Timothy LaPointe 1

Literature Review

Introduction:

Neck pain is becoming a serious problem in society. It causes one of the highest health

care costs in the United States and is the reason for many job absences. Mechanical neck pain

(MNP) also has an increasing prevalence as people get older.1 As there are not definitive

treatments for MNP, there are many options out there. One such option is the use of muscle

energy techniques (METs) to help decrease pain and increase range of motion (ROM). METs,

however, are divided into further categories of reciprocal and autogenic inhibition techniques.

This review sought to answer the following question: In adults with MNP, what is the effect of

autogenic inhibition METs, compared to reciprocal inhibition METs, on pain and ROM?

Three sources were found to be of interest for this review. The first article compared to

effects of autogenic inhibition (AI) vs reciprocal inhibition (RI) combined with more

conventional techniques on pain, disability, and ROM.2 This very closely aligned with the

question this review wanted to answer. Since both groups within this study received the same

conventional therapy, it helps shed light on whether autogenic inhibition or reciprocal inhibition

could be better for the outcomes measured.

The second article compared the effects of autogenic and reciprocal inhibition on

isometric muscle strength in adults with MNP. This article also compared the use of METs to

static stretching to see if it had similar effects on strength.3 Though this article does not explicitly

study the use of METs on neck pain and ROM, studies have shown that isometrics have a

significant influence on decreasing neck pain and help in correcting cervical muscle

dysfunction.4
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The third article also used autogenic inhibition, reciprocal inhibition, and static

stretching, but this time looked at those treatments affects on pain, neck disability, and ROM. 5

Similar to the first article, this article will help show whether autogenic or reciprocal inhibition

will be more effective at treating MNP in adults.

Methods/Analysis:

The methods of the first article included dividing 80 participants, ages 20-50, into two

random groups. One group received autogenic inhibition MET, while the other received

reciprocal inhibition MET. The participants had moderate MNP for more than four weeks and

had limited neck ROM. Anyone with a history of trauma, fracture, or cervical surgery were

excluded, as well as those with signs and symptoms of cervical myelopathy, radiculopathy, or

serious pathologies like malignancies or rheumatic diseases.

There was a total of 12 sessions, 3 sessions per week for 4 weeks. Conventional therapy for

MNP was also provided to both groups which included: Maitland posterior-anterior central glides

(30 oscillations, 3 sets) at Grade 1 and 2, isometric neck strengthening (10 reps, 5-second holds,

1 set), followed by superficial heat for 10 minutes on the neck. For the METs, they were applied

to the upper trapezius, sternocleidomastoid (SCM), levator scapulae, and scalene muscles.

Patients were told to use 50% of the total patient’s effort during METs. In AI, the muscle being

stretched is contracting. The stretched position was held for 10 seconds with a 5 second rest in-

between reps. This was repeated 5 times. In RI, the agonist muscle contracts after the antagonist

muscle is stretched. The position was held for 10 seconds with a 5 second rest in-between reps.

This was repeated 5 times.

A visual analogue scale, the neck disability index, and goniometric measurements were used

to determine outcomes. A two-way ANOVA was used to determine significant differences

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between the groups and between the various outcome measures used. Before and after was also

compared within groups.2

The second article contained 78 participants that were randomly assigned to one of three

groups. The groups were static stretching, AI MET, and RI MET. These patients were

experiencing moderate pain (numeric pain rating scale 4-8) with limited ROM in the cervical

spine. Similar to the first study, if the patient had a history of trauma, fracture, surgery, or red

flags for more serious pathology, they were excluded.

The study was conducted over five consecutive sessions. Every group was given trans

cutaneous electrical nerve stimulation (TENS), a hot pack, and Maitland posterior-anterior

glides, followed by the intervention of their assigned group. TENS was administered for 10

minutes in combination with the superficial heat. The glides had 3 sets of 10-15 oscillations

within grade 1 or 2 for pain management. The static stretch group held each stretch for 15-30

seconds and repeated 3-5 times. Both AI and RI groups received 3-5 reps of their respected

treatment. The patients were told to 3-5 reps of their respected treatment. The patients were told

to use 30-50% max strength during the agonist contracting (RI group) or the antagonist

contracting (AI group). The stretch was held for 10 seconds, followed by a 5 second relaxation,

then stretch of 10-60 second holds. The same muscles were targeted as mentioned in the first

article description.

A numeric pain rating scale and modified sphygmomanometer dynamometry were used as

the outcome measures. A one-way ANOVA and repeated measures ANOVA were used to

determine statistical differences between groups and within group measurements. 4

The last article was published by the same author as the second article. This resulted in

similar inclusion/exclusion criteria. The same sample size was used consisting of 78 participants
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ranging in the ages of 18-70 years old. Only sub-acute and chronic MNP patients were included

(4-12 weeks). Again, the participants were divided into three groups: static stretch, RI MET, and

AI MET. The protocol was the exact same as the second study mentioned, including the use of

TENS, a hot pack, and Maitland posterior-anterior mobilizations.

In this article, a numeric pain rating scale, the neck disability index, and goniometric

measurements were used as the outcome measures. A one-way ANOVA was used for comparing

the groups at baseline and post-treatment, followed by Tuckey’s test for post-hoc analysis.5

Conclusion/Discussion:

The first article aimed to compare the effects of AI and RI METs with conventional

therapy for MNP. The study concluded that AI MET improved neck pain, improved disability

scores, and increased ROM better when compared to the RI MET group. The results of this study

do not discourage the use of RI MET when treating MNP as the results did show improvements

in that group’s scores as well. However, when comparing the two groups together, The AI MET

group had great improvements.2 This helps answer the question on which method is better for

treatment.

The second article aimed to compare the effects of AI MET, RI MET, and static

stretching on isometric muscle strength of the neck muscles. This study concluded that AI MET

was better at increasing the isometric strength. Significant differences were observed between

groups when comparing the dynamometer results, with AI MET having the greatest increase. RI

MET did have a significant improvement in strength when compared to static stretching, but not

as much as AI MET.4 Again, this study does not disapprove of the use of RI when treating neck

pain, but it does show that AI is the better option of the two.
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The third article aimed to discover which treatment was best for treating MNP and

increasing ROM. This study also assessed immediate effects of treatment and found that AI had

greater improvements in all outcome measures compared to static stretching and RI. However,

there was no significant difference between RI and static stretching after the first session. At the

end of the last treatment session, AI had, again, a greater effect on all outcome measures

compared to static stretching and was superior in terms of ROM when compared to RI. There

was, however, no significant difference between the AI and RI groups on the NDI and NPRS. RI

was superior over static stretching in NDI, NPRS, and ROM in rotation.5 This helps prove that

AI can be beneficial immediately when treating MNP and increase ROM better compared to RI,

but may not help with pain anymore than RI would.

Quality of Evidence:

According to the Physiotherapy Evidence Database (PEDro) scale, all three articles

received at least a “fair” score. The first article received an 8/10. The second article received a

7/10. The third article received a 5/10. PEDro classifies artcles in the 4-5 range as “fair”, while

articles in the 6-8 range are “good.” PEDro also states that in trials that evaluate complex

interventions, like therapy/exercises, 8/10 is “optimal.” This is due to the fact that the subjects

and administering therapist would not be blind to the treatments received and provided.

Since the PEDro scores were decently high for all three trials, it seems they are studies

that would be reproducible and trustworthy. They provide good clinical evidence that can be used

in practice. The only skeptical trial comes from article three. Receiving a score of 5/10 hurts its

trustworthiness and potential clinical application. However, it is still labeled as “fair” evidence. It

is overall not a poor trial to look at but may require a deeper look into or possibly an expansion

on its research.6 Blinding the assessors is an improvement the trial could make. Due to the fact
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that other, more strongly rated trials, agree with the third articles results, it would be safe to trust

what the trial presents.

Clinical Implications:

Based on the evidence provided by the literature reviewed and the PEDro scores given to

said literature, it would be best practice to use AI METs when treating patients with MNP over

stretching or RI METs. However, all three trials used conventional therapies in combination with

the studied interventions when treating the participants. This would indicate that an AI MET

should not be used in isolation when practicing. When deciding on treatments for patients with

MNP, the literature supports the use of AI METs to help increase ROM, decrease pain, decrease

scores on the NDI, and increase isometric strength of the neck muscles. The best dosage for the

AI METs appeared to be 30-50% of max strength of the involved muscle, 10 second stretch

holds, and 5 second rests in between reps. This should be repeated 3-5 times.2,4,5
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References

1. Kazeminasab S, Nejadghaderi SA, Amiri P, et al. Neck pain: global epidemiology, trends

and risk factors. BMC Musculoskelet Disord. 2022;23(1):26. Published 2022 Jan 3.

doi:10.1186/s12891-021-04957-4

2. Siddiqui M, Akhter S, Baig AAM. Effects of autogenic and reciprocal inhibition

techniques with conventional therapy in mechanical neck pain - a randomized control

trial. BMC Musculoskelet Disord. 2022;23(1):704. Published 2022 Jul 25.

doi:10.1186/s12891-022-05668-0

3. Osama M. Effects of autogenic and reciprocal inhibition muscle energy techniques on

isometric muscle strength in neck pain: A randomized controlled trial. J Back

Musculoskelet Rehabil. 2021;34(4):555-564. doi:10.3233/BMR-200002

4. Yang J, Yang M, Lin Q, Fu J, Xi R. Effects of isometric training on the treatment of

patients with neck pain: A meta-analysis. Medicine (Baltimore).

2022;101(39):e30864. doi:10.1097/MD.0000000000030864

5. Osama M, Rehman S. Effects of static stretching as compared to autogenic and reciprocal

inhibition muscle energy techniques in the management of mechanical neck pain: A

randomized controlled trial. Journal of the Pakistan Medical Association. 2020;70(5).

doi:10.5455/jpma.9596

6. Pedro scale. PEDro. September 9, 2020. Accessed March 15, 2024.

https://pedro.org.au/english/resources/pedro-scale/.