ORIGINAL ARTICLE ISRA MEDICAL JOURNAL | Volume 10 - Issue 4 | Jul – Aug 2018

Comparison between Effectiveness of Ischemic Compression and Muscle

Energy Technique in Upper Trapezius Myofascial Trigger Points

Mehak Hamna Zahra Gilani1, Summiyah Obaid2, Mariam Tariq3

ABSTRACT

OBJECTIVES: To assess the comparative effectiveness of Ischemic Compression and muscle energy technique for the treatment of
Myofascial trigger point in the Upper Trapezius muscle.
STUDY DESIGN: A randomized comparative trial
PLACE AND DURATION: The study was conducted in University of Faisalabad, in six months from 1 st March 2017 to 1st August 2017.
METHODOLOGY: Thirty Subjects were randomly placed into two group’s i.e. G1- received ischemic compression and G2- received
muscle energy technique. Passive stretching was the baseline treatment. Cervical flexion, extension, bilateral side bending and
rotations measured with Goniometer; pain level measured with numeric pain rating scale and limitations in activities of daily living
was measured by neck disability index.
RESULTS: Both interventions are significantly effective but ischemic compression showed more reduction in pain then muscle
energy technique as p value=0.000 after 12 sessions of both interventions. There is also significant difference in both groups related
to range of motion. Muscle energy technique is more effective than ischemic compression as p value is 0.000 after 12 sessions of
both interventions. After 12 sessions of intervention, measurements showed 9% and 13.67% disability rate of ischemic compression
and muscle energy technique group respectively on neck disability index.
CONCLUSION: The treatment program consists of ischemic compression and muscle energy technique may be effective in reducing
pain, but for range of motion, muscle energy technique is more effective than Ischemic compression in upper trapezius myofacial
trigger points to reduce pain and improve the range of motion.
KEY WORDS: Female, Sewing machine operators, Range of motion, Neck, Numeric pain scale, Neck disability index, Myofascial pain
syndrome, Myofascial trigger points, Ischemic Compression, Muscle energy technique,.

HOW TO CITE THIS:

Gilani MHZ, Obaid S, Tariq M. Comparison between Effectiveness of Ischemic Compression and Muscle Energy Technique in Upper
Trapezius Myofascial Trigger Points. Isra Med J. 2018; 10(4): 230-234.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-Noncommercial 4.0 International License
(http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.

INTRODUCTION
1. Doctor of Physical Therapy
2. Assistant professor of Musculoskeletal Physical A myofascial trigger point seems like a hyperirritable spot,
Therapy present inside a tight band of skeletal muscle, which produce
3. Student, Master in Musculoskeletal Physical Therapy pain on compression and referred pain in a specific pattern and
motor dysfunction1,2. There is evidence of relationship
The University of Faisalabad, Faisalabad
between mechanical neck pain (MNP) and impairment of
Correspondence to: cervical spine muscles3
Mehak Hamna Zahra Gilani Trigger points within the cervical muscles have specific
Doctor of Physical Therapy referred pain patterns. Myofascial pain syndrome is a type of
The University of Faisalabad, Faisalabad myalgia characterized by specific area of muscle hardness and
Email: hamnagilani206@gmail.com tenderness that leads to referred pain. The significant feature
is the trigger point, muscle having a tender, taut band that can
Received for Publication: 15-01-18 be painful spontaneously or when compression is applied 4-5.
1st Revision of Manuscript: 16-03-18 Referred pain pattern stimulated by trigger points in the upper
2nd Revision of Manuscript: 20-04-18 trapezius muscle consist of posterior-lateral region of the
3rd Revision of Manuscript: 26-04-18 cervical spine, temporal region and back of the ear6
4th Revision of Manuscript: 15-05-18 There are two types of myofascial trigger points; one is Active
5th Revision of Manuscript: 01-06-18 and second is Latent trigger point. These both types of trigger
6th Revision of Manuscript: 27-06-18 point initiate pain on palpation but only active myofascial
Accepted for Publication: 13-07-18 trigger point produces pain on rest and at movement but the

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Mehak Hamna Zahra Gilani et al
latent trigger point does not produces pain at rest 7.
Continuous or recurrent biomechanical overloading of soft
tissues leads to muscular injury8. Travell and Simons originally
recommended ‘ischemic compression’ for trigger points (TrPs)
with thumb pressure firm enough to cause the skin to blanch 9.
However, ‘ischemic compression’ be replaced with ‘trigger
point pressure release later 10. A constant pressure applied on
affected muscle by digits. It slows down the blood supply there
and decrease the pain, when pressure is released blood rushed
towards muscle and waste material remove from there 11,12
The significance of our study showed that the more effective
therapy will provide significant clinical value for the
development of treatment protocols to evaluate the patient
presenting with active upper trapezius Myofascial trigger point.
Non–invasive quality of Ischemic compression and muscle
energy technique (Muscle Energy Technique (MET) is a form
of a manual therapy which uses a muscle’s own energy in
the form of gentle isometric contractions to relax the
muscles via autogenic or reciprocal inhibition, and lengthen
the muscle.) for Myofascial trigger point release is of worth
importance.
Study background showed that the incidence of developing
upper trapezius myofascial trigger point in sewing machine
operators is much higher due to continuous overloading and
bad posture. Taking into account the increased risk to develop
myofascial trigger points due to improper posture in females
operating sewing machines, we decided to take “Female
sewing machine operators of sapphire textile factory Lahore as
they work continuously for 8 to 9 hours and more prone to
develop upper trapezius trigger point.
The rationale of our study is that there is limited result related
to this population (female sewing machine operators) in
treating upper trapezius Myofascial trigger points. We select
this population as there is increased risk of developing
Myofascial trigger point in upper trapezius muscle in female
sewing machine operators due to bad posture such as forward
neck posture.There is very limited dataavailable on search
engines related to our topic as comparison of muscle energy
technique and ischemic compression in Myofascial upper
trapezius trigger points.
Objective of our study is to assess the comparative
effectiveness of Ischemic Compression and muscle energy
technique for the treatment of Myofascial trigger point in the
Upper Trapezius muscle.
METHODOLOGY
This randomized comparative trial was done in university of
Faisalabad, in six months from 1st March 2017 to 1st August
2017. Total 30 female sewing machine operators of age 20 to
50 years are included on the basis of assessment of myofascial
trigger point and inclusion exclusion criteria after taking
informed consent from them. All cases of female with age 20
to 50 years, Active myofascial trigger points in upper trapezius
which are present bilaterally, taut band having palpable nodule
within in upper trapezius muscle and pain produced in specific
pattern which is radiating in character when a firm pressure is
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ISRA MEDICAL JOURNAL | Volume 10 - Issue 4 | Jul – Aug 2018
applied on trigger point were included.
Participants with pain pattern which is similar to pain of trigger
point due to any other reason not related myofascial trigger
points, any trauma to cervical spine (whiplash injury),
osteoporosis of cervical spine, cervical myeloma, complex
regional pain syndrome, any cervical spine surgery, thoracic
outlet syndrome and patient using analgesic drugs were
excluded.
Thirty Participants included in this study by taking inform
consent. Assessment was done by self-developed screening
questionnaire. Travel and Simon criteria was used to diagnose
trigger point.13, 14 Permission from sapphire ethical committee
was taken. Participants were randomly allocated into
experimental and control groups by using convenient sampling
technique in order to study two intervention. Group A received
ischemic compression in supine position and Group B received
Muscle energy technique in supine position. Both groups
received passive stretching of upper trapezius as a base line
treatment. Intervention was given for 4 weeks (12 sessions per
month).One treatment session of ischemic compression and
muscle energy technique included 10 minutes and 15 minutes
respectively for each patient. Outcomes measurement was
taken after every 3rdsession (1 week) of intervention. Primary
outcome measures were Pain and Range of motion which were
measured through numeric pain rating scale and goniometer
respectively. Percentage of disability in activities of daily living
and all segments of neck disability index were secondary
outcome measures that were examined by standard neck
disability index questionnaire.
Data Analysis: Data was analyzed on Statistical Package for
Social Sciences (SPSS) version 20. Independent t test was
applied on the quantitative variables such as pain, range of
motion and percentage disability. Repeated measure ANOVA
was applied on the quantitative variables to evaluate
difference with in each group measurements. Descriptive
statistics (cross tab) applied on neck disability index.
Confidence interval was 95% for analysis. P-value ≤0.05 was
considered significant.
RESULTS
Total thirty participants were divided in two equal groups.
Level of significance speaks for p value, (P Value =0.05) for
every test. Results showed that ischemic compression and
muscle energy technique are both effective to increase neck
flexion as (p<0.05). Ischemic compression and muscle energy
technique are both effective to increase neck extension after 2
weeks but muscle energy technique is more effective than
ischemic compression after third and fourth week as
(p<0.05).Muscle energy technique is more effective than
ischemic compression to improve left Lateral flexion and right
lateral flexion as (p<0.05). MET and IC are both effective to
increase left rotation after 2 weeks but muscle energy
technique is more effective than ischemic compression after
3rd and 4th week to improve left rotation and right rotation
after 1st 2nd and 3rd week but MET is more effective than IC to
improve right rotation after 4th week as (p<0.05) (cluster bar
Mehak Hamna Zahra Gilani et al ISRA MEDICAL JOURNAL | Volume 10 - Issue 4 | Jul – Aug 2018

Fig -1). From statistical point both interventions are effective to muscle energy technique to decrease pain (p<0.05) (cluster bar
reduce pain but ischemic compression is more effective then Fig-2).

Table-I: Independent t test for Neck Range of Motions between two groups (N=30)
GROUP I (N=15) GROUP II (N=15)
Variables Time Points Mean difference p-Value
(Mean±SD) (Mean±SD)
Baseline 34.47±4.068 31.73±4.36 2.733 0.08
Follow up I 35.53±2.94 36.33±2.76 1.200 0.26
Follow up II 39.67±1.799 39.20±2.210 0.467 0.53
Flexion Follow up III 38.27±1.62 41.3±1.83 1.933 0.05
Follow up IV 38.60±1.549 44.13±0.99 -2.533 0.01
Base Line 50.33±7.007 49.13±6.97 1.200 0.638
Follow up I 52.20±5.401 53.67±3.83 -1.467 0.399
Follow up II 54.27±4.317 55.67±3.69 -1.400 0.348
Extension
Follow up III 55.53±3.77 57.53±2.23 -2.00 0.091
Follow up IV 56.13±3.75 59.27±1.94 -3.133 0.009
Base Line 30.53±1.846 29.93±1.944 0.600 0.394
Follow up I 31.53±1.598 36.20±2.178 -4.667 0.000
Right lateral flexion
Follow up II 34.87±1.87 40.00±1.648 -5.133 0.000
Follow up III 35.80±1.014 42.27±1.710 - 6.467 0.000
Follow up IV 38.60±1.134 44.60±0.828 -6.600 0.000
Base Line 30.53±1.246 29.47±1.642 1.067 0.07
Follow up I 31.73±1.163 35.60±2.354 -3.861 0.000
Left lateral flexion Follow up II 34.93±0.799 39.13±2.066 -4.200 0.000
Follow up III 36.27±0.961 41.87±1.356 -5.600 0.000
Follow up IV 37.93±1.486 44.07±0.704 -6.133 0.000
Base Line 44.60±3.996 44.53±3.182 0.067 0.960
Follow up I 51.40±4.239 52.40±5.705 -1.000 0.590
Right rotation
Follow up II 55.67±5.394 57.47±7.501 -1.800 0.457
Follow up III 59.87±6.988 62.80±6.050 -2.933 0.229
Follow up IV 60.80±7.523 68.80±4.507 -8.000 0.002
Base Line 45.33±4.685 43.20±8.504 2.133 0.404
Left rotation Follow up I 51.27±4.026 51.13±5.655 0.133 0.941
Follow up II 55.93±5.637 57.00±6.414 -1.067 0.632
Follow up III 56.33±5.740 63.07±5.325 -6.733 0.001
Follow up IV 59.27±5.612 69.07±5.370 -9.800 0.000

Fig-2: Independent t test for restriction in ADLs% between

Fig-1: Independent t test for numeric Pain Rating Scale
two groups (N=30)
between two groups (N=30)

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Mehak Hamna Zahra Gilani et al
From statistical point both interventions are effective to
reduce disability but ischemic compression is more effective
then muscle energy technique to improve activities of daily
livings as percentage disability decrease up to 9% by ischemic
compression as compare to muscle energy technique that is up
to 13%.(p<0.05) (Table - I)
Baseline: Before treatment, Follow up 1: after 1st week of
intervention, Follow up II: after 2nd week of intervention,
Follow up III: after 3rdweek of intervention, Follow up IV: after
4th week of intervention. Group I: Ischemic compression Group
II: Muscle energy technique
DISCUSSION
In our study the outcome measures included pain intensity by
VAS plus NPRS, cervical ranges by standard Goniometer and
percentage disability by NDI. Each outcome variable is
measured five times during study. First prior to intervention
application, second, third, fourth and fifth after follow up 1 (1
week) follow up 2 (2nd week), follow up 3(3rd week), and follow
up 4(4th week). Different studies have also assessed the
outcome of intervention by Visual analogue scale, CROM
Goniometer and pain pressure threshold. 15-17 In our study the
intergroup comparison of VAS score was done using
independent t-test which showed 'P' significant after 4 weeks
of treatment, comparison of ROM of both Groups A and B was
done using independent t-test which showed 'P' value
significant for all the ranges. Statistical analysis shows when
comparing VAS score between Groups A and B, shows same
reduction but ischemic compression is slightly more effective
then muscle energy technique. Statistical analysis shows in
Group A 38 degree improvement in cervical side flexion,
whereas in Group B 44 degree improvement in cervical side
flexion. Statistical analysis shows in Group A 59 degree
improvement in cervical rotation, whereas in Group B 69
degree improvement in cervical rotation. When comparing the
ranges in improvement in ROM between Groups A and B,
shows there is more increase in ROM in Group B at the end of
the treatment (after 4 weeks) compared to Group A.
Our result supports the study of Shah and shah et. al who
worked with individual suffered from neck pain to compare the
effect of ischemic Compression and muscle energy technique.
Outcome measures were pain from VAS, pressure pain
threshold and cervical range of motion of lateral flexion of
contra lateral side on the 1st day at baseline and on the 6th
day after the intervention. Ischemic compression proved to be
more adequate than MET in decreasing PPT. MET was more
productive than Ischemic compression technique in improving
rang18
Another study conducted by Jagad et al supported our study
who worked on upper trapezius trigger point to compare the
effectiveness of ischemic compression passive stretching and
active general neck exercises followed by stretching. Pressure
Pain Threshold (PPT) measured by pressure algometry was
used to measure trigger point sensitivity and Visual Analogue
Scale (VAS) was scored as a measure of pain intensity on day 1
and day 8 in both the groups. Ischemic compression technique
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ISRA MEDICAL JOURNAL | Volume 10 - Issue 4 | Jul – Aug 2018
is highly effective in reducing the trigger point sensitivity and
pain intensity in the trapezius muscle19
A study conducted by Kumar et al. also supports our study as a
4 week treatment of Ischemic compression, Strain Counter
strain and Muscle energy technique were productive in the
treatment of upper Trapezius trigger points while there is
some difference seen in the Muscle energy technique group.
Outcome measures were Visual analogue scale (VAS) for pain,
cervical lateral flexion range of motion (CROM) and neck
disability index (NDI). At the end the study proved that Muscle
energy technique is more effective than ischemic compression
and strain counter strain intervention20
The investigation done by Fryer et al, shows same results as
our study in which after 12 treatment sessions of both MET
and MFR in combination to therapeutic ultrasound were
effective in reduction of pain in upper trapezius trigger point
while, the MET when combined with therapeutic ultrasound
was more effective than that of MFR21
CONCLUSION
The treatment program consists of ischemic compression and
muscle energy technique are effective in reducing pain, but for
range of motion muscle energy technique is more effective
than IC in upper trepezius myofacial trigger points to reduce
pain and improve the range of motion.
RECOMMENDATIONS
The further studies could be conducted on large sample size
for more accurate presentation of population which will allow
for more apparent trends within the results.
Biomechanical perpetuating factors should also be addressed
in study which could not be done in this study due to number
of variables.
For clinical practice there should be further investigation of
other manual therapies to treat MTrPs.
The study could be done checking the effects on active cervical
ROM as well as cervical spine movement strength.
CONTRIBUTION OF AUTHORS
Gilani MHZ: Conceived idea, Designed methodology,
Manuscript writing, Statistical analysis.
Obaid S: Data analysis and Interpretation
Tariq M: Data collection.
Disclaimer: None.
Conflict of Interest: None.
Source of Funding: None.
REFERENCES
1. Shah JP, Thaker N, Heimur J, Aredo JV, Sikdar S, Gerber L.
Myofascial trigger points then and now: a historical and
scientific perspective. Phys Med Rehab. 2015;7(7):746-61.
Mehak Hamna Zahra Gilani et al
2. Cagnie B, Castelein B, Pollie F, Steelant L, Verhoeyen H,
Cools A. Evidence for the use of ischemic compression and
dry needling in the management of trigger points of the
upper trapezius in patients with neck pain: a systematic
review. Am J Phys Med Rehab. 2015;94(7):573-83.
3. Ashina S, Bendtsen L, Lyngberg AC, Lipton RB, Hajiyeva N,
Jensen R. Prevalence of neck pain in migraine and tension-
type headache: a population study. Cephalalgia.
2015;35(3):211-19.
4. Fernández‐de‐las‐Peñas C, Ge HY, Arendt‐Nielsen L,
Cuadrado ML, Pareja JA. Referred pain from trapezius
muscle trigger points shares similar characteristics with
chronic tension type headache.Eur J Pain. 2007;11(4):475-
82.
5. Desai MJ, Saini V, Saini S. Myofascial pain syndrome: a
treatment review.Pain Ther 2013;2(1):21-36.
6. Stecco A, Gesi M, Stecco C, Stern R. Fascial components of
the myofascial pain syndrome.Curr Pain Headache Rep.
2013;17(8):352.
7. Barbero M, Cescon C, Tettamanti A, Leggero V, Macmillan
F, Coutts F, et al. Myofascial trigger points and innervation
zone locations in upper trapezius muscles.
BMC Musculoskelet Disord. 2013;14(1):179.
8. Cagnie B, Dewitte V, Coppieters I, Van Oosterwijck J, Cools
A, Danneels L. Effect of ischemic compression on trigger
points in the neck and shoulder muscles in office workers:
a cohort study. J Manipulative Physiol Therap.
2013;36(8):482-89.
9. Ganesh GS, Singh H, Mushtaq S, Mohanty P, Pattnaik M.
Effect of cervical mobilization and ischemic compression
therapy on contralateral cervical side flexion and pressure
pain threshold in latent upper trapezius trigger points.J
Body Mov Therap. 2016;20(3):477-83.
10. Fernández-de-Las-Peñas C, Dommerholt J. Myofascial
trigger points: peripheral or central phenomenon?Curr
Rheumatol Rep2014;16(1):395.
11. Oliveira-Campelo NM, de Melo CA, AlburquerqueSendin F,
et al: Short- and medium-term effects of manual therapy
on cervical active range of motion and pressure pain
sensitivity in latent myofascial pain of the upper trapezius
muscle: a randomized controlled trial. J Manipulative
Physiol Ther op 2013;36:300-9
12. Moraska AF, Hickner RC, Kohrt WM, Brewer A. Changes in
blood flow and cellular metabolism at a myofascial trigger
234
ISRA MEDICAL JOURNAL | Volume 10 - Issue 4 | Jul – Aug 2018
point with trigger point release (ischemic compression): a
proof-of-principle pilot study. Arch Phys Med Rehab.
2013;94(1):196-200.
13. Martín-Pintado-Zugasti A, Pecos-Martin D, Rodríguez-
Fernández ÁL, Alguacil-Diego IM, Portillo-Aceituno A,
Gallego-Izquierdo T, et al. Ischemic compression after dry
needling of a latent myofascial trigger point reduces
postneedling soreness intensity and duration. Phys Med
Rehab. 2015;7(10):1026-34.
14. Kim SA, Oh KY, Choi WH, Kim IK. Ischemic compression
after trigger point injection affect the treatment of
myofascial trigger points. Ann Rehab Med 2013;37(4):541-
46.
15. Tough EA, White AR, Cummings TM. Acupuncture and dry
needling in the management of myofascial trigger point
pain: a systematic review and meta-analysis of randomised
controlled trials. Eur J Pain 2009; 13:3-10
16. Myburgh C, Lauridsen HH, Larsen AH, Hartvigsen J.
Standardized manual palpation of myofascial trigger points
in relation to neck/shoulder pain; the influence of clinical
experience on inter-examiner reproducibility. Man Therap.
2011;16(2):136-40.
17. Nambi GS, Sharma R, Inbasekaran D, Vaghesiya A, Bhatt U.
Difference in effect between ischemic compression and
muscle energy technique on upper trepezius myofascial
trigger points: Comparative study. Int J Health Allied Sci.
2013;2(1):17.
18. Shah N, Shah N. Comparison of two treatment techniques:
Muscle energy technique and Ischemic compression on
upper trapezius trigger point in subjects with non-specific
neck pain. Int J Athl Therap. Train 2015;4(5):260.
19. Jagad BH, Jagad KB. Effects of Ischemic Compression on
the Trigger Points in the Upper Trapezius Muscle. Indian J
Physiother Occup Therap. 2013;7(1):99.
20. Kumar GY, Sneha P, Sivajyothi N. Effectiveness of Muscle
energy technique, Ischaemic compression and Strain
counterstrain on Upper Trapezius Trigger Points: A
comparative study. Int J of Phys Edu, Sports & Health.
2015;1(3):22-26.
21. Fryer G, Hodgson L. The effect of manual pressure release
on myofascial trigger points in the upper trapezius muscle.
J Body Mov Therap. 2005;9(4):248-55.