Indian Journal of Health Sciences and Care

Vol. 2, No. 1, April, 2015, pp- 8-13 IndianJournals.com

A product of Diva Enterprises Pvt. Ltd.
DOI: 10.5958/2394-2800.2015.00002.4

Original Research Article

Comparing Effectiveness of Myofascial Release and Muscle Stretching on

Pain, Disability and Cervical Range of Motion in Patients with Trapezius
Myofascial Trigger Points

Sonia Pawaria1*, Sheetal Kalra2

1
Assistant Professor, 2Associate Professor, Faculty of Physiotherapy, SGT, University, Gurgaon, Haryana

*Corresponding author email id: sonupawaria@gmail.com

ABSTRACT
Downloaded From IP - 210.212.82.17 on dated 22-May-2017

Myofascial Release and Muscle stretching are the two technique used in the treatment of active Myofascial trigger points of a
Members Copy, Not for Commercial Sale

muscle. There is limited evidence for the comparison of Myofascial Release and Muscle stretching in the treatment of active
www.IndianJournals.com

trigger points of Trapezius muscle. The purpose of the study was to compare the effect of Myofascial Release and Muscle
stretching on pain, disability and cervical range of motion in patients with trapezius Myofascial trigger points.Total numbers of
thirty two patients were randomly assigned to receive either Myofascial Release or Muscle stretching along with hot pack for
3 times/week for 2 weeks. Pain, neck disability index and range of motion were taken at baseline, 1week, 2 week and follow up
(after 1 week) in both the groups. Data analysis was performed using SPSS software 12 version. In both the group significant
improvement occurred in VAS score, ROM, and Neck disability index. Between groups analysis revealed that improvement in
VAS score and Neck disability index was more in Group A than Group B. There was no significant difference found in ROM in
between groups analysis. Myofascial Release is a better treatment technique compared to Ultrasound in the treatment of active
Myofascial trigger point.

Keywords: Myofascial release, Trigger points, Stretching

INTRODUCTION of pain to a distant site and peripheral and central

Myofascial trigger point (MTrP) is claimed to be a
common source of musculoskeletal pain in people
presenting to manual therapists for treatment. Simons
et al. defined myofascial trigger point as hypersensitive
tender spots associated with a taut band of a skeletal
muscle that is painful on compression and on stretch
and gives rise to a typical referred pain pattern1.
Myofascial trigger points are the hallmark characteristics
of myofascial pain and feature motor, sensory and
autonomic components. Motor aspects of active and
latent myofascial trigger point may include disturbed
motor function, muscle weakness as a result of motor
inhibition, muscle stiffness and restricted range of motion.
Sensory aspects may include local tenderness, referral
sensitization2.
MTrPs are typically located by physical examination and
palpation. The diagnosis of a MTrP is accomplished by
the identification of clinical sign on physical examination:
which may include
 The presence of a taut band in a skeletal muscle
 The presence of a tender spot within the taut band
 Palpable or visible local twitch response on snapping
palpation, and/or needle, of the MTrP
 A jump sign
 The presence of the typical referred pain pattern of
the MTrP
 Restricted range of motion of the affected tissues3

8
 Comparing Effectiveness of Myofascial Release and Muscle Stretching on Pain, Disability and Cervical Range of Motion in Patients
with Trapezius Myofascial Trigger Points
Trigger points can arise virtually in any muscle group.
However, the most common sites are the muscles
involved in maintaining posture: levator scapulae, upper
trapezius, sternocleidomastoid, scalene and quadrates
lumborum muscle4. The upper trapezius is probably the
muscle most often beset by myofascial Trigger point.
Sciotti et al. measured the pressure pain threshold
(PPT) of eight different muscles with a pressure
algometer and determined that the upper trapezius was
most sensitive to the pressure of the muscles tested5.
The two trigger point locations in the upper trapezius
commonly refer pain along the posterolateral aspect of
the neck6.
There are many treatments aimed at eliminating MTrPs:
Ischemic compression, Spray and stretch, Strain &
counterstrain, Ultrasound therapy and Needling
Downloaded From IP - 210.212.82.17 on dated 22-May-2017
therapies7. Rischard Shacksnous et al, investigated the
Members Copy, Not for Commercial Sale
immediate effects of Myofascial release on pain
www.IndianJournals.com
reduction, MTrP sensitivity and improvement in cervical
range of motion in 48 women with upper trapezius
muscle MTrPs. They found myofascial release is most
effective for easing MTrP pain and increasing cervical
ROM 8.
To our knowledge, there is dearth of evidence of
comparison of myofascial release and stretching in
treatment of active myofascial trigger point. Hence the
purpose of the present study was to find out the
effectiveness of myofascial release in active myofascial
trigger point, in conjunction with muscle stretching for
easing MTrP pain and increasing cervical ROM.
METHODS
Design
Pre-test post-test experimental group design was carried
out with a sample of 26 participants of active myofascial
trigger points of upper trapezius muscle. Participants
were randomly allocated using sealed envelope method
to receive either Myofascial release technique or
Muscle stretching. Informed consent was taken from
all the participants included in the study. All the
participants who met the inclusion criteria were
evaluated thoroughly using a screening performa.
Indian Journal of Health Sciences and Care
Source of Data
Physiotherapy OPD of SGT Hospital, Gurgaon
Participants
Participants with chronic neck pain were screened for
eligibility. Participants were included in the study after
meeting the following inclusion criteria:- Male and
female between the age group of 20 and 40 years were
selected, patients having active trigger point in the upper
fibers of trapezius muscle. The diagnosis of trigger point
was based on the criteria described by Travell and
Simons and patients having chronic pain for past 2-3
months 6. Subjects with following conditions were
excluded from the study:- having symptoms and signs
meeting the American college of Rheumatology criteria
for fibromyalgia, taking myofascial trigger point
injections or receiving physical medicine in the year
preceding this study, having a history of acute trauma,
having a history of inflammatory joint or muscle disease,
infection, or malignancy, having a history of neurologic
deficit.
Intervention
Hot Pack was given in both the groups over trapezius
muscle in supine lying position.
Group A was given Myofascial release for 3 times/
week. Group B was given Muscle stretching for 3 times/
week.
Myofascial release: The subject was placed supine
and the therapist stood behind the subject head, sliding
left hand under the patient head and placing index finger
at the upper trapezius. Using the thumb of right hand,
stretched diagonally downward on the neck portion of
the upper trapezius. Hold, wait for the release and
stretch the neck portion again. Without breaking contact,
stretching down and slightly out following the curve of
the muscle fibers. Holding, wait for release and stretch
again. Moving thumb farther down the shoulder portion
of the upper trapezius and repeating the release
sequence until the entire upper trapezius has been
released with the patient’s head in midline9.
Muscle stretching: The treatment was carried out for
two consecutive weeks consisted of a 5 minute thrice
9
 Sonia Pawaria, Sheetal Kalra

weekly for 6 sessions. The exercises were performed
in a series of five repetitions, remaining in the same
position for 45 seconds. The targeted muscle was
stretched until tension was sensed at the end of the
ROM. The patient exhaled allowing the muscle to relax,
increasing the stretch. The newly gained position was
held while the patient inhales. Further length was gained
through succeeding exhalations, allowing the muscle to
relax out rather than push through.
Outcomes and Measurement
Pain was measured using visual analog scale, Disability
by Neck Disability Index (NDI) and Range of motion
was measured by Universal Goniometer.
All the outcomes measurement were taken at the
baseline, 1 week, 2 week and follow up (after 1 week)
Downloaded From IP - 210.212.82.17 on dated 22-May-2017
the pairs VASO-VAS1, VAS1-VAS2, VAS2-VAS3 and
VAS0-VAS3 for both groups separately.
Change in ROM
The measurement of ROM in degree was done at
baseline (ROM0), 1 week (ROM1), 2 week (ROM2)
and 1week after the treatment (ROM3, follow up).
Difference between the values of all variables within
the groups were calculated using repeated measures
analysis of variance (ANOVA) post hoc for the pairs
ROMO-ROM1, ROM1-ROM2, ROM2-ROM3 and
ROM0-ROM3 for both groups separately.
Change in NDI Score
The measurement of NDI in percentage (%) was done
Table 1: Comparison of VAS scores between Group A and

in both the groups. Group B

Members Copy, Not for Commercial Sale

Variable Group A Group B T Value P Value

Statistical Analysis (VAS) Mean± SD Mean± SD
www.IndianJournals.com

VAS0 6.76±0.83 7.15±0.80 1.201 0.241 NS

Data analysis was performed with the software
VAS1 4..15±0.80 5.07±0.75 3.016 0.006*
package SPSS 12 for window version. Mean and
VAS2 2.07±0.75 3.00±0.70 3.207 0.004*
standard deviation of all the variables were calculated.
VAS3 2.00±0.70 2.84±0.80 2.856 0.009*
Comparison between the groups for all the variables *Not significant; **Significant at p<0.05; Group A – Myofascial
(VAS score, ROM and NDI Score ) on Day 0, 1 week, release; Group B - Muscle stretching
2 week and follow up at 1 week was done using paired
t test. Comparison of effect of treatment within the group Table 2: Comparison of ROM scores between Group A and
for all the variables was done using one way ANOVA. Group B
The significance level was kept at 95% (p <0.05). Variable Group A Group B T Value P Value
(ROM) Mean± SD Mean± SD
RESULTS ROM 0 32.23±3.76 30.84±3.23 1.005 0.32NS
ROM 1 37.15±3.15 34.84±2.93 1.928 0.66NS
The results revealed a significant difference between ROM 2 40.84±2.51 38.23±2.42 2.703 0.12NS
group A and B at the end of the study depicting that ROM 3 40.76±2.68 38.07±2.36 2.717 0.12NS
Myofascial Release Technique combined with hot pack *Not significant; **Significant at p<0.05; Group A – Myofascial
was more effective than Muscle stretching combined release; Group B - Muscle stretching
with hot pack in improving pain, decreasing disability
and increasing range of motion of cervical spine. Table 3: Comparison of NDI scores between Group A and
Group B
Change in VAS Score Variable Group A Group B T Value P Value
(NDI) Mean± SD Mean± SD
The measurement of Visual Analogue Scale (VAS) was NDI 0 32.30±6.72 33.69±7.38 1.000 0.62NS
done at baseline (VAS0), 1week (VAS1), 2 week NDI 1 18.23±5.06 22.84±6.46 0.324 0.05*
(VAS2) and 1 week after the treatment (VAS3, follow NDI 2 12.38±2.81 17.07±5.46 0.011 0.011*
up). Difference between the values of all variables NDI 3 12.15±2.99 16.92±5.21 0.018 0.009*
within the groups were calculated using repeated *Not significant; *Significant at p<0.05; Group A – Myofascial release;
measures analysis of variance (ANOVA) post hoc for Group B - Muscle stretching

10 Vol. 2, No. 1, April, 2015

 Comparing Effectiveness of Myofascial Release and Muscle Stretching on Pain, Disability and Cervical Range of Motion in Patients
with Trapezius Myofascial Trigger Points

at baseline (NDI 0), 1week (NDI 1), 2 week (NDI 2) Comparison between mean values of Group A
and 1 week after the treatment (NDI, follow up). and Group B for VAS
9
Difference between the values of all variables within 8

Mean values
the groups were calculated using repeated measures 7
6
analysis of variance (ANOVA) post hoc for the pairs 5
4
NDI O- NDI 1, NDI 1- NDI 2, NDI 2- NDI 3 and 3
Group A
NDI 0- NDI 3 for both groups separately. 2 Group B
1
0
DISCUSSION VAS0 VAS1 VAS2 VAS3

The result of this study showed that Myofascial release Intervention period
is a more effective technique than muscle stretching in Figure 1: Change in VAS between group A and B
reducing pain (measure by VAS), disability (measure
by NDI) and increasing range of motion (measured by
Comparison between mean values of Group A
goniometer) in patients with myofascial trigger point of and Group B for ROM
trapezius muscle. Subjects included in this study had 45
40
similar baseline values of all dependent variables
Mean values
35
Downloaded From IP - 210.212.82.17 on dated 22-May-2017

30
selected suggesting that both group had homogenous 25
distribution of patients. The age, VAS, ROM, NDI of 20
Members Copy, Not for Commercial Sale

15
both groups came out to be non significant at baseline Group A
10
www.IndianJournals.com

5 Group B
when compared using ‘t’ test. 0
VAS0 VAS1 VAS2 VAS3
Within group A, pain intensity was measured from
Intervention period
baseline-1 week and 2 week with means difference of
2.61, 2.06 which was significant (p<0.05) and further Figure 2: Change in ROM between group A and B
from 1 week-follow up which was not significant. The
percentage change in pain intensity within was 70.41%. Comparison between mean values of Group A
Range of motion (ROM) was measured from baseline- and Group B for NDI
45
1 week and 2 week with means difference of 4.92, 40
Mean values

35
3.69 which was significant (p<0.05) and further from 2 30
week-follow up which was not significant. The 25
20
percentage change in pain intensity with in group was 15
Group A

26.46%. NDI was measured from baseline-1 week and 10 Group B

5
2 week with means difference of 14.07, 5.84 which 0
VAS0 VAS1 VAS2 VAS3
was significant (p<0.05) and further from 2 week-follow
up which was not significant. The percentage change Intervention period
in neck disability index score with in group was 62.38%. Figure 3: Change in NDI Score between group A and B
The results of our study are in accordance with the
by reducing pain, muscle tension and improving range
results of previous studies. Manheim, Carl in his study
of motion9.
concluded that Myofascial releases technique releases
the fascia restriction which causes pressure in the According to Kostopoulos, Dimitrios and Rizopoulos
fibrous band of connective tissue10. It causes capillary pain reduction with myofascial release technique in
dilation and an increased in the blood flow to the muscle myofascial trigger point may result from reactive
which in turns increase the removal of waste products hyperaemia in the local area, due to counter-irritant
that causes stimulation of nociceptors pain fibers there effect or a spinal reflex mechanism that may produce

Indian Journal of Health Sciences and Care 11

 Sonia Pawaria, Sheetal Kalra
reflex relaxation of the involved muscle. The treatment
of myofascial trigger point involves lengthening of the
sarcomeres, which reduces the energy consumption and
in turn will cease the release of noxious substance10.
Within group B, pain intensity was measured from
baseline-1week and 2 week with means difference of
2.07, 2.07 which was significant (p<0.05) and further
from 2week-follow up which was not significant. The
percentage change in pain intensity within was 60.27%.
In range of motion (ROM) was measured from baseline-
1 week and 2 week with means difference of 4.00,
3.38 which was significant (p<0.05) and further from 2
week-follow up which was not significant. The
percentage change in pain intensity within was 23.44%.
In disability (NDI) was measured from baseline-1 week
and 2 week with means difference of 10.84, 5.76 which
Downloaded From IP - 210.212.82.17 on dated 22-May-2017
was significant (p<0.05) and further from 2 week-follow
up which was not significant. The percentage change
Members Copy, Not for Commercial Sale
in pain intensity within was 49.77%.
www.IndianJournals.com
When a muscle is suddenly stretched, muscle spindles
produce a reflex resistance to the stretch. This is a
protective mechanism that acts to prevent or resist the
muscle being excessively stretched and injured.
However, with static or prolonged stretches that are
held for between 6 and 60 seconds, the golgi tendon
organs cause a reflex relaxation of the muscle, allowing
the muscle to stretch through relaxation before
extensibility limits are reached7.
Passive stretching is directed at lengthening the over
shortened muscle fibers. It involves slow stretching
because in a fast stretch, only healthy fibers will be
extended. Slow stretching with proper concentration,
relaxation and breathing will inhibit the gamma spindle
response that causes the muscle to shorten when rapidly
stretched. Passive stretching involves stretching the
muscle to the end of range of motion and holding it
there for 45 sec until the muscle relaxes. Whereas
Myofascial release works directly on the trigger points,
passive stretching involves the whole muscle in a way
that allows for the lengthening of the contracted
sarcomeres 6.
In the follow up after 1 week the mean difference was
not significant, it may be decrease in length of the
12
affected muscle promotes vasoconstriction and induction
of a hypoxic state at the affected areas of the muscle.
The pain may attempt to compensate for it by restricting
motion, generating further muscle shortening.
In between group, pain intensity p value was significant
difference from 1 week to follow up (p<0.05). In muscle
length, p value was not significant from baseline to 1
week and further from 2 week to follow up was
significant (p<0.05). In range of motion, p value was
not significant from baseline to follow up was not
significant (p>0.05). In disability, p value was significant
difference from 1week to follow up (p<0.05).
The combined effect of myofascial release, with hot
pack causes increase in blood circulation helping the
muscle to achieve an energetically adequate metabolic
state.
Limitations of Study
1. The sample size was small.
2. There were no long term follow up.
3. Immediate effect was not measured.
5. Only trigger point in the upper trapezius was
evaluated.
Relevance to Clinical Practice
The study provides therapists with the evidence on which
to base their judgment of the effectiveness of the
myofascial release, with respect to pain, disability, ROM,
Muscle length in patients with active myofascial trigger
point.
Thus, it reinforces that Myofascial release can be used
as an adjunct to conventional Physiotherapy program
in the management of myofascial trigger point.
Future Research
Future research can be done with a large group of
samples including subjects with different age groups.
Future research is also needed to see whether the
myofascial release continued for a longer period of time
can reduce more pain, disability and increase range of
motion.
Vol. 2, No. 1, April, 2015
 Comparing Effectiveness of Myofascial Release and Muscle Stretching on Pain, Disability and Cervical Range of Motion in Patients
with Trapezius Myofascial Trigger Points
CONCLUSION
On the basis of present study, it can be concluded that
although, both the Myofascial release and muscle
stretching have found to be effective in reducing pain,
disability and increasing range of motion. However the
subjects treated with Myofascial release showed better
results in reduction of pain,functional status and
improved ROM. Hence it is concluded that Myofascial
release with hot pack is an effective therapeutic option
in the treatment of active myofascial trigger point.
REFERENCES
1. Mariana RS, Fernandes C, Blanco CR, Sequra RM, Rafel
GL. Change in pressure pain sensitivity in latent myofascial
trigger points in the upper trapezius muscle after a cervical
spine manipulation in pain-free subjects. J Manipulative
Downloaded From IP - 210.212.82.17 on dated 22-May-2017
Physiol Ther 2007; 30: 551-556.
2. Dommerholt J, Boren C, Franssen J. Myofascial trigger
Members Copy, Not for Commercial Sale
points: Evidence-Informed Review. J Manual & Manipulative
www.IndianJournals.com
Ther 2006; 14(4): 203-221.
3. Fernandez C, Alonso C, Blanco, Fernandez - Carnero J,
Miengolarra JC. The immediate effect of ischemic
compression technique and transverse friction massage on
tenderness of active and latent myofascial trigger point: a
Indian Journal of Health Sciences and Care
pilot study. Journal of Bodywork and Movement Therapies
2006; 14(4): 203-221.
4. Lavelle ED, Lavelle WF, Smith HS. Myofascial pain trigger
points. Medical Clinics of North America 2009; 4(4): 353-
361.
5. Sciotti VM, Mittak VL, DiMarco L, Ford LM, Plezbert J,
Santipadr E, et al. Clinical precision of myofascial trigger
point location in the trapezius muscle. Pain 2001; 93(3):
259-266.
6. Simon DG, Travel JG, Simons LS. Myofascial pain and
dysfunction: The Trigger point. Manual; Volume 1. The
Upper half of the body. 2nd ed. Williams and Wilkins, 1999.
7. Esenyel M, Cagar N, Aldemir T. Treatment of Myofascial
Pain. American Journal of Phys Med & Rehab 2000; 79: 48-
52.
8. Richard Shacksnovis. Effectiveness of myofascial
manipulation versus Ischaemic compression in the treatment
of myofascial trigger points of the upper trapezius muscle.
2002; 34-46.
9. Manhem C. The Myofascial Release Manual. 3rd ed. 2001.
SLACK Incorporated.
10. Kostopoulos, Dimitrios, Rizopolous K. The Manual of
Trigger Point and Myofascial Therapy, SLACK Incorporated,
Thorofare, NJ; 2004.
13