ARTICLE IN PRESS

Effects of Exercise and an Integrated

Neuromuscular Inhibition Technique
Program in the Management of Chronic
Mechanical Neck Pain: A Randomized
Controlled Trial
Dimitrios E. Lytras, PT, MSc, a Evaggelos I. Sykaras, PT, PhD, a Kosmas I. Christoulas, PhD, a
Ioannis S. Myrogiannis, PT, MSc, b and Eleftherios Kellis, PT, PhD c
ABSTRACT

Objective: The aim of this study was to evaluate the effect of adding the integrated neuromuscular inhibition
technique (INIT) to therapeutic exercise (TE) in individuals with chronic mechanical neck pain (CMNP).
Methods: In this 34-week, assessor-blind randomized controlled trial, 40 participants (men and women) with CMNP
with active or latent myofascial trigger points on the neck muscles were divided into 2 groups. The participants
followed 4 treatments per week for 10 weeks. The intervention group followed a TE program in combination with the
INIT, whereas the control group followed the same program without the INIT. Both protocols were applied by
physiotherapists. Pain, disability, pressure pain threshold, active range of motion, and health-related quality of life
were evaluated before, during, and after the intervention, whereas patients were followed for 6 months after
completion of treatment. Repeated-measures ANOVA was applied.
Results: Both groups showed a significant improvement in all dependent measures after the intervention (P < .05).
However, the intervention group showed greater improvement in the visual analog scale and neck disability index
score, in the neck muscles pressure pain threshold, in the range of motion, and in the 36-Item Short Form Health
Survey score, than the control group. In many of the above variables this improvement was seen from the second week
and was maintained for 6 months after the intervention.
Conclusion: The results of this preliminary study suggest that the addition of the INIT to a TE program had a positive
effect on pain, functionality, and the quality of life in individuals with CMNP. (J Manipulative Physiol Ther
2020;00;1-14)
Key Indexing Terms: Exercise; Neck Pain; Therapy; Soft Tissue

a
Laboratory of Ergophysiology, Department of Physical Edu-
cation and Sports Sciences, Aristotle University of Thessaloniki,
Thermi Thessaloniki, Greece.
b
Laboratory of Hygiene Medical Statistics, School of Medi-
cine, Aristotle University of Thessaloniki, University Campus,
Thessaloniki, Greece.
c
Laboratory of Neuromechanics, Department of Physical
Education and Sport Science at Serres, Aristotle University of
Thessaloníki, Agios Ioannis Serres, Greece.
Corresponding author: Dimitrios E. Lytras, PT, MSc, Depart-
ment of Physical Education and Sports Sciences, Aristotle Univer-
sity of Thessaloniki, 57001 Thermi Thessaloniki Greece.
(e-mail: lytrasde@gmail.com).
Paper submitted June 16, 2018; in revised form January 29,
2019; accepted March 1, 2019.
0161-4754
© 2020 by National University of Health Sciences.
https://doi.org/10.1016/j.jmpt.2019.03.011
TAGEDH1INTRODUCTIONTAGEDEN
Neck pain shows a high rate of recurrence and chronic-
ity. Three out of 10 neck pain patients will develop chronic
symptoms that last more than 6 months,1,2 whereas 34%
will show symptoms for more than 12 months.3 Chronic
mechanical neck pain (CMNP) is characterized by a persis-
tence of symptoms for a period longer than 3 months.4 The
exact origin and pathophysiological mechanisms of chronic
neck pain remain unclear. Many researchers have linked
chronic symptoms to changes in neck muscles.5-7 Individu-
als with CMNP exhibit muscle weakness and reduced
endurance in the neck flexor muscles compared to healthy
adults,8 which is highly associated with pain and
disability.8,9
Therapeutic exercise (TE) has proven to be beneficial to
individuals with CMNP.1,2,9,10-13 Improvement of neck
muscle strength and endurance has been associated with
pain reduction and improved functional capacity. Six
weeks of TE in people with CMNP resulted in short-term
 ARTICLE IN PRESS
2 Lytras et al
Management of Chronic Mechanical Neck Pain
effects by reducing pain and improving neck muscle weak-
ness and isometric strength,14 but these effects do not seem
to remain after 6 months. In contrast, Ylinen et al13
reported long-term benefits with pain reduction and disabil-
ity improvement following a 12-month TE program.
The TE programs of individuals with CMNP often
involve resistance and endurance training for neck and
shoulder muscles. The combination of both is a more com-
plete approach with better results.4,13,15,16
Many researchers have pointed out the therapeutic value
of combining TE with manual therapies.2,17,18 Miller et
al16 reported that the combination of exercise and manipu-
lation or mobilization of the cervical and thoracic spine
brought better short- and medium-term reduction of pain
and disability than the application of each type separately.
However, in studies that have implemented a combination
of exercise and manipulation in contrast to manipulation
only, it is not clear whether the differences identified
between the groups are due to the exercise alone or to the
particular combination.19 Thus, the appropriate choice of
techniques and dosage requires further investigation.18
Many researcher studies associate neck pain with the
presence of myofascial trigger points (MTrPs) in the neck
muscles.20-22 MTrP has been defined as a hyperirritable
spot within a taut band of skeletal muscle fibers painful on
compression.23 It has been shown that in people with
chronic neck pain there are almost always more trigger
points in more than 1 muscle. Cerezo-T
ellez et al20 in a
study of 2000 patients with chronic neck pain found that all
participants displayed trigger points in the cervical muscles
with a higher incidence of trigger points in the upper trape-
zius. However, although the occurrence rate is so high, few
studies in chronic neck pain have used a combination of
exercise and MTrPs deactivation techniques.21,24 This por-
trays an important literature gap in the research field of
manual therapy. The presence of MTrPs in individuals
experiencing chronic pain is associated with increased
intramuscular electromyographic activity of the agonist25
and antagonist26 muscles during synergistic muscle activa-
tion and with increased muscle fatigue during isometric
muscle contraction.27 At the same time, Ylinen et al28
reported that people with chronic neck pain have decreased
values in strength and endurance in all muscle groups of
the neck compared with healthy individuals. For this rea-
son, this specific combination of exercise and trigger point
deactivation technique presents a research interest.
The integrated neuromuscular inhibition technique (INIT)
is a manual MTrPs deactivation technique, which has been
described by Chaitow.29,30 It includes the combination of
the ischemic compression technique, the strain-counter-
strain technique, and the muscle energy technique. Sadaat
et al31 reported that 1 session of the INIT is able to reduce
pain and pressure pain threshold (PPT) in individuals with
CMNP due to MTrPs in the upper trapezius muscle.
Nagrale et al32 claimed that the INIT is more effective
Journal of Manipulative and Physiological Therapeutics
2020
than the muscle energy technique in improving pain,
disability, and range of motion (ROM) in individuals with
neck pain, whereas Sibby et al33 suggested that the INIT
is equally effective with laser application in upper trapezius
MTrPs.
The INIT, based on the phenomenon of reciprocal inhibi-
tion and post-isometric relaxation, can resolve muscle spasm
in painful areas29,30 and thus could be optimally combined
with TE in muscles housing MTrPs. The combination of TE
and manipulation, mobilization, or connective tissue mas-
sage has been employed recently for treating CMNP.19,34-38
However, the combination of TE and a MTrPs deactivation
technique has not been widely applied. The purpose of this
study was to evaluate the effect of adding INIT to a TE pro-
gram for management of CMNP. The hypothesis of this
study was that the combination of INIT and TE yields
greater improvement in pain, disability, neck muscle tender-
ness, neck ROM, and quality of life of patients with CMNP
than TE alone. To better monitor treatment effects, several
intermediate measurements were performed.
TAGEDH1METHODSTAGEDEN
Design
This was an assessor-blind, randomized controlled trial
(clinicaltrials.gov number: NCT02802189). Two experi-
enced physiotherapists applied the 2 protocols, the first was
responsible for supervising and conducting the exercise
program and the second was implementing the INIT and
relaxation exercises. It was not possible for care providers
or participants to be unaware of group allocation. A masked
assessor conducted the measurements.
Participants signed an informed consent and were ran-
domly divided into 2 groups. Group allocation was per-
formed by using opaque sealed envelopes, and concealed
allocation was attained with the following procedure: Con-
secutively numbered, opaque envelopes with coded treat-
ment assignment cards were created off-site by the
statistician prior to the start of enrollment, using a 1:1 allo-
cation ratio and randomly mixed permuted blocks of differ-
ent sizes. The randomization schedule and block sizes were
concealed from the team of the study. Randomization took
place at the end the first visit. If the patient met the entry
criteria, the envelopes were opened in consecutive order by
study staff in the presence of the patient. The statistician
prepared the files and secured the random distribution of
the people in the groups. In order to ensure that the partici-
pants of both groups would spend the same treatment time
with their therapist, and get the same level of care, the con-
trol group received an extra 15 minutes of breathing exer-
cise and gentle stretching to balance the 15-minute INIT
program that was applied in the intervention group. This
study abides by the Code of Ethics of the World Medical
Association (Declaration of Helsinki).
 ARTICLE IN PRESS
Journal of Manipulative and Physiological Therapeutics
Volume 00, Number 00
Participants
Forty outpatients, men and woman, aged 30 to 60 years
diagnosed with CMNP were recruited from a rehabilitation
center between June 2016 and March 2017. Inclusion crite-
ria were symptoms with a duration of at least 3 months,
existence of at least 1 active or latent MTrP in any of the
levator scapulae, upper trapezius, splenius capitis (SC), and
sternocleidomastoid (SCM) muscles, diagnoses by radio-
diagnostic tests (x-ray or magnetic resonance imaging),
and medical referral for physiotherapy.
Exclusion criteria were severe neck pain confirmed by
visual analog scale (VAS) (score >70 mm), treatment dur-
ing the past 3 months (physiotherapy, anesthetic blocks,
etc), participation in a neck muscle exercise program dur-
ing the past 6 months, neck surgery, chronic progressive
inflammatory diseases leading to joint damage (rheumatoid
arthritis and ankylosing spondylitis), joint infections, and
history of malignancy in the cervical region.
Procedure
The general study design is illustrated in a flowchart
(Fig 1). During the first meeting, individuals were asked to
rate their pain intensity on a VAS. Furthermore, a masked
assessor examined the neck and shoulder region to identify
at least 1 latent or active MTrP. After the primary screen-
ing, for every patient who met the inclusion criteria, a
sealed envelope was opened in consecutive order by study
staff in the presence of the patient. Each envelope con-
tained the group allocation sheet and general information
concerning the study procedure. Baseline measurements
were recorded on a second visit. The group allocation sheet
Fig 1. CONSORT flow diagram of the study. CONSORT, Consolidated Standards of Reporting Trial.
Lytras et al 3
Management of Chronic Mechanical Neck Pain
inside the envelope was coded using the letters A and B
and, therefore, patients and assessors were blind to the
group allocation during baseline assessment. Participants
underwent 4 sessions per week for 10 weeks. Measure-
ments were performed at an extra (fifth) visit after the treat-
ment sessions for the week. There were no missed visits or
missed measurement visits. Even if a participant for any
reason missed a planned visit, it was rescheduled within
the same week (often made on Saturdays). Any other treat-
ment for the neck or shoulder area during the intervention
period was not allowed.
Measurements
All measurements were conducted in the baseline week
and in the second, fourth, sixth, 10th, 14th, 22nd, and 34th
weeks of the intervention (VAS, ROM, and PPT). Excep-
tions were the neck disability index (NDI) measurements
(performed in the baseline, sixth, 10th, 14th, 22nd, and
34th weeks) and the 36-Item Short Form Health Survey
(SF-36) measurements (taken in the baseline, 10th, 14th,
22nd, and 34th weeks).
Pain intensity. Pain was assessed by the VAS, which is
a card with an uncalibrated scale ranging from 0 to 100
(with 0 representing no pain and 100 representing the high-
est level of pain imaginable). A vertical line on the scale
drawn by the patient marked their subjective pain estima-
tion ranging from 0 to 100 mm. Subsequently, a single
ruler was used to record the exact pain level. Hence, the
higher the value, the more intense the pain.39 The psycho-
metric characteristics of the VAS make it easy to apply,
and as a consequence, its use is extensive.39,40 The
 ARTICLE IN PRESS
4 Lytras et al
Management of Chronic Mechanical Neck Pain
reliability of the scale is quite satisfactory, especially in
people with moderate and high educational levels (r = .94,
P = .001) than the less educated (r = .71, P = .001).41
Disability. Disability was evaluated using the NDI
questionnaire.42 It is a self-reported 10-item scale. Each
item assesses different neck pain complaints. Most of the
items are related to restrictions in activities of daily life,
and each item is expressed by 6 different assertions in the
range 0 to 5, with 0 indicating no disability and 5 indicating
the highest disability. The total score ranges from 0 to 50.
The NDI has satisfactory support in the literature, being the
most commonly used to report neck pain.43,44 Its credibility
in people with neck pain is moderate to high and has been
considered a valid tool in patients with neck problems.2
Cleland et al45 reported moderate reliability in mechanical
neck pain patients (intraclass correlation [ICC], 0.50),
whereas Juul et al46 report high reliability (ICC 0.97) and
good internal validity (Cronbach’s alpha = 0.86).
Neck muscles pressure pain threshold. The pressure pain
threshold (PPT) is defined as the minimal amount of pres-
sure that produces pain. Pressure algometry was conducted
using a Wagner digital algometer (Wagner FPX 25 Digital
Algometer; Wagner Instruments, Greenwich, CT). PPT
was assessed bilaterally over the upper border of the trape-
zius muscle, halfway between the midline and the lateral
border of the acromion, the levator scapulae muscle 2 cm
above the lower insertion and located in the upper medial
border of the scapulae, the SCM upper insertion, and the
SC 2 cm lateral to the spinous processes of the axis. This
selection was made according to Ylinen et al.47 The metal
rod of the algometer was placed vertically on the site, and
the examiner applied gradually increasing pressure at a rate
of 1 kg/s. The examinees indicated when they began to feel
pain or discomfort. Then, the examiner ceased the pressure
and noted the value. Pressure algometry showed from satis-
factory to fairly high reliability by various researchers both
in repeated measurements of the same examiner and
between measurements of different examiners.5,48-50
Cervical ROM. Active range of motion was measured
with 2 bubble inclinometers (Baseline Bubble Inclinome-
ter, White Plains, NY). One was placed on the top of the
head and the second on the spinous process of C7. Active
cervical flexion, extension, and side-bending ROM were
assessed with participants sitting in the upright position.
Both inclinometer dials had to be adjusted to 0 before the
participant started moving. The participant was then
instructed to perform the movement while the hands of the
examiner followed without moving the centers of the
inclinometers. The total range was derived from the mathe-
matical difference between the 2 inclinometers. The bubble
inclinometer showed moderate to satisfactory reliability in
neck ROM measurements with ICC ranging from 0.66 to
0.84.2,45
Quality of Life. The short form of SF-36 Health Survey
questionnaire was used in this study. SF-36 consists of 36
Journal of Manipulative and Physiological Therapeutics
2020
questions, selected from the Medical Outcomes Study.
These questions are related to 8 different parameters of
mental and physical health. Similar to the NDI, SF-36 has
satisfactory support in the literature.51 Total Physical and
Mental Health, and the subcategory of Bodily Pain, were
evaluated in this study. SF-36 shows a high rate of validity
and reliability in patients with neck pain.46,52,53 In all 8 cat-
egories, both the ICC and the Cronbach's alpha index are
high (0.75-0.94 and 0.69-0.88, correspondingly).46
Interventions
Intervention group. A combination of TE and the INIT
was applied in the intervention group (IG). The exercise
program included endurance and resistance training exer-
cises for the neck and scapula muscles and lasted 45
minutes. This program was based on that of Jull et al.54
Each session included retraining of the longus colli and
endurance training of the deep cervical flexors; neck mus-
cle ROM exercises in all directions; resistance exercises for
the neck and the upper limb muscles between 12 and 15
repetitions maximum with resistance bands; isometric exer-
cise for the muscles involved in neck flexion, extension,
side bending, and rotation (20%-70% of maximum volun-
tary contraction); and stretching exercises for the neck and
upper limb muscles. More details about this program are
available at https://ebm.bmj.com/content/suppl/2003/08/
08/8.4.109.DC1/84109authorreply.pdf.
The INIT protocol was sequentially applied for 15
minutes. The technique was implemented based on the
instructions of Chaitow and DeLany29 as follows.
1. Ischemic compression: After MTrPs identification,
ischemic compression was applied in an intermittent
manner for up to 2 minutes for each MTrP. The pincer
grasp (for the trapezius muscle and SCM) or direct
digital pressure (for the levator scapulae and SC mus-
cle) was used with the patients in either the supine
position or sitting upright.
2. Strain-counterstrain technique: When general or local
pain began to diminish, the muscle was placed in a
position of ease and was held for approximately 20 to
30 seconds. Moderate digital pressure was applied to
the identified MTrP as participants rated their level of
pain on a scale ranging from 1 to 10. Ease was defined
as the point at which a reduction in pain of at least
70% was achieved. Once the position of ease was
identified, it was held for 20 to 30 seconds.
3. Muscle energy technique: After the ease position was
maintained for 20 to 30 seconds, an isometric contrac-
tion focused on the muscle fibers around the MTrP
was performed. Each isometric contraction was held
for 7 to 10 seconds and was followed by a soft-tissue
stretch. Each stretch was held for 30 seconds, and it
was repeated 3 times during the treatment session. The
 ARTICLE IN PRESS
Journal of Manipulative and Physiological Therapeutics
Volume 00, Number 00
treatment was performed on the 3 most painful areas
between the upper border of the trapezius muscle, the
SCM, the levator scapulae, and the SC muscle. Muscle
selection was conducted after a palpating examination
before each treatment session.
Control group. The CG performed the same exercises
excluding the application of INIT. At the end of the exer-
cise program, a relaxing breathing exercise and gentle
stretching were applied for 15 minutes.
Statistical Analysis
Data were analyzed using SPSS Statistics for Windows,
version 23.0 (SPSS Inc, Chicago, IL). For each outcome
parameter, normal distribution was checked with the Sha-
piro-Wilk test. A 2-way analysis of variance (ANOVA)
was applied to examine the interaction effect of “group”
(IG and Control Group [CG]) and “time of measurement”
(weeks 1, 2, 4, 6, 10, 14, 22, and 34) on each dependent
measure. Fewer time points were measured for NDI score
(weeks 1, 6, 10, 14, 22, and 34) and SF-36 (weeks 1, 10,
14, 22, and 34). All follow-ups were included in the model.
The overall comparisons between groups were made using
the “group” £ “time” interaction effects. If the interaction
was statistically significant, the simple main effects were
reported using the Tukey post hoc test (HSD). The 95%
confidence intervals of the group differences at each time
point were also calculated.
Intention-to-treat analysis methodology was used to
avoid the effect of dropouts in order not to disrupt the ran-
domized group assignment of the study. All participants
were included in the analysis and they were analyzed in the
original group assigned. For each drop out during the inter-
vention period, the missing values were replaced with the
value of each variable from the previous time point. Statis-
tical significance was accepted at a level of .05.
A total sample size of at least 32 subjects was recruited
based on an a priori power analysis (G*Power 3.0.10). As
a basic prerequisite for this calculation, the power (1-b)
was set at 95%, and the detection of a difference in the
order f = .5 (Cohen’s f).55 Because this was a preliminary
study, the alpha was set at .05 for all tests. At the same
time, an additional 10% was added to the calculated sample
size for each follow-up measurement performed after the
intervention (weeks 14, 22, 34).
TAGEDH1RESULTSTAGEDEN
Participants
During the recruitment period 62 individuals applied for
evaluation. Of these, 8 people refused to participate in the
research and 14 did not meet the inclusion criteria. Forty
were randomly assigned to the 2 groups. Counseling and
Lytras et al 5
Management of Chronic Mechanical Neck Pain
education of patients on the benefits of cervical muscle exer-
cise was provided to the participants of both groups at
the beginning of the study. According to O'Riordan et al,4
the fear of suffering pain and the lack of knowledge of exer-
cise benefits are strictly connected with the non-adherence to
exercise. The briefing was made both verbally by the mem-
bers of the research team and in writing with information on
exercise benefits described in the consent form. When the
participants completed their treatment phase, they were
instructed to continue their exercise at home and recommen-
dations were made to avoid sedentary lifestyles. In general,
the compliance of the participants with the program was sat-
isfactory. There were no missed care visits or evaluation ses-
sions during the treatment phase. Two patients from the IG
and 2 patients from the CG voluntarily dropped out of the
study for personal reasons after the 22nd week (between the
22nd and 34th weeks) (Fig 1). Demographic features of both
groups are summarized in Table 1. The prevalence of MTrPs
during the initial evaluation is summarized in Figure 2.
Outcome Measures
Visual Analog Scale. The 2-way ANOVA analysis dis-
played a significant “group” £ “time” interaction effect
(P < .001) for the visual analog scale (VAS) score;
whereas, a main effect on the “time” factor was observed
(P < .001) (Table 2). Tukey’s (HSD) post hoc test dis-
played a significant difference between groups in the VAS
score from the second week until the 34th week (P < .05,
95% CI). The above analysis shows that the VAS score
was significantly reduced in both groups. However, this
reduction was greater in the IG, 70% by the 10th week
( 38.14 mm) vs 46% ( 24.5 mm) reduction in the CG
(relative to baseline). The difference in the IG appeared
from the second week, whereas the reduced values
remained statistically significant until the 32nd week.
Neck Disability Index. The 2-way ANOVA analysis dis-
played a significant “group” £ “time” interaction effect
(P < .001) for the NDI score, whereas a main effect on the
“time” factor was observed (P < .001) (Table 2). Tukey’s
(HSD) post hoc test displayed a significant difference
between groups in the NDI score from the sixth week until
the 34th week (P < .05, 95% CI). The earlier analysis
shows that the NDI score declined more after the interven-
tion in the IG than the CG. In the IG, it decreased by
46.7% (13 points) in the 10th week, whereas in the CG it
decreased by 28.6% (8 points).
Pressure Pain Threshold. A significant “group” x “time”
interaction and a main effect on “time” measurements for
all PPT muscles were observed (P < .05) (Table 3). From
Tukey’s (HSD) post hoc test, a significant difference
between groups in the PPT values was noted. Increased
values for the right upper trapezius were noted from the
second week until the 34th week and for the left SC from
the fourth week until the 34th week (P < .05, 95% CI).
 ARTICLE IN PRESS
6 Lytras et al Journal of Manipulative and Physiological Therapeutics
Management of Chronic Mechanical Neck Pain 2020

Table 1. Demographics of the 2 Groups “Time” factor was measured in all ROM measurements
Demographics Intervention Group Control Group (P < .05) (Table 4). From Tukey’s (HSD) post hoc test,
greater improvement of ROM was noted in the IG only for
Age (y) 46.8 (8.85) 45.8 (7.73)
the left-side-bend ROM from the sixth week until the 10th
Sex 25% (n = 5) 25% (n = 5) week, and for the extension ROM only in the 34th week
(P < .05, 95% CI). There were no differences between the
(Men/Women) 75% (n = 15) 75% (n = 15) groups at any time point for the flexion range and right-
side-bend (P > .05) measurements (P < .05, 95% CI).
Duration of symptoms (mo)
SF-36 Health Survey Questionnaire. The 2-way ANOVA
3-6 60% (n = 12) 35% (n = 7) analysis displayed a significant “group” £ “time” interac-
tion and a main effect on measurements of the “time” fac-
6-12 35% (n = 7) 35% (n = 7) tor in all 3 variables (P < .05) (Table 5). Tukey’s (HSD)
post hoc test displayed a significant difference between
More than 12 5% (n = 1) 30% (n = 6)
groups in the “Total Physical Health” score and the
Employment 65% (n = 13) 65% (n = 13) “Bodily Pain” score in the IG from the 10th week until the
34th week (P < .05, 95% CI). In "Total Physical Health,"
(yes/no) 35% (n = 7) 35% (n = 7) the IG score increased in the 10th week (compared with
the baseline measurement) by 50.44% (+20.05), whereas
Sedentary job 75% (n = 15) 80% (n = 16)
the CG score increased by 21.04% (+8.25). In “Total Men-
(yes/no) 25% (n = 5) 20% (n = 4) tal Health,” the IG scored higher only in the 34th week
(P < .05, 95% CI).
Working h/wk

Less than 20 35% (n = 7) 30% (n = 6)

TAGEDH1DISCUSSIONTAGEDEN
Between 20-40 25% (n = 5) 30% (n = 6)
The results of this study suggest that both groups experi-
More than 40 40% (n = 8) 40% (n = 8) enced a clinically meaningful improvement in all the varia-
bles examined during the intervention period. However,
H of computer work/wk
the IG showed greater improvement in several variables
0-5 per wk 35% (n = 7) 20% (n = 4) over CG. This provides support to our hypothesis that the
addition of the INIT to TE may be beneficial for treating
5-10 per wk 5% (n = 1) 10% (n = 2) patients with CMNP.
The VAS score was reduced in both groups during the
10-20 per wk 25% (n = 5) 20% (n = 4)
intervention period. However, this reduction was greater in
More than 20 per wk 35% (n = 7) 50% (n = 10) the IG in all follow-ups (Table 2). The percentage reduction
observed in the VAS score in this study is much greater
Sports 30% (n = 6) 35% (n = 7) than in other similar studies in which the combinations of
exercise and manipulation,19,36,38 mobilization,56 or soft
(yes/no) 70% (n = 14) 65% (n = 13)
tissue massage34 were applied. The efficiency of INIT is
Previous physiotherapy 95% (n = 19) 85% (n = 17) based on the mechanism of reciprocal inhibition and posti-
sometric relaxation to resolve muscle spasm and reduce
(yes/no) 5% (n = 1) 15% (n = 13) pain.29,30 Exercise, on the other hand, is capable of effec-
tively reducing pain in people with CMNP, but this effect
is not acute; it takes approxinaely 6 weeks for pain adapta-
The values for the 10th week increased for the right trape- tions to occur.4 Furthermore, in the early stages of applica-
zius in the IG by 61.61% (+1.83kg/cm2) compared with tion of exercise, caution is needed because of prolonged
an increase of 39.06% (+1.09kg/cm2) in the CG, and for immobilization of the spasming muscles, which are likely
the left SC by 50.62% (+1.62 kg/cm2) compared with to react to painful exercise and create a further spasm, acti-
37.74% (+1.17 kg/cm2) in the CG. An increase in the PPT vating TrPs.4,23 It is possible that the implementation of
of the SCM and the levator scapulae (right and left) was INIT further enhanced the positive effect of exercise.
observed only in the fourth and in the sixth week (P < Perhaps its application immediately after exercise reduced
.05, 95% CI). the pain that preexisted owing to muscle spasms and also
Active ROM. In all ROM measurements, except flexion prevented further worsening of muscle spasms as a result
(P < .05), a statistically significant “Group” x “Time” of exercise. This reduction in the VAS score also has
interaction was found. Furthermore, a main effect on the clinical significance57 because the differences between the
 ARTICLE IN PRESS
Journal of Manipulative and Physiological Therapeutics Lytras et al 7
Volume 00, Number 00 Management of Chronic Mechanical Neck Pain

80%
70%
60%
50%
40%
30%
20%
10%
0%
Trapezius Trapezius Levator Levator SC Right SC Le SCM Right SCM Le
right Le Scapulae Scapulae
Right Le

Fig 2. Prevalence of trigger points in the whole sample in the baseline assessment.Trapezius right = 67%; trapezius left = 43%; leva-
tor scapulae right = 14%; levator scapulae left = 9%; SC right = 34%; SC left = 29%; SCM right = 18%; SCM left = 14%.

Table 2. VAS Score (mm) and Mean (SD) NDI Scores of the Intervention Group and Control Group for Each Time Point
Baseline Week 2 Week 4 Week 6 Week 10 Week 14 Week 22 Week 34
VAS in mm (SD)

IG 54.32 (8.71) 33.27 (9.40)a 23.62 (8.09)a 19.32 (9.45)a 16.18 (6,18)a 17.87 (6.36)a 19.34 (7.1)a 19.74 (5.63)a

CG 53.67 (10.13) 43.37 (10.04) 37.87 (8.44) 33.07 (9.32) 29.27 (7.98) 28.07 (8.86) 30.87 (8.88) 32.90 (8.47)

P value .82 .02 .00 .00 .00 .00 .00 .00

95% CI ( 5.40 to 6.70) ( 16.32 to 3.87) ( 19.54 to 8.95) ( 19.76 to 7.73) ( 17.66 to 8.51) ( 15.14 to 5.26) ( 16.68 to 6.38) ( 17.76 to -8.55)

NDI (SD)

IG 27.80 (4.77) 19.16 (4.93)a 14.75 (4.56)a 16.26 (5.22)a 17.6 (5.27)a 18.35 (6.58)a

CG 27.90 (4.93) 23.35 (7.27) 20.15 (5.72) 22.05 (6.53) 23.5 (5.78) 24.40 (6.62)

P value .94 .04 .00 .00 .00 .00

95% CI ( 2.98 to 2.78) ( 8.17 to 0.20) ( 8.71 to 2.08) ( 9.57 to 2.00) ( 9.44 to 2.35) ( 10.27 to 1.82)

The 95% CI of the group differences and the corresponding P values are also presented.
CG, control group; CI, confidence intervals; IG, intervention group; NDI, neck disability index; SD, standard deviation; VAS, visual analog scale.
a
Between groups significant comparisons in the post hoc testing.

groups were quite large (a difference of 13.09 mm at the
10th week). This reflects both the lower levels of pain of
IG participants after completion of the exercise program
and the smoother adaptation of the cervical muscles to the
exercise at the beginning of the program.
The NDI score also declined more after intervention in
the IG than the CG (Table 2). This might reflect differences
in changes in pain levels between the 2 groups during the
intervention period. Falla et al9 stated that prolonged neck
pain is associated with decreased functionality in individu-
als with CMNP. Probably the greater reduction in pain in
the IG is also responsible for fewer functional limitations
owing to pain in this group. The reduction in the NDI score
observed in this study is consistent with similar studies of
10 to 12 weeks duration in subjects with CMNP.19,36-38
However, the results of this study contrast those reported
by Evans et al,36 who did not identify differences in the
NDI score between the groups when comparing the effect
of the combination of exercise and manipulation to the
effect of exercise alone. The differences between the 2
groups in NDI score are also of clinical importance. Pool et
al58 stated that the minimal clinically important change on
the NDI score in individuals with neck pain is 10.5 points.
IG had a 13.5-point change in score in the 10th week
 8
Management of Chronic Mechanical Neck Pain
Lytras et al
Table 3. Mean (SD) Pressure Pain Threshold kg/cm2 of the Intervention Group and Control Group for Each Time Point
Baseline Week 2 Week 4 Week 6 Week 10 Week 14 Week 22 Week 34
PPT kg/cm2

Right trapezius PPT

IG 2.97 (0.41) 3.5 (0.52)a 4.0 (0.59)a 4.56 (0.84)a 4.80 (0.95)a 4.61 (0.96)a 4.53 (0.84)a 4.4 (0.87)a

CG 2.79 (0.25) 3.04 (0.42) 3.07 (0.45) 3.49 (0.84) 3.88 (0.818) 3.79 (0.8) 3.74 (0.76) 3.54 (0.83)

P value .10 .00 .00 .00 .00 .00 .00 .00

95% CI ( 0.37 to 0.40) (0.15-0.76) (0.62-1.30) (0.52-1.61) (0.35-1.49) (0.25-1.38) (0.26-1.30) (0.31-1.41)

Left trapezius PPT

3.81 (0.48)a 4.17 (0.61)a 4.47 (0.74)a 4.62 (0.75)a 4.33 (0.74)a

ARTICLE IN PRESS
IG 3.42 (0.42) 4.74 (0.69) 4.54 (1.09)

CG 3.34 (0.41) 3.36 (0.46) 3.55 (0.54) 3.8 (0.66) 4.16 (0.75) 4.14 (0.75) 4.05 (0.73) 3.83 (0.84)

P value .51 .00 .00 .05 .01 .05 .10 .05

95% CI ( 0.18 to 0.35) (0.15-0.76) (0.24-0.98) (0.21-1.12) (1.18-1.04) ( 0.00 to 0.96) ( 0.11 to 1.08) ( 0.01 to 1.00)

Right levator scapulae PPT

IG 4.6 (0.98) 5.04 (0.84) 5.74 (0.97)a 6.37 (1.21)a 7.32 (1.43) 7.02 (1.13) 7.04 (1.44) 6.87 (1.29)

CG 4.43 (0.73) 4.61 (0.86) 4.77 (1.08) 5.15 (1.01) 6.48 (1.21) 6.56 (1.14) 6.51 (1.81) 6.23 (1.25)

P value .52 .11 .00 .00 .06 .24 .20 .12

Journal of Manipulative and Physiological Therapeutics

95% CI ( 0.37 to 0.73) ( 0.11 to 0.97) (0.30-1.60) (0.50-1.93) ( 0.00 to 1.69) ( 0.32 to 1.25) ( 0.31 to 1.37) ( 0.17 to 1.45)

Left levator scapulae PPT

IG 4.61 (1.0) 4.91 (0.9) 5.63 (0.94) 6.3 (0.98)a 7.23 (1.1) 6.94 (1.12) 6.72 (1.0) 6.84 (1.1)

CG 4.53 (0.85) 4.56 (0.86) 4.74 (0.94) 5.43 (1.10) 6.52 (1.24) 6.44 (1.11) 6.33 (1.99) 6.33 (1.2)

P value .77 .22 .00 .01 .06 .17 .28 .16

95% CI ( 0.51 to 0.68) ( 0.21, to 0.91) (0.28-1.50) (0.19-1.54) (0.04-1.46) ( 0.22 to 1.20) ( 0.33 to 1.10) ( 0.22 to 1.25)

(continued)

2020
 Volume 00, Number 00
Journal of Manipulative and Physiological Therapeutics
Table 3. (Continued)
Baseline Week 2 Week 4 Week 6 Week 10 Week 14 Week 22 Week 34
Right SC PPT

IG 2.92 (0.37) 3.34 (0.58) 3.8 (0.76)a 4.16 (0.82) 4.75 (0.82) 4.64 (0.78) 4.56 (0.73) 4.27 (0.79)

CG 2.85 (0.32) 3.1 (0.43) 3.16 (0.5) 3.72 (0.66) 4.26 (0.86) 4.08 (0.8) 3.98 (0.8) 3.82 (0.79)

P-Value .54 .13 .00 .07 .07 .32 .22 .08

95% CI ( 0.15 to 0.29) ( 0.08 to 0.57) (0.22-1.05) ( 0.44 to 0.91) ( 0.05 to 1.03) (0.05-1.06) (0.08-1.07) ( 0.05 to 0.95)

Left SC PPT

IG 3.2 (0.44) 3.43 (0.47) 3.89 (0.77)a 4.59 (0.86)a 4.82 (0.79)a 4.76 (0.76)a 4.75 (0.89)a 4.39 (0.71)a

ARTICLE IN PRESS
CG 3.1 (0.37) 3.22 (0.52) 3.4 (0.56) 3.78 (0.85) 4.27 (0.79) 4.23 (0.69) 4.00 (0.76) 3.99 (0.75)

P value .44 .19 .02 .05 .03 .03 .00 .02

95% CI ( 0.16 to 0.36) ( 0.11 to 0.53) (0.06-0.92) (0.25-1.35) (0.43-1.06) (0.58-0.99) (0.21-1.28) (0.06-1.00)

Right SCM PPT

IG 2.78 (0.7) 3.02 (0.93) 3.61 (1.0)a 4.63 (1.24)a 5.5 (1.14) 5.18 (1.12) 4.90 (1.09) 4.57 (1.00)

CG 2.55 (0.72) 2.68 (0.98) 2.93 (1.06) 3.69 (1.11) 5.18 (1.31) 4.95 (1.18) 4.53 (1.16) 4.20 (1.03)

P value .31 .27 .04 .01 .41 .53 .30 .26

95% CI ( 0.22 to 0.68) ( 0.27 to 0.95) (0.00-1.36) (0.18-1.69) ( 0.47 to 1.11) ( 0.50 to 0.96) ( 0.35 to 1.08) ( 0.28 to 1.01)

Management of Chronic Mechanical Neck Pain

Left SCM PPT

IG 3.06 (0.79) 3.52 (0.84) 3.95 (1.02) 4.79 (1.02)a 5.62 (1.11) 5.53 (1.07) 5.35 (1.05) 5.15 (1.05)

CG 2.75 (0.85) 3.13 (1.0) 3.48 (1.26) 3.96 (1.27) 5.45 (1.31) 5.21 (1.180) 5.07 (1.16) 4.81 (1.19)

P value .24 .20 .20 .03 .65 .36 .42 .38

95% CI ( 0.22 to 0.83) ( 0.21 to 0.98) ( 0.26 to 1.20) (0.82-1.56) ( 0.60 to 0.95) ( 0.39 to 1.04) ( 0.43 to 0.99) ( 0.37 to 1.06)
The 95% CI of the group differences and the corresponding P values are also presented.

Lytras et al
CG, control group; CI, confidence intervals; IG, intervention group; PPT, pressure pain threshold; SC, splenius capitis; SCM, sternocleidomastoid; SD, standard deviation.
a
Between groups significant comparisons in the post hoc testing.

9
 ARTICLE IN PRESS
10 Lytras et al Journal of Manipulative and Physiological Therapeutics
Management of Chronic Mechanical Neck Pain 2020

Table 4. Mean (SD) ROM Degrees of the Intervention Group and Control Group for Each Time Point
Baseline Week 2 Week 4 Week 6 Week 10 Week 14 Week 22 Week 34
Flexion ROM°

IG 47.25 (4.01) 49.5 (5.68) 51.9 (5.49) 53.85 (4.51) 54.0 (5.21) 53.45 (4.76) 52.1 (4.98) 51.35 (5.27)

CG 49.0 (2.26) 49.1 (7.77) 49.7 (6.93) 52.6 (5.88) 53.7 (5.84) 52.45 (5.56) 51.25 (5.57) 50.85 (5.91)

P value .18 .85 .27 .45 .86 .54 .61 .77

95% CI ( 4.40 to 0.90) ( 3.96 to 4.70) ( 1.80 to 6.20) ( 2.10 to 4.60) ( 3.24 to 3.84) ( 2.31 to 4.31) ( 2.53 to 4.23) ( 3.08 to 4.08)

Extension ROM°

IG 55.2 (5.11) 58.05 (6.1) 60.1 (6.0) 61.65 (5.64) 63.0 (5.46) 61.85 (5.86) 61.20 (5.65) 61.6 (5.44)a

CG 56.3 (5.5) 57.25 (6.14) 57.5 (6.41) 59.55 (5.81) 61.0 (5.28) 59.75 (5.77) 58.95 (5.66) 57.8 (5.28)

P value .51 .68 .19 .25 .24 .26 .21 .03

95% CI ( 4.50 to 2.30) ( 3.12 to 4.72) ( 1.39 to 6.59) ( 1.56 to 5.76) ( 1.44 to 5.44) ( 1.62 to 5.82) ( 1.37 to 5.87) ( 0.36 to 7.23)

Right bend ROM°

IG 37.25 (2.98) 38.35 (3.67) 39.05 (3.72) 40.05 (3.80) 40.85 (3.45) 39.45 (3.51) 38.90 (3.62) 38.85 (2.73)

CG 38.45 (3.21) 38.5 (3.7) 39.1 (3.43) 39.7 (3.37) 39.85 (3.11) 38.85 (2.94) 38.45 (3.15) 37.60 (2.87)

P value .22 .89 .96 .76 .34 .56 .67 .16

95% CI ( 3.18 to 0.78) ( 2.51 to 2.21) ( 2.34 to 2.24) ( 1.95 to 2.65) ( 1.10 to 3.10) ( 1.47 to 2.67) ( 1.72 to 2.62) ( 0.54 to 3.04)

Left bend ROM°

IG 32.0 (4.71) 33.85 (4.24) 36.55 (4.31) 38.85 (4.14)a 40.95 (3.95)a 39.35 (3.58) 38.90 (3.97) 38.25 (4.06)

CG 32.6 (4.77) 33.65 (4.09) 34.05 (4.28) 35.6 (3.93) 38.6 (2.89) 38.8 (3.75) 37.65 (2.92) 36.75 (3.25)

P value .61 .88 .07 .01 .03 .63 .26 .21

95% CI ( 3.63 to 2.43) ( 2.47 to 2.87) ( 0.25 to 5.25) (0.66-5.83) (0.13-4.56) ( 1.79 to 2.89) ( 0.98 to 3.48) ( 0.88 to 3.88)

The 95% CI of the group differences and the corresponding P values are also presented.
CG, control group; CI, confidence intervals; IG, intervention group; NDI, neck disability index; ROM, range of motion; SD, standard deviation.
a
Between groups significant comparisons in the post hoc testing.

compared with the baseline measurement, whereas the CG
changed only by 7.75 points (Table 2). This difference in
NDI score reflects the reduction in the disability of IG indi-
viduals, which, according to many researchers, is associ-
ated with prolonged care, increased treatment costs, and a
negative impact on the health system.2,4,13
Our results showed statistically significant differences
between the groups in the PPT values of all the examined
muscles. Larger differences were found in the trapezius
and SC from the second week, which were maintained until
the 34th week (Table 3). The factors that may have contrib-
uted to this result are unclear. The application of ischemic
pressure at the TrPs of these 2 muscles possibly has
contributed to their inactivation, thus reducing the local
tenderness of these muscles from the beginning.59 The dif-
ferences identified between the 2 groups were large enough
to be considered clinically important.49 These differences
show that the IG participants experienced lower levels of
pain in these 2 muscles from the beginning of the interven-
tion. It is worth noting that the trapezius and SC were the
muscles with the highest prevalence of MTrPs in all the
participants.
Regarding the PPT of the levator scapulae and the ster-
nocleidomastoid, the results showed a better improvement
of the IG group over the CG group only in intermediate fol-
low-ups (in the fourth and sixth weeks) (Table 3). Individu-
als in the IG probably had MTrPs in these muscles, and the
combination of the INIT and exercise helped to reduce pain
more rapidly. In subsequent follow-ups, however, the CG
group displayed the same pain threshold increase as the IG
group, probably owing to the effect of the exercise.
According to O’Riordan et al4 an exercise period of at least
6 weeks is required for the first neck muscle adaptations.
Therefore, it is reasonable to suggest that exercise
 ARTICLE IN PRESS
Journal of Manipulative and Physiological Therapeutics Lytras et al 11
Volume 00, Number 00 Management of Chronic Mechanical Neck Pain

Table 5. Mean (SD) SF-36 Scores of the Intervention Group and Control Group for Each Time Point
Baseline Week 10 Week 14 Week 22 Week 34
SF-36 score

Total physical health

IG 39.75 (3.81) 59.80 (8.89)a 59.65 (8.60)a 57.45 (8.66)a 55.30 (7.90)a

CG 39.20 (4.0) 47.45 (7.57) 47.05 (6.93) 45.15 (6.43) 44.10 (6.71)

P value .65 .00 .00 .00 .00

95% CI ( 1.95 to 3.05) (7.06-17.63) (7.59-17.60) (7.41-17.18) (6.50-15.89)

Total mental health

IG 44.30 (3.68) 59.90 (9.36) 58.40 (7.47) 57.25 (8.56) 55.55 (6.52)a

CG 43.75 (5.52) 54.20 (9.08) 55.15 (7.59) 52.60 (7.44) 50.10 (7.58)

P value .71 .06 1.81 .07 .02

95% CI ( 2.46 to 3.56) ( 0.20 to 11.60) ( 1.57 to 8.07) ( 0.48 to 9.78) (0.92-9.97)

Bodily pain

IG 41.90 (5.99) 66.40 (10.41)a 64.15 (6.93)a 61.30 (7.29)a 58.95 (7.30)a

CG 42.40(6.75) 54.35 (9.57) 52.90 (9.19) 51.65 (9.94) 51.35 (9.48)

P value .80 .00 .00 .00 .00

95% CI ( 4.58 to 3.58) (5.64-18.45) (6.03-16.47) (4.06-15.23) (2.18-13.02)

The 95% CI of the group differences and the corresponding P values are also presented.
CG, control group; CI, confidence intervals; IG, intervention group; SD, standard deviation; SF-36, short form 36.
a
Between-group significant comparisons in the post hoc testing

adaptations after the sixth week contributed to reduction of
the local muscle tenderness in CG individuals. The selec-
tive application of the INIT to the 3 most painful muscles
after each exercise session helped reduce the local tender-
ness of these muscles more rapidly. Nevertheless, it appears
that the INIT has no additional benefit for the levator scap-
ulae and the sternocleidomastoid PPTs compared with TE
alone.
Regarding the neck ROM, the IG showed greater
improvement in the left side bending ROM than the CG
only between the sixth and 10th week (Table 4). This may
be due to the fact that most of the participants exhibit
MTrPs in the right trapezius (Fig 2), which is responsible
for restricting the ROM of the side bending to the opposite
side.23 Thus, it is possible that the application of the INIT
to the trapezius contributed to the deactivation of the
MTrPs of this particular muscle. In addition, there were
similar responses to interventions in cervical extension
ROM; only in the 34th week measurement point did the IG
group show a greater increase than the CG. This improve-
ment of the IG might indicate that the participants were
able to maintain the positive effect of the exercise for a
longer period of time, but further research is essential to
verify such a suggestion. The findings of this study are in
line with some research studies supporting the positive
effect of exercise on the ROM of patients with
CMNP.13,19,49 However, they are in contrast with the find-
ings of Bronfort et al19 who did not notice differences
between groups in the ROM when comparing the combina-
tion of exercise and manipulation to exercise alone. Collec-
tively, our results suggest that the addition of the INIT
offered some additional benefits in the ROM, but these
were diminished 6 months after the intervention. These
benefits do not appear to carry a meaningful clinical signifi-
cance because the differences found between the groups,
although statistically significant, were actually negligible
(from 2.3 to 3.8 degrees difference, Table 4).
The results of this study showed that the IG displayed a
greater improvement in “Total Physical Health” and “Bodily
Pain” throughout the intervention period (Table 5). These dif-
ferences can be attributed to the different levels of pain expe-
rienced by the 2 groups during the intervention period.
Concerning the subcategory “Total Mental Health,” the IG
showed a greater improvement than the CG only during the
 ARTICLE IN PRESS
12 Lytras et al
Management of Chronic Mechanical Neck Pain
34th week. This implies that although both groups showed a
gradual (small but continuous) decrease in values during the
intermediate measurement sessions (Table 5), the IG retained
positive effects in “Total Mental Health” for longer than the
CG. The differences between the 2 groups were quite large.
At 10 weeks, the score of “Total Physical Health” in IG par-
ticipants had increased by 20 points compared with the initial
measurement, whereas in the CG the corresponding increase
was only 8.2 points. The corresponding increases in the
“Bodily Pain” score at week 10 were 24.5 in the IG and only
12 in the CG (Table 5). These differences between groups
mean that IG participants felt healthier after completing the
program. Although the effect of exercise on the quality of life
of individuals with CMNP is known,15,60 the increase in the
SF-36 score observed in this study was much greater than in
other similar studies.36,61 Additionally, the findings of this
study contrast those of Celenay et al,34 who compared the
combination of exercise and massage of connective tissue to
exercise alone and found differences between the groups
only in “Total Mental Health.” The results of our study sug-
gest that the addition of the INIT offered some additional
benefits to health-related quality of life in IG individuals.
These benefits seem to be related more to “Total Physical
Health” and “Bodily Pain.”
Limitations
This was a preliminary study with a limited capability of
enrolling individuals with CMNP. The relatively small sam-
ple size and recruitment of the participants from the same
rehabilitation center did not allow the formation of an INIT-
only group in order to determinate the influences of the exer-
cise protocol. Furthermore, there is the possibility of a sam-
pling error because of the many outcomes without adjusted
alpha error levels. Another limitation concerns the fact that
neither the care providers nor the participants could be blind
to the study. In addition, the INIT was applied to only 3
muscles in each session for study purposes, and this could not
satisfy 100% of the concerns of the IG patients; they may
have had symptoms in more than 3 muscles on both sides of
the body.
TAGEDH1CONCLUSIONTAGEDEN
The results of this preliminary study suggest that the thera-
peutic combination of TE and the INIT may be more effective
than TE alone in the management of CMNP, as reflected by a
greater reduction in pain, disability, local tenderness of the
muscles, and some indices of health-related quality of life.
TAGEDH1FUNDING SOURCES AND CONFLICTS OF INTERESTTAGEDEN
No funding sources or conflicts of interest were reported
for this study.
Journal of Manipulative and Physiological Therapeutics
2020
TAGEDH1CONTRIBUTORSHIP INFORMATIONTAGEDEN
Concept development (provided idea for the research):
D.E.L., E.I.S., K.I.C., E.K.
Design (planned the methods to generate the results):
D.E.L., E.I.S., K.I.C., I.S.M., E.K.
Supervision (provided oversight, responsible for organiza-
tion and implementation, writing of the manuscript):
D.E.L., E.I.S., K.I.C., E.K.
Data collection/processing (responsible for experiments,
patient management, organization, or reporting data):
D.E.L., E.I.S., I.S.M.
Analysis/interpretation (responsible for statistical analysis,
evaluation, and presentation of the results): D.E.L., I.S.M.,
E.K.
Literature search (performed the literature search): D.E.L.,
I.S.M.
Writing (responsible for writing a substantive part of the
manuscript): D.E.L., I.S.M., E.K.
Critical review (revised manuscript for intellectual content,
this does not relate to spelling and grammar checking): E.K.
Practical Applications
 The therapeutic combination of TE and INIT
on neck muscles have better short-term and
medium-term positive effects in pain, disabil-
ity, muscle sensitivity, ROM, and the quality
of life than TE alone in patients with CMNP.
 Therapeutic exercise benefits could be obtained
more quickly and to a greater extent when
combined with the MTrPs deactivation tech-
nique.
 More studies including TE and MTrPs deacti-
vation techniques should take place in the
future in patients with CMNP.
TAGEDH1REFERENCESTAGEDEN
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