JOSHI: EFFECT OF MET & POSTURE CORRECTION EXERCISE IN PATIENTS WITH NON-SPECIFIC NECK PAIN

R E S E A R C H

The Effect of Muscle Energy Technique and Posture

Correction Exercises on Pain and Function in Patients
with Non-specific Chronic Neck Pain Having Forward
Head Posture—a Randomized Controlled Trail
Reema Joshi, MPT,* Nishita Poojary, BPT

Dr. D.Y. Patil College of Physiotherapy College, Pune, India

https://doi.org/10.3822/ijtmb.v15i2.673

Background: Neck pain is a common Conclusion: The combined effect of MET

problem in individuals despite different and posture correction exercises provides
types of working patterns. Forward head signif icantly greater results than neck
posture is a common identified cause of range of motion treatment, and muscle
chronic neck pain in patients. The effect energy technique should be included in
of long-term forward head posture can the treatment of non-specif ic chronic
be loss of function which can limit indi- neck pain in individuals with forward
viduals’ capacity to work or do activities head posture.
of daily living; hence it becomes neces-
sary to intervene with muscle strength- KEYWORDS: non-specific chronic neck
ening to improve neck stability, as well pain; forward head posture; MET
as mobility.
Purpose: To assess effectiveness of mus-
cle energy technique (MET) and posture INTRODUCTION
correction exercises on pain and function
in patients with non-specific chronic neck The neck is the most commonly affected
pain having forward head posture. site of non-traumatic musculoskeletal
Study Setting: Outpatient department pain. Neck pain is defined by Mersky as
of Dr. D. Y. Patil College of Physiotherapy, pain “anywhere within the region bounded
Pune, India. superiorly by the superior nuchal line, in-
Participants: Both males and females feriorly by an imaginary line through the
between the ages of 21-60 years with a tip of first thoracic spinous process and
cranio-vertebral angle of less than 480 laterally by a sagittal plane tangential
were included in study. to the lateral borders of the neck.”(1) The
Research Design: A randomized clini- worldwide prevalence of neck pain in the
cal trial. adult population ranges f rom 16.7% to
Methodology: MET group received 75.5%.(2) The most common characteristics
muscle energy treatment + posture of neck dysfunction are pain, discomfort or
correction exercises, and control soreness which are experienced in the area
group receiving neck range of motion between inferior margin of the occipital
treatment. Outcomes measures were pain bone and the T1 vertebrae.(3)
(Numerical Pain Rating Scale), function The source of symptoms in mechanical
(Neck Disability Index), and cranio- neck pain is not completely understood,
vertebral angle (MB ruler). but has been purported to be related to
Results: Forty-eight subjects were various anatomical structures, particularly
included in the analysis, with 23 partici- zygapophyseal or vertebral joints of the cer-
pants in Group A (MET) and 25 in Group vical spine.(4) Assessment of non-specific
B (Control). While both groups showed neck pain includes the exclusion of any
within-group improvements, Group A radiculopathy and the consideration of any
had signif icantly greater decreases in prognostic factors such as old age or previ-
neck pain (p < .001), Neck Disability Index ous history. The confirmation or exclusion
scores (p < .001), and significantly greater of radiculopathy can be done using a com-
improvements in cranio-vertebral angles bination of the Spurling test, the traction/
(p < .025) compared to group B. distraction test, and the upper limb tension

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International Journal of Therapeutic Massage and Bodywork—Volume 15, Number 2, June 2022
 JOSHI: EFFECT OF MET & POSTURE CORRECTION EXERCISE IN PATIENTS WITH NON-SPECIFIC NECK PAIN

test. A commonly used assessment tool for relaxation for a brief latent period to allow
neck pain intensity and disability is the vali- gentle muscle lengthening. According to
dated self-reported Neck Disability Index. Chaitow,(11) MET is an active isometric con-
Non-specific neck pain is categorized traction method, along with application of
using a grading system:(5) moist heat therapy, that relaxes the muscle
and restores the normal blood and lym-
• GRADE 1: no signs of pathology and little phatic circulation by altering the interstitial
or no interference with daily activities; pressure and trans-capillary blood flow
• GRADE 2: signs of pathology and inter- that helps in washing out the nociceptive
ference with daily activities; stimulants which relieves pain. MET with
• GRADE 3: neurologic signs of nerve PIR helps to increase muscle flexibility
compression; and due to viscoelastic changes in the muscle
• GRADE 4: signs of major pathology. and reduce muscle tension. Both muscle
energy technique and static stretching are
A study done by Patwardhan et al. (6) commonly used techniques in the field of
in 2018 stated that chronic forward head physiotherapy. MET is an advanced stretch-
posture (FHP) can place large stresses ing technique. Studies using these two
on the muscles and connective tissue in techniques individually, in symptomatic
the cervical spine (CS) region and may as well as in asymptomatic individuals,
be a contributing factor to non-specific have shown improvement, but fewer stud-
neck pain. ies have compared these techniques in a
Quek and colleagues (7) and Kim and symptomatic population, where conflict-
Kim (8) reported FHP is an abnormality ing results are seen.(12)
identified by examining the position of the In this study, muscle energy technique
head with respect to the cervical spine (CS). was administered to the overactive muscles
In FHP, the head projects anteriorly over along with posture correction exercises,
the CS with simultaneous hyperextension including chin tuck, scapular bracing,
of the upper CS occurring from a tilting and pectoral stretching, to determine the
of the head in a posterior direction. The effect in individuals with non-specific neck
backward rotation of the head on the CS is pain with forward head posture. The aim
a compensation that enables an individual of the study is to assess the effectiveness
with FHP to look straight ahead instead of of the combined effect of muscle energy
towards the ground. techniques and posture correction among
Janda et al.(9) in their description of up- individuals with non-specific neck pain.
per cross syndrome stated that FHP often
results in movement dysfunction with
some muscles such as the deep neck flex- METHODS
ors, cervical erector spinae, lower trapezius,
and rhomboids becoming underactive and Design
other muscles becoming overactive such
as the upper trapezius, levator scapula, The study uses a randomized clinical trial
scalene, sternocleidomastoid, and the sub study methodology, see Figure 1.
occipitals which are also described by.
These muscle imbalances and movement Registry
dysfunctions may have a direct effect on
joint surfaces, thus causing forward head This study was approved by the insti-
posture. Neck stabilization is used to cor- tutional sub-ethical committee of Dr.
rect posture, and helps to elongate the D.Y. Patil Vidyapeeth, Pune DYPCPT/
underactive musculature and strengthen ISEC/48/2019.
overactive muscles.(10)
Muscle energy techniques (MET) are Setting
a class of soft tissue osteopathic ma-
nipulation methods that are directed The treatments were given at the outpa-
and controlled patient-initiated isomet- tient department of Dr. D.Y. Patil College
ric or isotonic contractions designed to of Physiotherapy, the Dr. D.Y. Patil Medical
improve musculoskeletal function and College Hospital and Research Institute
reduce pain. In post-isometric relaxation outpatient department, and the Dr. D.Y.
(PIR), overactive muscles are contracted Patil Ayurveda Hospital outpatient depart-
isometrically for period of time, followed by ment, Pimpri, Pune.

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 JOSHI: EFFECT OF MET & POSTURE CORRECTION EXERCISE IN PATIENTS WITH NON-SPECIFIC NECK PAIN

Assessed for eligibility (n= 119)

Enrollment
Excluded (n= 69)
 Not meeting inclusion criteria (n= 58)
 Declined to participate (n= 9)
 Other reasons (n= 2)

Randomized (n= 50)

Allocation
Allocated to intervention (post-isometric relaxation + Allocated to control (range of motion and
posture correction exercises) (n=25) strengthening exercises) (n=25)
 Received allocated intervention (n= 23)
 Did not receive allocated intervention (n=2)  Received allocated intervention (n=25)
 Personal reasons (n=1)
 Had an accident (n= 1)

Follow-Up

Lost to follow-up (n= 0) Lost to follow-up (n= 0)

Analysis

Analysed (n= 23) Analysed (n= 25)

Figure 1. CONSORT flow diagram of study participants.

Sample Size Calculation less than 48°. Subjects with recent cervical
spine fracture, radiculopathy in the upper
Sample size was calculated using statisti- extremity, neck pain with headaches, seri-
cal software Primer Version No.7 (PRIMER-e, ous pathology, malignancy, osteoporosis,
Auckland, NZ). Assuming 1.1 as the effect and disc prolapses were excluded f rom
size, with an α-error of 0.05 and power of the study.
0.8, the sample size was 25 in each group.
Recruitment, Randomization and Blinding
Participants Procedures

Eligible participants included males Recruitment took place between October

and females between the ages of 21 and 2019 and December 2020 when patients
60 years with a cranio-vertebral angle of attended the Outpatient Department

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 JOSHI: EFFECT OF MET & POSTURE CORRECTION EXERCISE IN PATIENTS WITH NON-SPECIFIC NECK PAIN

Dr. D. Y. Patil College of Physiotherapy, anatomical landmarks and a photograph

Pune. Patients were screened on a regular was taken. The photograph was uploaded
basis and every second patient who met to a computer and the MB ruler software
with the study criteria was invited to was used to calculate the CVA.
participate in the study. The rationale for
inviting every second participant was to Interventions
give an equal chance for participation
in the study. The potential participants The study involved an experimental
were informed about the study benefits, group (Group A), which received muscle
risks, and procedures in a regional lan- energy treatment + posture correction exer-
guage that was best understood by them cises, and a Control group (Group B), which
(Hindi or Marathi). Those who consented received neck range of motion treatment.
to participate were randomized into two
groups, using a simple lottery random Group A
sampling method: Group A (experimental Treatment consisted of a muscle energy
group) and Group B (conventional treat- technique called post-isometric relaxation
ment group/Control group). The second (PIR) and posture correction exercises.
researcher (NP) undertook all the study These techniques were applied to the sub-
treatments and assessment according to occipital area. In the PIR portion of the
the study protocols. The primary investi- treatment, the patient was asked to apply
gator (RJ) undertook the analysis and was approximately 20% of his strength to pro-
blind to the study group allocation. tract the shoulder girdle in supine position
or asked to match the therapist’s strength.
Outcomes Measures This isometric contraction was maintained
for a period of 7 seconds while holding the
Outcomes measures were undertaken breath and then the patient was asked to
pre-treatment and three weeks post- relax and exhale. During the period of relax-
treatment. Primary outcome measures ation, the therapist stretched the pectoralis
were pain intensity measured by a Numeri- minor muscle to its new length and the
cal Pain Rating Scale (NPRS), and impact stretch force was maintained for a period
of neck pain on the ability to manage of 10 seconds. The procedure was repeated
in everyday life which was measured by for a minimum three times per session for
the Neck Disability Index (NDI). Cranio- a period of three weeks. MET was followed
vertebral angle (CVA), measured using by posture correction exercises which in-
a MB ruler, was used to assess cervical cludes chin tuck exercises and scapular
neck posture. bracing pectoral stretch.
The NPRS is a subjective pain rating scale
using an 11-point scale from 0 to 10, where 0 Group B
means ‘no pain’ and 10 means ‘intolerable Pa t i e n t s re ce i ve d a co nve n t i o n a l
pain’. Participants select the whole num- exercise programme which included
ber that best represents their level of pain. strengthening exercises for deep neck
The NDI is a self-reported questionnaire flexors, rhomboids, lower trapezius, and
which is formulated to assess pain that serratus anterior because they are weak
restricts the activities of daily living (ADL); muscles in the upper crossed syndrome
it also helps to determine self-assessed dis- (two sets of 10 repetitions once a day) and
ability. NDI has 10 domains covering pain stretching exercises for pectoralis muscles
intensity, personal care, lifting, reading, (20-second hold with f ive repetitions
headaches, concentration, work, driving, each). Each exercise was repeated for a
sleeping, and recreation. Scores range total of 10 times.
from 0 to 50, with 50 being the greatest
levels of dysfunction. Statistical Analysis
The CVA is measured via drawing an
imaginary horizontal line through the Data analysis and interpretation was
C7 spinous process and a line joining the done using the free online statistical pack-
spinous process of C7 vertebra with the age WinPepi (version 11.65; http://www.
tragus of the ear. The Markus Bader ruler brixtonhealth.com/pepi4windows.html)
(MB ruler) is computer-based objective tool and Primer of Biostatistics version 7.(13)
that measure angles and distances. Reflec- Normality of the data was checked using
tive markers were placed on participants Shapiro-Wilk Test in WinPepi software and

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 JOSHI: EFFECT OF MET & POSTURE CORRECTION EXERCISE IN PATIENTS WITH NON-SPECIFIC NECK PAIN

was concluded as normally distributed Table 1. Baseline Characteristics of the Participants in

if p > .05 or not normally distributed if p Both Treatment Groups
≤ .05. Then the pre- and post-reading of
each outcome was compared with respec- MET Group Control Group
tive outcome of other group. If the data (n=23) (n=25) t- and
were normally distributed, the intra-group Variables Mean ± SD Mean ± SD p value
comparison used an unpaired t-test and
t=1.780,
the inter-group comparison used a paired Age 43.27±.68 43.5±1
p=.081
t-test. The significance level was set at p ≤
.05 and a 95% CI. t=0.470
Weight (kg) 61.16±14.77 59.38±11
p=.640
t=0.520,
Height (cm) 159.5±4.59 158.72±5.78
RESULTS p=.606
Duration of t=0.529,
One hundred and nineteen individuals 11.61±7.47 10.55±6.31
pain (months) p= .600
were assessed for eligibility, with 50 indi-
t=2.630,
viduals meeting the criteria to participate NPRS 7.13±1.39 6.24±0.92
p=.012
(see Figure 1). Two participants from MET
group withdrew prior to receiving any t=1.313,
NDI 30.96±4.49 29.48±3.24
treatment; 48 participants completed p=.196
the study. The MET group had 23 subjects CVA 42.15±3.28 43.13±4.23
t=0.890,
and the Control group had 25 subjects p=.378
for statistical analysis. The demographic
NPRS = numerical pain rating scale, NDI = neck
characteristics for both groups compared
disability index, CVA = cranio-vertebral angle.
using t-test was not statistically significant
for age (p = .081), height (p = .606), weight
(p = .640), and duration of pain (p = .600). (CVA) improved significantly pre-treatment
Baseline characteristics were assessed for to post-treatment for MET group (MET
neck pain, function, and posture using NDI group 42.15 to 46.9; p ≤ .02 and Control
and CVA and were not significantly differ- group 43.13 to 44.6; p = 0.001 (Table 2).
ent at baseline, but NPRS was significantly
greater for those in the MET group (p = .012) Between-Group Comparisons
as presented in Table 1.
MET group had a significantly greater
Within-Group Comparisons decrease in neck pain compared to Con-
trol group (MET group 4.87 decrease vs.
Neck pain decreased significantly pre- Control group 2.72 decrease; p ≤ .001) (Table
treatment to post-treatment for both 3). MET treatment showed a significantly
groups (MET group 7.12 to 2.28 and Control greater decrease in Neck Disability Index
group 6.24 to 3.52; p ≤ .05 for both groups). scores compared to Control group (MET
The Neck Disability Index scores decreased group 20.17 decrease vs. Control group
significantly pre-treatment to post-treat- 10.68 decrease; p ≤ .001). MET also showed
ment for both groups (MET group 30.96 to an improvement in cranio-vertebral angles
10.78 and Control group 29.48 to 18.8; p ≤ .05 compared to Control group, with a statis-
for both groups). The cranio-vertebral angle tically significance of p = .025 (MET group

Table 2. Within-Group Change in Outcome Measures for Both ET and Control Groups Using Dependent t-Test

MET Group (n=23) Control Group (n=25)

Pre Post p Pre Post p

Outcome Mean ± SD Mean ± SD value Mean ± SD Mean ± SD value

NPRS 7.13±1.39 2.261±1.13 0.0001 6.24±0.92 3.52±1.12 .001

NDI 30.96±4.49 10.78±4.37 0.0001 29.48±3.42 18.8±3.30 .001
CVA 42.15±3.28 46.9±3.71 0.002 43.13±4.23 44.6±4.31 .001

NPRS = Numerical pain rating scale, NDI = Neck disability index, CVA = Cranio-vertebral angle.

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 JOSHI: EFFECT OF MET & POSTURE CORRECTION EXERCISE IN PATIENTS WITH NON-SPECIFIC NECK PAIN

3.93° improvement vs. Control group 1.46° muscles which stimulates the muscle and
improvement; Table 3). joint mechanoreceptors and propriocep-
tors which, in turn, reduces the sensation
of pain, making the consecutive stretch
DISCUSSION easier and more tolerable.
The results of the present study obtained
The study was intended to assess the for pain reduction in the MET group is
effect of muscle energy technique using similar to the previous studies where pain
PIR and posture correction exercises to al- intensity was found to be reduced follow-
leviate neck pain and enhance function in ing MET over the neck area. The mecha-
comparison to a conventional treatment nism behind this MET application to the
protocol. To avoid selection bias, subjects sub-occipital muscles is that it helps to
were allocated into two groups by comput- decrease hyper activation and tightness
erised randomization technique. Baseline of the shortened muscles via the neuro-
characteristics were not statistically differ- physiological mechanism activated by
ent between groups for anthropometric the Golgi tendon reflex which inhibits the
variables or for NDI or CVA, but NPRS was alpha motor neuron and results in reflex
statistically higher in the MET group, which relaxation of muscles and decreases pain.
could mark an error in randomization. On Results of this study help to draw attention
comparison, both groups showed signifi- to postural input, which also helps in cor-
cant improvement in NPRS after receiving rection of forward head posture among the
their respective treatments. MET reduced individuals with non-specific neck pain in
pain perception by increasing the stretch comparison to static stretching.(17,18,19)
tolerance; those who received the muscle A study by Gupta et al.(12) on the effects
energy technique (post-isometric relax- of post-isometric relaxation versus iso-
ation) and posture correction exercises had metric exercises in non-specif ic neck
decreased pain and neck disability, along pain also concluded that MET showed
with greater improvement of their cranio- a significant improvement in pain and
vertebral angle compared to the Control functional status. Our results for Group
group. Table 2 summarizes the effect of A are also supported by a study by Abha
MET on patients with non-specific neck and Angusamy(20) which compared post-
pain typically presenting with alterations isometric relaxation with an integrated
in cervical proprioception and postural neuromuscular inhibition technique on
stability. Many studies explain the eff i- the upper trapezius trigger points and
cacy of manual therapy and therapeutic concluded that MET is effective in improv-
exercise for pain reduction and cervical ing pain and functional status. Results
disability.(14,15,16) of a study by Sharmila(21) on the effects
Both groups had significant decrease of MET versus conventional exercises
in pain, but the muscle energy technique in non-specific neck pain in secondary
(post-isometric relaxation) with posture school teachers are in accordance with our
correction exercises group demonstrated results for MET group, which concluded
significantly better results than those re- that post-isometric relaxation had better
ceiving conventional exercises. This could reductions in pain and disability. Muscle
be due to the isometric contraction of the energy technique combined with posture
correction exercise helps to improve pos-
ture by recruiting muscles and stimulating
Table 3. Between-Group Comparison of Pre-Post Mean the muscle and joint mechanoreceptors
Differences (± SD) Between MET and Control Groups
and proprioceptors, as well as giving posi-
Using Independent t-Test
tive feedback to the spinal musculature to
MET Group Control
maintain erect position; thus the results
(n=23) (n=25) p mentioned in Table 3 helps to provide
Outcome Mean Diff ± SD Mean Diff ± SD value evidence that MET with posture correc-
tion exercise can be considered together
NPRS 4.87 ± 1.84 2.72 ± 0.79 .001 in the treatment of non-specific neck pain
NDI 20.17 ± 5.52 10.68 ± 2.59 .001 to improve neck disability over conven-
tional exercises.
CVA 3.93 ± 5.23 1.46 ± 1.07 .025
The therapist-guided neck range of
NPRS = Numerical pain rating scale, NDI = Neck motion group was observed to have sig-
disability index, CVA = Cranio-vertebral angle. nificant within-group decreases in pain.

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 JOSHI: EFFECT OF MET & POSTURE CORRECTION EXERCISE IN PATIENTS WITH NON-SPECIFIC NECK PAIN

According to a study published by EI CONFLICT OF INTEREST NOTIFICATION

Laithy and Fouda,(22) the mechanism be-
hind the reducing in pain for this group The authors declare there are no con-
is that the isometric neck exercises cause flicts of interest.
the activation of the muscle stretch recep-
tors which occur during strong isometric
contraction of muscle and this leads to the COPYRIGHT
release of beta endorphins from the pitu-
itary gland, thereby decreasing the pain. Published under the CreativeCommons
This hypothesis is supported by research Attribution-NonCommercial-NoDerivs
study by Rupesh et al.(23) on the effects of 3.0 License.
sitting posture modification and exercises
in school going children with neck pain
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