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Year : 2019  |  Volume : 1  |  Issue : 2  |  Page : 114-121

Effect of myofascial release versus muscle energy technique on trapezius spasm in head and neck cancer patients: A randomized clinical trial

Department of Oncology Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India

Date of Submission19-Apr-2019
Date of Decision01-Nov-2019
Date of Acceptance01-Nov-2019
Date of Web Publication23-Dec-2019

Correspondence Address:
Dr. Renu Pattanshetty
Department of Oncology Physiotherapy, KAHERI Institute of Physiotherapy, Belagavi - 590 010, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijptr.ijptr_27_19

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Objectives: Variety of physiotherapy interventions have proven to be efficient in reducing pain and neck disability, to improve range of motion (ROM) which results in the improvement in quality of life (QoL) in head and neck cancer (HNC) patients. The aim of this study was to determine the effect of myofascial release (MFR) versus muscle energy technique (MET) on trapezius spasm for pain, disability, ROM, and QoL in postoperative HNC patients.
Materials and Methods: Twenty-four patients with HNC cancers who underwent surgery were recruited in the study. The pre–post assessment for neck disability, pressure pain threshold, cervical and shoulder ROM, and QoL was done at baseline and after 6 days of intervention using Neck Disability Index, pressure algometer, universal goniometer, and Functional Assessment of Cancer Therapy - Head and Neck scale, respectively.
Results: MFR and MET groups are effective for pain reduction P = 0.0001 and neck disability P = 0.0022 when compared within the groups. Cervical and shoulder ranges showed significant improvement in cervical flexion (P = 0.0162), cervical extension (P = 0.0096), shoulder flexion (P = 0.0205), shoulder extension (P = 0.0408), shoulder abduction (P = 0.0037), and shoulder adduction (P = 0.0037) when compared between the two groups. When compared within the two groups cervical and shoulder ranges showed significant improvements (P = 0.0001) in both the groups.
Conclusion: MFR and MET are effective when applied individually to reduce pain and neck disability and increase cervical and shoulder ROM in HNC patients.

Keywords: Head and neck cancer, Muscle energy technique, Myofascial release, Trapezius spasm

How to cite this article:
Parab AA, Pattanshetty R. Effect of myofascial release versus muscle energy technique on trapezius spasm in head and neck cancer patients: A randomized clinical trial. Indian J Phys Ther Res 2019;1:114-21

How to cite this URL:
Parab AA, Pattanshetty R. Effect of myofascial release versus muscle energy technique on trapezius spasm in head and neck cancer patients: A randomized clinical trial. Indian J Phys Ther Res [serial online] 2019 [cited 2023 Oct 1];1:114-21. Available from: https://www.ijptr.org/text.asp?2019/1/2/114/273718

  Introduction Top

According to World Health Organization cancer is considered to be the leading cause of death globally accounting 9.6 million deaths in year 2018.[1] Over 200,000 cases of head and neck cancer (HNC) are seen in India in comparison to USA which account for 30,000 cases per year. In India, the occurrence of death due to HNC is 8%. All over the world, HNC stands as the fifth most common cancer with seventh highest mortality rate [2] with females being more affected than males.[3] Two-third of HNC patients with squamous cell carcinoma present with a progressed stage of the disease involving the regional lymph nodes [4] with squamous cell carcinomas constituting for 90% of all HNC.[3]

Among the risk factors for HNC, tobacco and alcohol abuse are the most commonly listed risk factors accounting for 75% of all HNC cases.[2] Physical impairments seen in HNC patients are problems in swallowing, speaking, decrease in–voice quality, decreased mouth opening, and dysfunction of neck and shoulder.[5] Myofascial pain syndrome is seen in 11.9%–44.8% of HNC and breast cancers.[2] It is intense deep pain resulting from one or more muscles/fascia with one or more hypersensitive areas. Myofascial pain is observed in affected side of upper trapezius muscle than any other muscles.[6]

Myofascial release (MFR) is a progressive pressure release technique which is used to decrease muscle tension by elongation of the muscle fiber thereby increasing gradual pressure on the motor trigger point. Study has proved successful to decrease pressure pain sensitivity.[7] Muscle energy technique (MET) is also known as postisometric relaxation technique as it is a direct active postfacilitating technique. The concepts of MET are formed on the basis of autogenic inhibition and reciprocal inhibition.[8] MET has demonstrated to be useful in increasing the range of motion (ROM) along with also facilitating the lymphatic circulation.[9]

There are numerous studies to suggest the use of manual therapy techniques in various musculoskeletal conditions. However, there is paucity of literature highlighting the use of manual techniques such as MFR and MET in the treatment of cancer patients, especially in HNC survivors. The current study aimed to investigate the effectiveness of MFR and MET on trapezius spasm in HNC in terms of alleviating pain and improving quality of life (QoL).

  Materials and Methods Top

The present clinical trial was conducted in a tertiary cancer hospital in postoperative HNC patients. The study included both males and females patients above 18 years of age and undergone surgical treatment for HNCs, anterior neck dissection, complete modified neck dissection and other types of selective neck dissection and willing to participate in the study. Patients with structural instability and osteoporotic changes of cervical spine, torticollis, spondylosis of cervical spine, and prolapse of cervical disc were excluded. As per the effect “P” 0.05 and dropout rate of 5%, the sample calculated was “24.” Sample size calculation:

S1 = 1.55 S2 = 1.47

α = 1.96 β = 0.84

n = 2S 2 (Zα+ Zβ)/d 2

=2× (1.51) 2× (1.96 + 0.84)/102

=2 × 2.28 × 2.8/100


=12 in each group.


Ethical clearance was obtained from Research and Ethics Committee, Belagavi (Ref. No. KIPT/223/14-05-18). Each patient was explained the purpose of the study in vernacular language, and a written informed consent was taken. Closed envelope method was used for random allocation of the patients into either of two groups. A brief demographic data of all patients was obtained. All patients were assessed for pain, neck disability index (NDI), ROM (cervical and shoulder), and QoL pre- and post-intervention [Figure 1].
Figure 1: CONSORT chart

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Intervention protocol

Procedure for myofascial release technique (Group A)[10]

Position of the patient

The patient was sitting on chair with back support[Figure 2].
Figure 2: The patient receiving an application of myofascial release technique

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The therapist positioned herself behind the patient and placed her hands over the affected side, i.e., one hand was placed over the shoulder and the other hand was placed over the area below to the ear of the involved side. MFR was applied for 3–4 times with 20 s hold. It was administered once daily for consecutive 6 days.

Procedure for muscle energy technique (Group B)[10]

Position of patient

The patient was asked to lie on his/her back on the couch [Figure 3].
Figure 3: The patient receiving an application of muscle energy technique

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The therapist placed one hand over the ear/mastoid area of the side affected while the shoulder of the affected side was stabilized using the other hand. The patient was asked to elevate the affected side shoulder and touch the ear by applying 20% of the available strength. The isometric contraction was held for 7–10 s, 3–5 times repetitions, and was maintained for 30 s. The MET was given once daily for 6 days.

Outcome measures

Neck Disability Index

NDI includes 10 questions which has options of 6 answers and are scored with 0–5 points in each question and is later calculated as percentage. The NDI has test–retest reliability with intraclass correlation coefficient 0.93, with limitation of 95% confidence interval, i.e., 0.86–0.97.[11]

Pressure pain threshold-pressure algometer

The reliability and validity of pressure algometer is r = 0.990.[12] Pressure pain threshold (PPT) of upper trapezius muscle was assessed placing pressure algometer over the upper trapezius. Reading on pressure algometer was taken in the study.

Range of motion

The ROM was assessed using an universal goniometer.[13] Cervical ranges and shoulder ranges of the affected upper limb was taken.

Functional Assessment of Cancer Therapy - Head and Neck

This scale comprises of four domains, namely physical, social, emotional, and functional well-being. The validity of Functional Assessment of Cancer Therapy - Head and Neck is r > 0.75.[14]

  Results Top

Statistical analysis

Statistical analysis was done using SPSS statistical package of social sciences version 20.0, (IBM Corp., Armonk, NY: USA). Normality of all the parameters was determined by Kolmogorov–Smirnov test. Mann–Whitney U and Wilcoxon matched pair tests were used for statistical hypothesis to compare the outcome measures; postintervention scores were analyzed using Student's paired t-test.

The present study included twenty-four patients, in which twelve subjects were in Group A who received MFR and 12 subjects were in Group B who received MET. [Table 1], [Table 2], [Table 3] represents demographic data of the study participants.
Table 1: Gender distribution of all patients in both study groups (myofascial release and muscle energy technique)

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Table 2: Distribution of age and body mass index of all patients in both study groups (myofascial release and muscle energy technique)

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Table 3: Cancer diagnosis in both the study groups (myofascial release and muscle energy technique)

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Within-group comparison of pretest and posttest scores in MFR and MET groups demonstrated reduction of pain with neck disability scores with P = 0.0001 and P = 0.0022, respectively [Table 4] and [Table 5]. No significant difference was noted in QoL when compared between the groups [Table 6]. Between group comparison for cervical and shoulder ranges showed improvements in cervical flexion (P = 0.0162), cervical extension (P = 0.0096), shoulder flexion (P = 0.0205), shoulder extension (P = 0.0408), shoulder abduction (P = 0.0037), and shoulder adduction (P = 0.0037) [Table 7]. The comparison of cervical ROM between both the study groups is depicted in [Table 8] and [Table 9].
Table 4: Comparison of neck disability index scores in both study groups before and after intervention

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Table 5: Comparison of pressure pain threshold scores of all patients in both the study groups before and after the intervention

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Table 6: Comparison of individual domains of functional assessment of cancer therapy-head and neck of all the patients in both the study groups before and after intervention

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Table 7: Comparison of shoulder range of motion for all the patients between both the study groups before and after intervention

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Table 8: Comparison of domains of functional assessment of cancer therapy - head and neck for all the patients within the two study groups before and after intervention

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Table 9: Comparison of cervical range of motion for all the patients between both the study groups before and after the intervention

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  Discussion Top

The present study evaluated the effect of MFR and MET in the treatment for trapezius spasm along with pain in terms of improvement in PPT, neck disability, and ROM in the 24 postoperative HNC patients. The study findings proved the alternate hypothesis as there was significant change with MFR and MET on trapezius spasm and PPT in HNC patients. There seemed to be no significant difference between the groups before and after the intervention which suggests that both the manual therapies are effective individually, in reduction of pain, improving neck disability, and increasing cervical and shoulder ROM.

The distribution of patients in both groups were homogeneous in nature. study suggests that HNC are the most common type of cancer affects in males and fifth among females in India.[15] This could be attributed to the lifestyle changes that they tend to choose over a period of time. Similar to smoking, tobacco chewing and alcohol consumption are habits commonly seen in males rather females in the Indian context. The probable reason for HNC being lesser prevalent in females than males could be that the females in the Indian scenario are less likely to be employed as masons and laborers and that female labor is not well supported. Hence, owing to the more indoor orientation, the females are not exposed to the carcinogens from the ultraviolet rays, thus reducing the number of HNC in them.[16]

The maximum age distribution was in the age group of 50–60 years, i.e., 50.25 ± 12.19 years in MFR group and 50.08 ± 3.19 years in MET group in the current study which indicated the prevalence of HNC is more seen during the fifth decade of life, i.e., middle age group which was also similar in an observational study conducted to evaluate kinesiophobia in HNC patients with mean age of 52.33 ± 10.63 years in females and 53.05 ± 13.02 years in males. The middle age population is at risk of developing HNC due to their habits, lifestyle modifications, and westernization in the developing countries.[17]

Pain is stated as the most common problem noticed in HNC with little attention focused on pain control after the surgery. The local invasion causes destruction of the soft tissues and bone tissues causing the inflammation, and the compression to the nervous structures causes neuropathic pain in these patients. Functions such as speech, chewing, and/or swallowing increase pain intensity.[18] The reduction in the pain perception seen in the MET group could have been the effect of the preexisting hypoalgesia. During the isometric contraction, the inhibitory Golgi tendon reflex is activated which in turn heads to the reflex relaxation of the muscle. The somatic efferent is known to evoke an excitatory response in the sympathetic system that results in activating the muscle, joint receptors, and periaqueductal gray matter that directly helps in modulating the level of pain. The gating of nociceptive impulses causes inhibition in the dorsal horn of spinal cord as a result of the mechanoreceptor stimulation.[19] Improvements in the neck ROM, Neck Disability Index, and decrease in pain intensity may also be due to strengthening exercises.[20]

Effects of myofascial therapy on pressure hypersensitivity for supraspinatus and upper trapezius in the breast cancer patients have been well documented. Myofascial dysfunctions have shown to increase pressure hypersensitivity hence decreasing the ranges of motion too of the affected limbs.[21] Effect of MFR on upper limb mobility in females receiving radiation therapy in breast cancer survivors has shown improvement in movements such as flexion, abduction, abduction, external rotation, and the combined movement after MFR treatment. The probable mechanism for these improvements may be due to upregulation of activity of pain modulation in the tissues in the endocannabinoid system.[18] This physiology may be the probable reason for pain alleviation. Hence, consecutive six sessions of MFR to all patients in the MFR group in the present study may justify MFR as an appropriate therapy for such patients.

Improvements in ROM in cervical and shoulder region may be suggested due to postisometric relaxation leading to the inhibition of the motor activity through Golgi tendon organs and also an increase in the length of muscle due to the viscoelastic property of the tissue suggesting the reasons for improvements in both ROM in the present study.[22]

No significant changes were noted in QoL in both the groups. The health-related QOL (HRQOL) has been observed to be better in old patients than the younger ones. Along with common HNC symptoms, use of tobacco has shown to be poor physical, emotional, social, and functional well-being. Physical and functional well-being can be worse due to radiation but the HRQOL showed no difference when compared with patients not receiving radiation [23] which contradicts the present study as the patients in the present study had no habits of tobacco chewing. Kinesiophobia was evaluated in HNC patients along with its effect on QoL which states that there is fear in HNC patients to perform neck movements which hampers the daily activities of the person which leads to poor QoL [17] which goes in accordance to the present study.

Limitation of the study is that the sample size was small and long-term follow-up was not undertaken to confirm the results. Since the results of the present study has shown improvements when compared within the groups (i.e., MFR and MET) in cervical and shoulder ROM, reduction in PPT, and reduced burden of shoulder disability, similar studies may be carried out in larger populations to substantiate the evidence.

  Conclusion Top

Results of the present study demonstrated improvements in reduction of pain, neck disability, and improved neck and shoulder ROM which suggest that use of MFR and MET can be implemented individually to reduce trapezius spasm in postoperative HNC patients. Similar studies may be carried out in larger population in different clinical settings in the Indian Scenario.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Authors' contribution

Author 1: Data collection, data tabulation, preparing the initial part of the manuscript.

Author 2: Concept of the study design, interpretation of the study results, final write up of the manuscript.


We are grateful to the Medical Director Dr. M. V. Jali, Tertiary Care Hospital and Cancer Hospital for granting us permission to conduct the study. Our heartfelt thanks to the statistician Mr. Javali, Professor, USM KLE College and all the patients for participating in the study without whom the study would not have been possible.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]

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