins in the fascia and the muscle. This pain can be a result of Myofascial Pain
Syndrome. Deep tissue Manipulation might work out these adhesions and restore
motion and decrease the associated pain.
31
Shea 1995 founded that Nociceptors that are located in the fascia recognise the pain
stimulus which becomes sensitized when chronically stimulated. As pain is
considered as an autonomic nervous system phenomenon, this facilitation of the
receptors located in the fascia triggers a sympathetic response which was termed as
sympathetic tone thereby reducing the threshold of pain sensitivity in the subjects
resulting in serve pain. Facilitation of the proprioceptive receptors (Ruffini and
Pacinicorpuscles) that are located in the fascia during the application of the stretch
inhibited the sympathetic facilitation. This inhibition of sympathetic tone further
reduced the perception of pain. This may be cause for reduction of pain through
application of deep tissue manipulation.
Proposed that appropriate treatment of MTrPs involves lengthening the sarcomeres,

which reduces the energy consumption and in turn will cease the release of noxious
substance. The lengthening might occur with stretching or sustainable manual
pressure applied by therapist during the treatment.
Suggested that pain reduction in trigger point occur may result from reactive
hyperaemia in the local area, due to counterirritant effect or a spinal reflex mechanism
that may produce reflex relaxation of the involved muscle. Application of deep tissue
manipulation produces heat which lead to reflex relaxation and reduction of pain in
this study.
Under normative conditions, muscles and connective tissues tend to move with
minimal restrictions. However, injuries resulting from physical trauma, repetitive
strain injury, and inflammation are thought to decrease fascial tissue length and
elasticity, resulting in fascial restriction. So, by application of deep tissue
manipulation, there might be reorganisation of collagen to its normative length which
reduces the pain.
The Gate Theory suggested that sensory stimuli, such as pressure, travel along faster
nervous system pathways than do pain stimuli. The faster moving pressure stimuli
interfere with the transmission of painful stimuli to the brain, thus “closing the gate”
to the brain’s perception of pain. This personal attention and human touch often havea
calming effect that decreases the perception of pain. This relates to the
parasympathetic response of the autonomic nervous system. The stimulation of a
parasympathetic response decreases release of stress hormones, anxiety, depression,
and pain. The release of serotonin blocks the transmission of noxious stimuli to the
brain. Other inhibitory neurotransmitter, such as endorphins, may be released by the
pressure that is generated by the treatment. This may be a reason for reduction of pain
through deep tissue manipulation.
Various literatures suggest that there was a strong relationship exists between the pain
and the depression and quality of life. When the acute pain persists and it becomes
chronic this may lead to alteration in the hypothalamus hypophyseal-adrenal axis
which is the common pathogenic mechanism leads to depression. Anxiety and stress
32
in low back pain patients had altered mechanism in proteoglycan synthesis and
connective tissue metabolism. These changes with immobility results in facial
alteration and trigger the painful point and produces severe pain, which predisposes to
depression. By application of Deep tissue manipulation loosens up restricted
movement of spine, characterised by crepitus after which there is reduction of pain as
specified by the patient. Pain reduction promotes changes in psychological factors in
individuals with pain. The possible mechanism how Deep tissue Manipulation
reduces depression is by touch of therapist may help the nervous system, this reduces
the restriction on the duramatter which covers the brain and allow better circulation
and perfusion. The facial restriction release with the correction of dysfunction in the
fascia at intestinal level facilitates sleep and aids in secretion of serotonin. Serotonin
acts as calming mediator for the body, while the endorphins act as a happy stimulator
for the brain. When these hormones releases, automatically the stress hormone
(cortisol) reduces. It also helps in reduce tension and promotes relaxation more than
40%.
2. RANGE OF MOTION
A. CONTRALATERAL NECK SIDE FLEXION

In this study ROM of contralateral side flexion was measured after completion of 2nd
week and 4th week of the experimental group showed significant increase in ROM
than conventional group. Mean improvement in contralateral neck side flexion from
pre to post-2 in experimental and conventional groups was 17.24% and 10.9%
respectively.
In Deep Tissue Manipulation the pressure is adequately deep that it can manipulate
the underlying facet joints of Cervicothoracic spine and simultaneously release the
soft tissue of periscapular and Para spinal muscles, which is thought to give combine
effect of soft tissue release and ipsilateral facet joint mobilization, which tends to
increase the ROM at neck in Experimental group.
A study by conclude that improvement in Neck Side Flexion ROM through MET may
be due to neurophysiologic principle that account for neuromuscular inhibition that
occurs during application of these technique which states that after a muscle is
contracted, it is automatically relaxed for a brief latent period. Restriction in cervical
motion is caused by shortened, muscles of the cervical spine. Lengthening these
muscle group may help to restore gross physiologic range of motion in the neck.
33
When a muscle in contracted isometrically, a load is placed on the Golgi tendon organ
that, on cessation of effort, results in a period of hypotonicity, lasting in excess of 15
seconds. During this, a stretch of the tissues involved is more easily achieved than
before the contraction. Also, during and following an isometric contraction of a
muscle, its antagonists are reciprocally inhibited, allowing tissues involved to be more
easily stretched.
According to Leon Chaitow the physiological mechanisms behind the changes in

muscle extensibility produced by MET are reflex relaxation, viscoelastic or muscle
property change, and changes to stretch tolerance- a change to tolerance to stretching
is most supported by the scientific literature. These mechanisms bring about a change
in muscle physiology and hence lead to increased ROM at the joint.
Robert indicated the effects of MET as decreased pain, increased range of motion,
decreased muscle tension and spasm, and increased strength. Another study by,
Greenman (1989) depicts that Muscle Energy Technique helps to regain the mobility
of the hypo mobile joints by restoring normal length tension relationship which are
shortened and by strengthening the weakened muscles and reduce oedema by
pumping action for lymphatic system.
Deep Tissue Manipulation is thought to relax contract muscles, increasing circulation
and lymphatic drainage, and stimulating the stretch reflex of muscles. This might help
to increase soft tissue extensibility which improved range of motion.
According to Myers Fascia is a connective tissue along with tendon, ligaments, bone,
and muscle. Fascia is divided into three different layers. The first layer, which is the
superficial fascia, consists of connective tissue and adipose tissue. It provides a path
for nerves and blood supply. The second layer of fascia is called the potential space.
This area can become inflamed, which shows that it can be injured or stretched with
any type of injury. The final layer of fascia is the deep layer. This layer is a very
dense connective tissue that covers all the muscles and organs of the body. This layer
also divides the different muscles from each other, can provide attachments of some
muscles and it fills the spaces between some muscles and organ. At time the muscles
that are beneath and surrounded by this fascia become hypertrophied rather quickly.
This can cause the fascia to be too small and tight around the muscle. This causes
restrictions in range of motion of a particular muscle. So, stretching can be applied not
only to ‘length’ problem, but also to ‘stuck layer’ problems by fixing one layer and
requiring stretching movement of the adjacent layer, shear is created that allows the
restoration of increase relative movement between the adjacent planes of fascia.
A study by immobility of soft tissue structure due to pain, spasm leads to ground
substance dehydration. With loss of water the tissue become stiffer by formation of
34
intermolecular crosslink fibres restricting inter-fibre mobility and extensibility.
Therapeutically soft tissue mobility can be restored by altering scare tissue matrix,
stimulating the GAG synthesis, thereby prevent dehydration, breaking of restrictive
intermolecular crosslink, gaining the mechanical and viscoelastic elongation of
collagen tissue through creep and hysteresis phenomenon. Utilising the described
physiology, deep tissue manipulation of periscapular muscle has an effect on
improving flexibility of neck.
According to sustained contractile activity of sarcomeres increase the metabolic

demands and also squeezes the rich capillaries network that supply the nutritional and
oxygen needs of that region and decreased blood flow in the muscle at the site of
latent trigger (the combination of increased metabolic demand and impaired metabolic
supply produces a local energy crisis. The local hypoxia and tissue energy crisis
stimulates production of vasoreactive substances which will sensitize local
nociceptors causing pain. In this study might be enough to induce a gel-like state in
the fascia leading to increased soft tissue complain and subsequently greater cervical
spine rom. Deep tissue manipulation also exert uniaxial stretch spine ROM. Deep
tissue manipulation also exert uniaxial stretch over the muscle which might increase
the soft tissue compliance resulting in improvement of neck side flexion ROM.
In a study by (Kiran etal 2017) increase hydration of thoracolumbar fascia due to

upper back fascia stretching may help to increase the extensively to thoraco-lumber
fascia and in turn contribute to additional increase in spinal range of motion in
experimental group. Since each muscle slip attached to fascial expansion that then
attach to periosteum-ligaments-joint capsules, which ultimately attach to bone, a
stretch designed to target a supposedly ‘isolated’ muscle can be directed laterally,
muscle also stretch the attached fascia to it and in turn contribute to the increase in
Spinal range of motion.
It was seen that soft tissue release dilates the arterial system which restore soft-tissue,
and improve vascular plasticity. Dilation of the arterial system means an increase in
blood flow to the muscles, which will increase how much O2 is available to the
muscles along with other key nutrients. Wastes may also be taken away from muscles
much more quickly. This may be a reason for reduction pain and increase in ROM
through Deep Tissue Manipulation.
B. NECK EXTENSION
In the study Neck Extension ROM was measured after completion of 2nd week and 4th
weeks of the study. Both the groups showed significant increase in ROM, but after
completion of study, experimental groups showed significant increase in ROM than
conventional group. Mean improvement in neck extension ROM from pre to post-2 in
experimental and conventional group was 11.66% and 7.28% respectively.
35
Lee and Evans (1997, 2000) suggested that PA is essentially three-point bending of
the lumbar spine. This theory may also be applicable to the cervical spine which is a
beam supported by the head and the thoracic cage. Application of the PA load
produces an extension moment leading to backward bending of the cervical spine.
This explains the extension moment generally observed at the upper cervical
segments. The beam is free to rotate at the head end, leading to rocking of the head
that accompanies the bending of the spine. The lower end of the beam appears to be
somehow fixed. The upper thorax imposes a restraining moment on the beam, leading
to flexion of the lower cervical segments as observed in this study. Dynamic response
of cervical spine to posterior anterior mobilisation. The mobilisation forces were
found to be similar among the five loading cycles, but there were increases in cervical
lordosis upon repeated loadings. Such increases were likely due to pre-conditioning of
the soft tissue of the spine. These findings suggested that mobilisation is able to
produce time-dependent changes in the mechanical properties of the spine, it was
shown that PA mobilisation of the cervical spine generally produce extension of upper
motion segments and flexion of the lower segments. The cervical lordosis was found
to increase with repeated PA loading cycle, but this pre-conditioning effect decreased
with time.
In the study by (park 2017) the cervical lordosis angle was increased from 3 to 8
degree following cervical centre and unilateral PA. Cervical posture must be
considered during a postural assessment. Specifically postural compensations are
expected in adjacent segment, considering that muscle chains are interconnected.
Power et al studied the effects of PA mobilization on lumber segments and reported
that PA spinal mobilization consistently produced lumbar extension. Application of
PA force can cause motion of the target and neighbouring vertebrae, and this motion
is propagated cranially and caudally. Application of PA force on the mid-lumbar
vertebrate could produce extension at all lumbar segments, which can increase the
degree of lumbar lordosis. In the current results, cervical lordosis might have
increased by a similar mechanism. Application of PA mobilization on one spinous
process produced movements at the target vertebra and also caused movement of the
entire cervical spine, resulting in increased cervical lordosis. In conclusion, muscle
stiffness and cervical and unilateral PA mobilization positively affected cervical
lordosis, muscle stiffness and cervical ROM in an AS patient.
Application deep tissue manipulation over the Para spinal muscles is adequately deep
that it might mobilize the underlying facet joint of cervical and Cervicothoracic,
which is characteristic by crepitus produced, helps in reducing pain during various
36
functional activities and proving an even distribution of load over whole spine, along
with there is improvement of extension range of motion.
Mobilization of facet joint has occurred in both the groups but result shows there is
more improvement in experimental group than in conventional group. Explanation is,
as there is application of deep tissue manipulation is experimental group which
manipulate the underlying facet joints along with facilitate the cervical extensor
muscles which are partially inhibited due pain and lack of extension in cervical
extensor muscles which are partially inhibited due pain and lack of extension in
cervical spine over months. This is how deep tissue manipulation helps in more
improvement of extension range in experimental group.
In his study (Mohanty 2015) concluded that, the additional effect of the thoracic
mobilisation i.e., stretching of tightened structures and increase mobility between the
motion segment which may be as reason for improvement in Neck extension in this
study.
Higgins 2015 states that, when facet joints are mobilized, it stimulates joints
mechanoceptors which decease pain, decrease pain, decrease muscle guarding,
improve joint proprioception maintain tensile strength and extensibility of articular
surfaces, positively affects the production and movement of synovial fluid, which
combinedly decrease the pain and improves ROM.
In this study by (Peter Pierre 2017) hypothesized that range of motion was notably
decreased in most direction in most directions of motion while position sense was
within normal limits. The application of standardised specific mobilization techniques
led to substantial improvement in range of motion and the restitution of normal
coupled motion, following treatment, rage of motion was considerably increased in all
directions of movement.
In his study (Wright 1995) hypothesised that with the rising of mechanical pain
threshold, a trend toward an improvement in neck pain at rest was also reported.
Theoretically, it is proposed that the cervical mobilization might stimulate the
dorsolateral system of the periaqueductal Gray area in the midbrain and lead to an
increase in sympathetic activity which is a non-opioid form of analgesia. As the pain
reduces the range of motion gradually improves.
3. NECK DISABILITY INDEX: -

In this study NDI was after completion of 2nd week and 4th week of the study. Both
the groups showed significant improvement, but after completion of study,
experimental group showed significantly improvement in NDI than conventional
group. Mean improvement in NDI from pre- to post-2 in experimental and
conventional group was 32.196% and 18.25 respectively.
37
Normal pain free ROM is essential for normal function. This holds true for any joint
in the body and accordingly for the cervical spine. The component of NDI viz. Pain
intensity, personal care, and lifting, reading, sleeping, social life and travelling are
directly related to patient’s pain. The reduction in NDI scores seen in the groups may
be due to reduction of pain and improvement in ROM. More reduction in NDI score
and more increase in ROM in experimental group. Concluded that there is strong
correlation found between pain score in VAS and functional scoring by NDI. In this
study there is improvement in range of motion and pressure pain threshold, which
leads to improvement in Neck Disability Index.
Capillary dilation and an increased in the blood flow to the muscle which in turns
increases the removal of waste products stimulation of nociceptors pain fibres there
by reducing pain, muscle tension and improving range of motion. The above
phenomenon might be occurring in Deep Tissue Manipulation.
Reactive hyperaemia in the local area, due to counter-irritant effect or a spinal reflex
mechanism that may produce reflex relaxation of the involved muscle. Application of
Deep Tissue Manipulation produces heat which might reduce pain and improvement
of NDI.
Stimulation of deep joint receptors by stretching the joint capsule causes sympathetic
stimulation by somatic efferent and local activities of periaqueductal Gray matter that
plays the role of descending modulation. Thus, pain control occurs at the level of the
spinal level and the dorsal horn of spinal cord. Deep Tissue Manipulation also
stretches the facet joint capsule which reduces pain.
Removing the impairment existing in the tissue such as disappearances of tissue

restriction and consequently increasing range of motion, reduction of tissue tension
and hence reduction of tissues stiffness, improvement in muscle activity level due to
pain reduction can result in better performance during daily activities and ultimately
reduction of one’s disability level.
According to the fear-avoidance model, certain movement of activities may be

avoided by the experiencing pain, and a vicious cycle of long-term back pain and
functional limitation can develop. Deep Tissue Manipulation may cease this vicious
cycle leading to improvement in neck disability index.
38
CHAPTER9
CONCLUSION
39
Neck pain with or without radiation to upper extremity is often associated with
myofascial pain syndrome of periscapular and Para spinal muscles. Deep Tissue
Manipulation of periscapular and Para spinal muscles is found to be effective for the
management of neck pain by: -
1. Inhibition of sympathetic tone and restoration of increased relative movement

between the adjacent planes of fascia due to stretching of periscapular muscle.
2. Modulation of the peripheral terminals of nociceptors, restoring uniform spinal
mobility and correction of abnormal posture due to mobilisation of underlying
facet joints which was characterised by crepitus produced.
CLINICAL IMPLICATION
Deep Tissue Manipulation of periscapular and Para spinal muscle of upper back
can be a treatment of choice in physiotherapy for persons with neck pain with or
without radiation to upper extremity to reduce pain and improve spinal ROM.
40
CHAPTER10
LIMITATAIONS AND FUTURE
SUGGESTION
41
LIMITATONS
1. Sample size was small.
2. Short duration of study.
3. No follow up to see long term effects.
FUTURE SUGGESTIONS
1. Further studies should be done with larger sample size and study duration.
2. Long term effects should be tasted with follow up.
3. To improve quality of study highly specific tools electronic algometer should
be used.
42
CHAPTER 11
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50
CHAPTER 12
APPENDICES
51
APPENDIX-I
CONSENT FORM
TITLE OF STUDY: “EFFECT OF DEEP TISSUE
MANIPULATION IN PERSON WITH NECK PAIN”.
I,
Mr./Mrs./Miss
Am willing to participate voluntarily as a subject for dissertation of Mr. Debadutta

Dibyajyoti Dey. I have been informed regarding the nature and duration of my
participation in the study. I understand that I will be evaluated in the department of
physiotherapy at the time convenient to me and the researcher may contact me for
more information in future. I have been explained that undergoing any invasive
procedure and no adverse effect are expected due to procedure. Also, I have explained
that I can withdraw from the study at any time during or post-test. I have no objection
to undergo the required examination and intervention involved pertaining to the study.
Conducted by:
Respondent
Mr. Debadutta Dibyajyoti Dey
Signature...
Researcher
MPT 2nd year
(Musculoskeletal)
52
APPENDIX – II
ASSESSMENT PROFORMA
1) SUBJECT INFORMATION:
. Name:
. Age/Gender
. Occupation
. Address
. Date of examination
. Pre- test
. Duration of injury
2) HISTORY
 History of present illness

 Past history
 History of pain:
- Onset
- Site
- Type of pain
- Character of pain
- Behaviour of pain
- Aggravating factors
- Relieving factors
- Diurnal variation
Special questions-
 Pain on cough/sneeze
 Disturbed sleep
 Early morning symptoms
 Medicine intake
 Weight loss
 Severity
 Irritability
3) EVALUATION:
. On observation
53
 Sitting Posture
 Standing posture
 Cervical lordosis
 Thoracic kyphosis
On Examination-
 Active physiological movements:
 Willingness of movement
 ROM
- Flexion
- Extension
- Side flexion(right)
- Character of the Movement
- Repeated Movement
 Tightness/ Contracture/ Deformity
 PAIVM (joint play)
 Special test
. On Palpation: -
 Temperature
 Texture
 Tenderness
 Moisture
 Trigger punts
 Shoulder joint
. Neurological signs: -
 Dermatomal sensory test
 Myotomal motor test
 Reflex testing
 Bladder and bowel function
FunctionalAbility:Neck Disability Index (to be filled by the patient) score.
54
APPENDIX – III
1. FUNCTIONAL OUTCOME MEASURE BY NECK
DISABILITY INDEX:
Neck Disability Index This questionnaire has been designed to give us information as
to how your neck pain has affected your ability to manage in everyday life. Please
answer every section and mark in each section only the box that applies to you. We
realise you may consider that two or more statement in any one section relate to you,
but please just mark the box that most closely describes your problem.
Section 1: Pain Intensity

 I have no pan at the moment.
 The pain is very mild at the moment.
 The pain is fairly severe at the moment.
 The pain is very severe at the moment.
 The pain is the worst imaginable at the moment.
Section 2: Personal Care (Washing, Dressing, etc.)

 I can look after myself normally without causing extra pain.
 I can look after myself normally but it causes extra pain.
 It is painful to look after myself and I am slow and careful.
 I need some help but can manage most of my personal care.
 I need help ever day in most aspect of self-care.
 I do not get dressed, I wash with difficulty and stay in bed.
Section 3: Lifting
 I can lift heavy weight without extra pain.
 I can lift heavy weight but it gives extra pain.
 Pain prevents me lifting heavy weights off the floor, but I can manage if
they are conveniently placed, for example on a table.
 Pain prevents me from lifting heavy weight but I can manage light to
medium weight if they are conveniently positioned.
 I can only lift very light weights.
 I cannot lift or carry anything.
55
Section 4: Reading
 I can read as much as I want to with no pain in my neck.
 I can read as much as I want slight pain in my neck.
 I can read as much as I want with moderate pain in my neck.
 I can’t read as much as I want because of moderate pain in my neck.
 I can hardly read at all because of severe pain in my neck.
 I cannot read at all.
Section 5: Headaches
 I have no headaches at all.
 I have slight headaches, which come infrequently.
 I have moderate headaches, which come frequently.
 I have moderate headaches, which come frequently.
 I have severe headaches, which come frequently.
 I have headaches almost all the time.
Section 6: Concentration
 I can concentration fully when I want to with no difficulty.
 I can concentration fully when I want slight difficulty.
 I have a degree of difficulty in concentrating when I want to.
 I have a lot if difficulty in concentrating when I want to.
 I have a great deal of difficulty in concentrating when I want.
 I cannot concentration at all.
Section 7: Work
 I can do as much work as I want to.
 I can only do mu usual work, but no more.
 I can do most of my usual work, but no more.
 I cannot do my usual work.
 I can hardly do any work at all.
 I can’t do any work at all.
 I can drive my car as long as I want with slight pain in my neck.
 I can drive my car as long as I want with moderate pain in my neck.
 I can’t drive my car as long as I want because of moderate pain in, y
neck.
56
 I can hardly drive at all because of severe pain in my neck
 I can’t drive my car at all
Section 9: Sleeping
 I have no trouble sleeping.
 My sleep in slightly disturbed (less than 1 hrs sleepless).
 My sleep is mildly disturbed (1-2 hrs sleepless).
 My sleep is moderately disturbed (2-3 hrs sleepless).
 My sleep is greatly disturbed (3-5 hrs sleepless).
 My sleep is completely disturbed (5-7 hrs sleepless).
Section 10: Reservation

 I am able to engage in all my recreation activities with no neck pain at
all.
 I am able to engage in all my recreation activities, with some pain in my
neck.
 I am able to engage in most, but not all of my usual recreation activities
because of pain in my neck.
 I am able to engage in a few of my usual activities because of pain in my
neck.
 I can hardly do any recreation activities because of pain in my neck.
 I can’t do any recreation activities at all.
Score: _/50 Transform to percentage score x 100= %points.
57
2. CERVICAL SPINE ROM MEASUREENT BY USING A
GONIOMETER.
EXTENSION
 The subject was asked to sit on the stool with leg well supported andupper
limb hanging by the side, fulcrum was placed over external auditory meatus,
stationary arm was placed perpendicular to the ground in reference to plumb
line and mobile arm was corresponds to base of nares. Subject was asked to
actively extend the neck and extension range of motion.
SIDE FLEXION
 The subject was asked to sit on the stool with leg well supported and upper
limb hanging by the side. Fulcrum was placed over the spinous process of C7
vertebra, stationary arm was placed perpendicular to the for reference. Subject
was asked to activity side flex the neck on the both side and the range of
motion was recorded.
3. PESSURE PAIN THRESHOLD BY USING SYRINGE

ALGOMETER
Identification of trigger point was done following the criteria given by Simon
et al 1983.
 A taut palpable band in the affected muscle.
 Exquisite focal tenderness pressure (the trigger point), in the taut band
of the muscle.
 A local twitch response, elicited through snapping palpation or needing
of the tender spot.
 Reproduction of typical referred pain pattern of Trigger Point in
response to compression.
 Subject was appropriately positioning so that the muscle in easily
palpable by the therapist. Muscle was placed on moderate slack. With a
pincer grasp, entire mass of free margin of the muscle was lifted off.
Then the muscle was firmly rolled between the finger and thumb to
palpate firm band and elicit local twitch response and to locate spot
tenderness of Trigger Point. The Trigger point identified were marked
with a skin marker.
Measurement of PPT:
Pressure pain threshold (PPT) is defined as the minimal amount pressure that
produces pain (Fischer 1990).
58
A simple hand-held pressure algometry (PA) with a spring is commonly used,
although more sophisticated electrical devices with a strain or pneumatic pressure
gauge have been developed. Handheld pressurealgometer have also been found to be
highly reliable with repeated measure over time, when tested in pain-free muscles of
either the hand or other body region. The syringe algometer is easy to construct and
performs reliably within a limit of 100% accuracy over the approximate range for
clinical use. Calibration of the device can be assumed to be constant as the physical
principle on which itrelies (compression of air) will vary only slightly with small
changein atmosphere pressure. Rolke et al 2005 compared hand-held spring and
electronic Pas and found no significant difference for clinical purposes. They hold the
pack force or pressure (KP kilopond) = 10 N, Newton=100 kpa (kilopascal) until
tared, and some may also be connected to a computer and thus have continuous
output.
PPT measured with a probe 1.6 mm in diameter or larger reflects the tenderness of
deep tissues andanaesthesia of skin only affects the results of smaller probes
(Takahashi et al 2005). The most commonly used surface area of probes is 0.5 or 1 cm
2. The algometer is placed perpendicular to the tissue surface and pressure applied
steadily at a constant rate. Reported pressure application rates have ranged from 0.05
to 20 N/s. Higher PPT scores were recorded at higher application rates. Ideally
compression should be performed slowly enough to allow the subject time to react
when pain is felt. When the subject report feeling pain the action of pressure is
stopped, or to avoid delay by the tester. The subjects were given a familiarization
session to become acquainted with the sensation of syringe pressure algometer on an
unaffected body part before the primary TrP was identified. Subject was explained to
state immediately when the pressure sensation turns into pain sensation at an interval
of 30 second by the same examiner were taken. Mean of 3 reading was used for
further analysis.
59
APPENDEX – IV
DATAENTRYSHEET
GROUP AGE GENDER DEPENDENT PRETEST POST POST
VERIABLES TEST 1 TEST 2
EXPERIMENTAL NDI
GROUP
NECK
(GROUP1)
EXTENSION
ROM
NECK
SIDE
FLEXION
AFFECTED
SIDE ROM
NECK
FLEXION
AWAY
FROM
AFFECTED
SIDE ROM
GROUP AGE GENDER DEPENDENT PRETEST POST POST

VARIABLE TEST 1 TEST 2
CONVENTIONAL NDI
GROUP
(GROUP2) NECK
EXTENSION
ROM
NECK
SIDE
FLEXION
TOWARDS
AFFECTED
SIDE ROM
NECK SIDE
FLEXION
AWAY
FROM
AFFECTED
SIDE ROM
60
APPENDEX – V
CONVENTION GROUP TREATMENT
1. Muscle Energy Technique (Chaitow L, Crenshaw K. Muscle energy
techniques. Elsevier Health Science 2006).
The muscles with taut band are hold in stretch position and the subjects is
asked to introduce a light resisted effort (20% of available strength). The
degree of effort should be mild and no pain should be felt. The contraction is
felt for 7-10second. Subjects stretch reduces the chance of stretch reflex being
initiated. Once the muscle is in a stretch reduces the chance of stretch reflex
being initiated. Once the muscle is in a stretchposition subject reflexes and the
stretch is held for up to 30seconds. Repeat for 5times or until no further gain is
possible.
2. McKenzie Cervical spine reaction in sitting (R.A McKenzie, The Cervical

and Thoracic spine Mechanical Diagnosis and therapy 1990).
Preferably patient sits on a back rest chair in upright position. Ask the patient
to look straight and tuck the chin without flexion and extension of neck, with
chin tucking there is flexion in upper cervical spine and extension in lower
cervical spine, which help in reduction of posterior derangement.
3. Posterior to anterior mobilisation of lower cervical and cervico-thoracic

junction [Maitland G D, 2005, Maitland Manipulation, 5th edition]
Subject is in prone lying over the couch with a breath hole with arm across the
chest. Therapist stand at the head end of the couch with the tip of both the
thumb over the articular pillar of the underlying spine and elbow straight.
Pressure was given for 2min at frequency of 2 Hz with amplitude as tolerated
by subject.
4. Ischaemic compression over Trigger points Travel and Simons 1983

Patients were placed such a position that the muscle with trigger points were
stretched. Then therapist locate trigger point using a pincer grasp, palpate the
muscle to feel for a taut band or a twitch response in the muscle belly. Once
trigger points is located apply Ischaemic compression by gradually applying
pressure to trigger point with thumb. The patient will likely feel referred pain,
keep in communication with the subject, checking to ensure that in staying
with the limits of his pain tolerance, hold this for 20 min to 1min, patient tells
you that pain has diminished or muscle fibres begin to relax under therapist’s
pressure. Once release is felt gradually release pressure. This was repeated 5
times for 5 session per week.
61
APPENDIX – VI
EXPERIMENTAL GROUP TREATMENT
SUBJECT STARTNG POSITION: subject in prone lying on a height

adjustable mobilisation bed with breath whole. Arms were crossed across the chest to
keep the targeted muscle in stretched position.
THERAPIST STARTING POSITION: For Levator Scapulae and

Periscapular muscle therapist stood in walk standing position on the subject facing
towards the leg and for Para spinal therapist stood in walk standing position on the
side of the subject facing towards the head.
INSTRUCION: Relax during the treatment session focussing on breathing.
PROCEDURE:
1. Deep soft tissue manipulation of Levator scapulae : with the

therapist thumb of contralateral hand reinforced by heel of the ipsilateral hand,
therapist applied sustained pressure by using the body weight till the subject
feels little discomfort. Movement was applied slowly with the pressure
maintained, laterally and downward direction from cervical spinous process
toward the superior border of scapula, for Levator scapulae.
2. Deep soft tissue manipulation of upper fibretrapezius : subject is

in prone lying with head rotated and side flexed away from affected side.
Affected side upper limb is over the back and non-affected side arm pull the
head away from affected side. With the therapist thumb of contralateral hand
reinforced by heel of the ipsilateral hand, therapist applied sustained pressure
by using the body weight till the subject feels little discomfort, in laterally and
downward direction from cervical spinous processes towards the spine of
scapula, for upper fibretrapezius.
3. Deep soft tissue manipulation of parascapular muscle: with the

therapist thumb of contralateral hand reinforced by heel of the ipsilateral hand,
therapist applied sustained pressure by using the body weight till the subject
feels little discomfort. Movement was applied slowly with the pressure
maintained, laterally and upward direction from the thoracic spinous processes
toward the medial border of scapula.
62
4. Deep soft tissue manipulation of Para spinal muscles: with the
therapist thumb of ipsilateral hand placed over Para spinal muscle, reinforced
by heel of the contralateral hand, therapist applied sustained pressure by using
the body weight till the subject feels little discomfort. Movement was applied
slowly in the upper thoracic region where hypo mobility was felt during the
manoeuvre along the length of Para spinal muscle. Deep soft tissue
manipulation over the Para spinal muscle. Deep soft tissue manipulation over
the Para spinal muscles was considerably deep that it might mobilize the
underlying facet joint, which was characterised by crepitus produced.
5. Deep soft tissue manipulation of sub occipital muscles: with the

therapist applied sustained pressure by till the subject by till the subject feels
little discomfort and slides the thumb with same pressure from the C2 vertebra
toward nuchal line in occipital bone.
63
APPENDIX-VII
STATISTICAL RESULT TABLE
1. ANOVA TABLE FOR NECK DISABILITY INDEX

Table 1.1 test between and within subject effect
Sum of df Mean F Significance

squares square
Between Group 10850.018 1 10850.018 28.324 .000
subject
effects
Error 27581.189 72 383.072
Within Time 31582.955 2 15791.477 1538.716 .000
subject
effects
Time 1941.874 2 970.937 94.608 .000
group
Error 1477.838 144 10.263
Table 1.2 mean and standard error of mean
Pre test Post-test 1 Post-test 2

Mean SEM Mean SEM MEAN SEM
Group 1 56.81081 2.619469 39.08108 2.48129 20.37838 2.255241
experimental
Group 2 63.945995 1.221643 52.32432 1.108291 41.94595 2.255241

conventional
Total 60.37838 1.920556 45.7027 1.7987055 31.162165 1.88036
64
Table 1.3. Turkey’s HSD post hoc analysis for NDI
MAIN EFFECT for interaction between group and time
Mean 1>= mean 2>= minimal significant difference
Group 1 Grp 1 po- Grp 1 po- Grp 2 pre- Grp 2 po- Grp 2 po-
pre- 1 39.0811 2 20.3784 57.7297 1 53.5153 2 42.9198
56.8180
Grp 1 pre- 0 17.7369 36.4396 0.9117 3.3045 13.8991
56.8180
Grp 1 po- 0 18.7027 18.6486 14.4324 3.8378
1 39.0811
Grp.po-2 0 37.3513 33.1351 22.5405
20.3784
Grp 2 pre 0 4.2162 14.8108
57.7297
Grp 2 po- 0 10.5946
1
53.5135
Grp 2 po- 0
2
42.9198
4. ANOVA TABLE FOR NECK EXTENSION
Table2.1 Test of between and within subject effect

Sum of df Mean F Significance
squares square
Between group 969.802 1 969.802 7.297 .009
subject
effect
Error 9569.009 72 132.911
Within Time 2846.009 2 1423.005 1371.499 .000
subject
effect
Time 95.793 2 47.896 44.345 .000
group
Error 155.532 144 1.080
65
Table 2.2 Mean and standard error of mean
Pre test Post-test1 Post-test2

Mean Sem Mean Sem Mean Sem
Group1 45.18919 1.299017 50.2973 1.266255 55.56757 1.182036
experimental
Group2 49 0.91775 54.21622 0.92965 57.78378 0.95215

convention
Total 47.09459 1.108383 77.40541 1.09795 56.67567 1.067093
Table 2.3 Turkey’s HSD post hoc analysis for neck extension
Main effect for interaction between group and time
Mean 1-mean 2=minimal significant difference
Grp 1 pre- Grp1 po- Grp 2 po- Grp2 pre Grp2 po-1 Grp2 po-2
45.18919 1 50.2973 2 49 54.21622 57.78378
55.56757
Grp 1 pre 0 5.10811 10.37838 3.81081 9.02703 12.59459
45.18919
Grp 1po-1 0 5.27027 1.2973 3.91892 7.48648
50.2973
Grp 1 po- 0 6.56757 1.35135 2.21621
2
55.5657
Grp2 pre 0 5.21622 8.78378
49
Grp 2 po- 0 1.43244
1
54.21622
Grp 2 po- 0
2
57.78378
66
5. ANOVA TABLE FOR NECK SIDE FLEXION TOWARDS
AFFECTED SIDE
TABLE 3.1 Test of between and within subject effect

Sum of Df Mean F Significance
square square
Between Group 53.518 1 53.518 1.847 .178
subject
Effect
Error 2086.162 72 28.974
Within Time 2218.622 2 1109.311 2245.596 .000
subject
effect
Time 105.577 2 52.188 106.860 .000
group
Error 71.135 144 494
Table 44.2 Mean and standard error of mean
Group1 28.2162 0.69655` 33.1081 0.65735 37.973 0.63611

experiment
Group2 28.4865 0.56102 31.7295 0.55433 34.8378 0.5622

conventional
Total 228.35135 0.62878 32.4189 0.60584 36.4054 0.59916
67
APPENDIX-VIII
GRAPHS
NDI
GROUP 1 GROUP 2
PRE POST1 POST2
NECK EXTENSION
60
50
40
30
20
10
0
GROUP1 GROUP2
PRE POST1 POST2
68
SIDE FLEXION TOWARDS UNAFFECTED SIDE
45
40
35
30
25
20
15
10
5
0
GROUP1 GROUP2
PRE POST1 Series 3
SIDE FLEXION TOWARDS AFFECTED SIDE

45
40
35
30
25
20
15
10
5
0
GROUP1` GROUP2
PRE POST1 POST2
69
PPT TRAPEZIUS (RIGHT)
7
0
GROUP1 GROUP2
PRE POST1 POST2
PPT TRAPEZIUS (LEFT)

7
0
group1 group2
pre post1 post2
70
PPT SUB OCCIPITAL (RIGHT)
6
0
group1 group2
pre post1 post2
PPT SUB OCCIPITAL (LEFT)

6
0
GROUP1 GROUP2
PRE POST1 POST2
71
APENDIX-IX
PHOTOGRAPHS
EXPERIMENTAL GROUP
DEEP TISSUE MANIPULATION
Upper trapezius
72
Para spinal
Levator scapulae
73
CONVENTIONAL GROUP
CHIN TUCKINGMET TO UPPER TRAPEZIUS
MET TO RHOMBOIDS
74
INSTRUMENTS USED
SYRINGE ALGOMETER
GONIOMETER
75

The Effects of Deep Tissue Manipulation in Person With Neck Pain D

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THE EFFECTS OF DEEP TISSUE MANIPULATION IN PERSON

WITH NECK PAIN

DEBADUTTA DIBYAJYOTI DEY

Guide Co. Guide

Dr. ANIRBAN PATRA PT, Dr. NIRAJ KUMAR PT,

SHRI GURU RAM RAI UNIVERSITY

COLLEGE OF PARAMEDICAL SCIENCES

Patel Nagar, Dehradun- 248001, Uttarakhand, India

CERTIFICATE BY THE CANDIDATE

DATE: Debadutta Dibyajyoti Dey

CERTIFICATE BY THE GUIDE

tissue manipulation in person with neck.” submitted by “Debadutta Dibyajyoti

of Physiotherapy of the Shri Guru Ram Rai University, Dehradun, Uttarakhand is

submitted for any Degree or Diploma.

Place: Dr. Anirban Patra (PT)

ENDORSEMENT BY THE HEAD OF THE

DATE: (Seal and Signature of HOD)

Dr. Niraj Kumar (PT)

CERTIFICATE BY THE EXAMINER

Accepted /Not Accepted Accepted/Not accepted

(Signature of Internal Examiner) (Signature of External Examiner)

DECLARATATION BY THE CANDIDATE

DATE: Debadutta Dibyajyoti Dey

PLACE: MPT 2nd Year (Musculoskeletal)

First of all, I feel immense pleasure to record my regards and to maintain

I would like to thanks Honourable Chairman “Shri Devendra Das

It gives immense pleasure and satisfaction to place my sincere thanks and

I humbly thanks to all the teaching membersDr. Tarang Srivastava PT,

With great regard I knowledge my sincere thanks to my siblings, friends,

Debadutta Dibyajyoti Dey

MPT 2nd year (Musculoskeletal)

Every challenging work needs self-efforts as well as guidance of elders especially

humble effort I dedicate to my sweet and loving

Father and Mother

get such Success and honour

Hard Working and Respected

Along with Generous and humble

Family, Friends and Colleagues.

2 Literature review 6-14

3. Aim and hypothesis 15-16

5. Data collection 21-22

6. Data analysis 23-24

10. Limitation, future suggestion 41-42

11. Reference 43-50

12. Appendices 51-75

Apendix-2(Assessment preform) 53-54

Appendix-3(Measurement procedures) 55-59

Appendix-4(Data entry sheet) 60

Appendix-5(Control group treatment) 61

Appendix-6(Experimental group treatment) 62-63

Appendix-7(Statistical result table) 64-67

Appendix-9(Photographs and instruments used) 72-75

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