Combined Effectiveness of Static Stretching With and Without Post-Isometric Relaxation (PIR) in Managing Pain, Range of Motion and Functional Status Among Upper Cross Syndrome Patients

Tightness of cervical muscles especially upper trapezius and levator scapulae leads to the limitation of cervical ranges and develop a painful condition named as Upper cross syndrome


M E T H O D S
[5] leading to forwarding head posture enhance cervical lordosis and thoracic kyphosis, shrugged with protracted shoulder, scapular winging with non-speci c cervical pain [6,7].Furthermore; dysfunction is observed at atlantooccipital, cervicothrociac and shoulder-joint along with different spinal segments including C4-C5 and T4-T5 vertebrae [7].Multiple treatment protocols including Static stretching, corrective exercises, myofascial trigger point release, Active release technique, strengthening techniques, Kineso-tapping, Mckenzie's exercise and Muscle energy techniques are used for managing USC [7,8].Post-isometric relaxation (PIR) is a MET technique focused on Autogenic Inhibition and Complementary Inhibition that helps in lengthening the short and tight muscles, restricting scope of movement and cause joint limitations [9].Gillani et al. concluded  This also helps in reducing pain, improving cervical ranges and functional status among the patients [11].Ali et al., further concluded that muscle energy technique is highly effective in improving the pain and ranges of cervical spine in patients of upper neck pain syndrome [12].Previous literature described the importance of stretching and muscle energy techniques in managing patients suffering with cervical neck pain and UCS.However, very limited studies conducted with the aim of nding the combine effectiveness of Static stretching and Posit Isometric Relaxation in managing UCS for managing pain, cervical ROM and functional status.Additionally; most of therapist either used static stretching or PIR in managing patient as this cause increase the prognosis rate among patient.Therefore, the current study also focuses on determining the combine effectiveness of static stretching and Post Isometric relaxation (PIR) on the prognosis rate of patient suffering with UCS.This also helps in providing awareness about the disease and the role of physiotherapists among the patient in reducing the morbidity rate.
A qausi experimental study was conducted from September 2022 to March 2023 in two governmental hospitals of Lahore, Services Hospital and Jinnah Hospital.The study was conducted after getting ethical approval from the Ethical Review board of Johar Institute of Professional Studies, Lahore with Reference Number JIPS/ACD/23-142.A sample of 22 patients were calculated by using G-power version 3.1 having d=1.628,Power (1-β err prob) = 0.95, with df = 20 and t=2.085.The patients were selected by using convenient sampling technique in which male and female patients of 18-50 years of age were selected.These patients were suffering with sub-acute mechanical neck pain having duration from 6 weeks to 3 months with limited neck movement were included.Patients having history of In ammatory, malignant, and neurological conditions, Metabolic Disease, Cervical radiculopathy, torticollis, facial pain, headache, disc prolapse, spondylolisthesis, trauma or fracture history and who were taking analgesics were excluded from the studies.The verbal and written consent form was taken and signed by each patient.After selection, patients were allocated in two groups: Group A (n=11) -Moist Heat Pack (MHP) + Post Isometric Relaxation + Static Stretching and Group B (n=11) -Moist Heat Pack (MHP) + Static Stretching.In Group A; the patients were managed by using Moist Heat Pack the supine lying position for 10 minutes.After MHP; a sustained Static stretching applied on upper trapezius, pectoralis major and cervical muscles by placing the tightened muscles in stretched and lengthen position for 15-30 seconds.The Static stretching was applied in 3 sets, 3 to 5 times per week [12].Additionally; Post isometric relaxation technique was applied to the upper trapezius, levator scapulae, and pectoralis major muscles by moving the muscles to barrier point.The patients were advised to perform isometric on traction against resistance for 3 to 5 sec.The patient than relax and move to the new limit.The whole technique was applied for 3-5 times, 3 to 5 times per week [10].In Group B; the patients were managed by using Moist Heat Pack in supine lying position for 20 minutes.After MHP; After MHP; a sustained Static stretching applied on upper trapezius, pectoralis major and cervical muscles by placing the tightened muscles in stretched and lengthen position for 15-30 seconds.The Static stretching was applied in 3 sets, 3 to 5 times per week [12].Furthermore; patients were provided with plan for home exercises including active range of motion and cervical isometrics performed with 10 repetitions, 2 sets daily.The data were collected by using Goniometer, Neck Disability Index (NDI) and Visual Analogue scale (VAS) on rst day and last day of physiotherapy session.NDI is a disability assessment tool excellent reliability of 95% (Cl: 0.46-0.97in).Disability is assessed with cut off values as 13.0 as no disability.45.5 as mild, 15. 6 as moderate and 18.2 as severe interference of loss of function [13].Furthermore; VAS is pain assessment tool having validity and reliability of (ICC >0.70) [14].The scale had ve pictorial that are described as in numerical values form 0-10 in which 0 described as no pain and 10 shows sever pain.The level further described as <3.4 as mild, 3.5 to 6.4 as moderate and >6.5 as severe interference of functioning and pain [15].The data were analyzed by using SPSS version 26.0 in which results were described in frequency (%), Mean and S.D. along with p-value <0.05.

R E S U L T S
The purpose of the study was to determine the effectiveness of Static Stretching with and without Post Isometric Relaxation in managing pain, improving range of motion and functional status in Upper Cross Syndrome The results of the study were described in the tabulated form.The demographic characteristics of patients were described in Table 1.According to Table 1; the mean age of participants was 38.73± 10.78.The gender distribution showed 9 (40.9%) were male while females were 13 (59.1%).Similarly; the behavior of pain showed 20 (90.9%) was suffering with radiating pain while 2 (9.1%) was suffering with localized pain and among all patients; 15 (68.2%) were married, 5 (22.7%) were single while 2 (9.1%) were widow.The within group analysis between groups were described in Table 2.According to Table 2; the VAS value of PIR with pretreatment was 7.00 ±1.67 while the post-treatment was 2.27± 1.27.Similarly; VAS value of Static Stretching with pretreatment was 6.18 ±1.88 while the post-treatment was 4.00± 1.94 with p-value = 0.00.In Table 2; the NDI value was described.According to results; NDI scoring of Static Stretching with pre-treatment was 32.36±3.32while the post-treatment was 25.09± 2.84 with the p-value =0.00.While; NDI scoring of PIR with pre-treatment was 34.45±3.07and the post-treatment was 24.90±2.21with the p-value =0.00.Furthermore; the cervical ranges within analysis were described in Table 2.Both groups showed signi cant improvement in the cervical ranges from pretreatment values to post-treatment values with p-value = 0.00.The results showed Static Stretching with and without PIR played signi cant result in improving cervical ranges among Upper Cross Syndrome patients.
that eccentric muscle energy technique and static stretching techniques were equally effective in treating UCS [10].Similarly; Joshi et al. reported METs (PIRP) plays an important role in improving posture by improving the muscular imbalance.

Table 1 :
Demographic values of patients

Table 2 :
Paired T-test analysis of GroupsThe between the group analysis was described by using Independent T-Test in Table3.The results showed in post-VAS; PIR value was 2.27± 1.27 and SS was 4.00± 1.94.The post-NDI value of PIR was 24.90±2.21and SS was 25.09± 2.84.The post exion value of PIR was 33.90±3.26and SS was 29.54±1.57,The post extension value of PIR was 35.72±1.84 and SS was 29.63±1.85, the Right sided post Lateral exion value of PIR was 35.72±2.79 and SS was 31.00±2.04,the Left sided post Lateral exion value of PIR was 34.27±2.28and SS was 34.63±1.50, the Right sided post Rotation value of PIR was 40.45±1.03and SS was 39.00±1.34 and the Left sided post Rotation value of PIR was 32.72±2.28 and SS was 29.90±1.64 with p-value <0.05.This showed Static Stretching with PIR played signi cant result in improving cervical ranges among Upper Cross Syndrome patients as compared to other groups.

Table 3 :
Independent T-test analysis of Groups:

PJHS VOL. 4 Issue. 10 October 2023
Copyright © 2023.PJHS, by Crosslinks International Publishers tight muscles.Still; METs (PIR) is statistically more signi cant in improving the exibility of muscles that ultimately enhance the limited ranges of affected joint[19].This again supported currents study results as Group A managed by PIR showed greater improvement in all cervical ranges of UCS patients.Shellock et al, 1985 supported that PIR focus on the activation of Golgi tendon organ through isometric contraction and it cause the stretching of Golgi tendon and inhibition of re ex leading to relaxation and lengthening of tightened muscle[20].PIR with Static Stretching is highly signi cant in improving pain, cervical ranges and disability Upper Cross Syndrome patients as compared to Static Stretching by focusing on inhibition of Golgi tendon organ and mechanoreceptors in UCS.