Introduction
Neck pain is the most common occupational stress throughout the globe. According to estimates from International Burden of Diseases 2010 study, neck pain was graded fourth highest in terms of disability as measured by Years Lived with Disability (YLD’S) and 21st in terms of overall burden in which the point prevalence starting from 5.9% to 38.7% [1]. Annual prevalence ranges from 16% and 75.1% [2]. While lifetime prevalence ranges from 14.2 to 70% [3].
Neck pain is a condition marked with a course of remission and exacerbation which can be disabling in some people. Most of people don’t get complete resolution of the neck pain and experience incidental disability [4].
Neck pain is a sensation or discomfort, which a person experiences within the neck or originating from different components of body like stress, upper cross syndrome in which the back muscles of the neck and shoulder muscles (upper trapezius and levator scapula) muscles become overused and strained while the muscles of the chest become shortened and tight. This results in counter muscles to become underused or weakened, which are neck flexors and thus cause headache [5].
Classification and diagnostic criteria of the Neck pain Task force 2000-2010 describes four grades that are: grade I is the pain in neck without any major structural pathology symptoms and no minor interference of the activity of the daily living, grade II is neck pain without any structural deficits but majorly affecting the activity of daily living, grade III is with no signs and symptoms of structural abnormality but presence of nerve compression signs, and grade IV is structural pathology [6].
Any condition or event (e.g., incorrect posture, acute injury, ageing, inherent or developmental defects) resulting in altered cervical joint mechanics or muscle structure and performance, that may end up in mechanical neck pain. Bergmann DC et al., represented five diagnostic criteria for joint dysfunction in the mechanical neck [7].
a) Pain/tenderness which is present on the affected area and its associated muscles.
b) Imbalance of the motion when symmetrical motions are compared bilaterally.
c) Presence of motion abnormality which differentiates the degree or quality of motion that is compromised inside the involved joint.
d) Any sign of inflammatory reaction such as altered tissue tone, texture and/or temperature.
e) Acceptable positive special orthopaedic tests such as cervical flexion and rotation test which is referred to as Kemps test which is a provocative test to detect pain which can be local or radicular in nature [7].
The importance of the primary rib which is also called as true ribs that attaches directly to the sternum (vertebro-sternal) arises from the fact that it’s in relationship to the cervico-thoracic spine which leads to spondylotic changes, and therefore the proven fact that it is positioned across the cervico-brachial junction where other vital structures such as brachial plexus are also present [8].
Scalene muscle involvement related to a primary rib dysfunction is related to cervical spine path-mechanics, this argument was supported by the previous discussions who expressed that the primary costo-transverse joint is that the only level that lacks ligamentous support superiorly, making these joint prone to mechanical dysfunctions [9].
First rib dysfunction with tight scalene muscle involvement additionally affects the lower cervical spine due to its attachment on cervico-thoracic junction. It may be common that patients with a primary rib dysfunction will also report cervical involvement with a resultant motion restriction and pain radiating up the trapezius muscle and scalene muscles [10].
Signs and symptoms of a first rib dysfunction include pain on the costo-sternal or costo-vertebral joints of the primary rib; pain within the head, neck, shoulder, or arm; and restrictions or pain throughout exhalation or inhalation. Swelling, tenderness, or sensitivity of the primary rib might also be present throughout palpation [11].
The fixated first rib syndrome in which the first rib is unable to move and smooth cervical spine flexion and rotations are altered. Mechanically scalene contracts on one side flex neck same side and elevate the first rib includes rounded shoulders, kyphotic t-spine, jutted chin, hyper extended (OA) atlanto-occipital joint, and internally revolved arms, pain deeply hidden inside the higher crossed pattern [12].
Spinal Mobilisation therapy may be a skillful technique of passive movement of a spinal section or region. It’s typically performed with the aim of achieving therapeutic impact. They are represented as mild, usually periodic, passive movement given to a spinal region or segment which gently enhances the passive vary of motion of that region [13].
MET uses the muscle’s energy with mild isometric contractions to loosen the muscles by using autogenic or reciprocal-inhibition therapy, and enhances the compliance of the muscle. As compared to static stretching that is a passive technique during which the patient force is less in comparison to MET, MET is an energetic technique in which patient uses their muscles and perform actively [14].
Similar study identifies the effect of first rib mobilisation in mechanical neck pain with radiculopathy by Sattar A et al., but did not compare with MET to identify which technique is most effective and did not mention the exact cause of first rib restriction neither they checked the involvement of head position sense alteration in chronic mechanical neck pain [15].
Therefore, the aim of the study was to check the impact of first rib Maitland mobilisation and MET on pain, disability and head position sense in patients with chronic mechanical neck pain, which will additionally enlighten the relation between first rib restriction and mechanical neck pain because of activity stresses and bad posture.
Materials and Methods
Type of Study
This was an experimental comparative study which included 40 patients, with mechanical neck pain of age group 25-40 years.
Participants
After receiving Ethical Clearance from the Institutional Committee of Shree Gurugobind Singh University. Ref. No. SGTU/FOP/2018/37, the study was carried out at Sir Ganga Ram Hospital, Delhi. The sample size of 40 patients was calculated using G power (power of the study is 0.95) with chronic mechanical neck pain evaluated from March 2018 to June 2018 and the data analysis writing took around five months (till November 2018). Patients who fulfilled the inclusion criteria:
(1) Male and female patients with chronic neck pain of duration three weeks to six months.
(2) Age group 25-45 years.
(3) Hypertonic scalene muscle which was determined via regional examination and by asking the patient to laterally flex and rotate the neck to tuck in sternocleidomastoid muscle and palpating the scalene belly.
(4) Pain was measured by Mc gill Pain Questionnaire (MPQ) (ANNEXURE 1): The MPQ was scored by counting the number of words selected to obtain a number of chosen words score (0-20). Pain Rating Index scoring range from 0-78 build on the rank values of the chosen words. The score accompanying with each descriptor is centred on its position or rank order in the word such that the first word is given a value of 1, the next given a value of 2 and so on. Rank values are added within each subcategory. Scores on the Present Pain Intensity scale ranges from 0-5. A greater score on the MPQ determines worse pain. The Pain Rating Index is given both in terms of quantity of pain, by the number of words used and the rank values of the words, as well as the quality of pain, by the particular words that are selected. The normative mean scores across painful conditions ranged from 24-50% of the maximum score were included in the study [16].
(5) Neck Disability Index (NDI) (ANNEXURE 2): Moderate disability greater than or equal to 15 were included in the study. NDI can be scored as a raw score or double or expressed as percentage and rated from 0-5 where 0-No pain and 5 mean worst pain. All points are summed and taken as total score where 0-4 points refers to (0-8%) no disability, 5-14 points refers to (10-28%) mild disability, 15-24 points refers to (30-48%) moderate disability, 25-34 points refers to (50-64%) severe disability, 35-50 points refers to (70-100%) complete disability [17].
(6) Head position sense relocation (ANNEXURE 3) of equal to or greater than 2 inches from starting point, aberrant motion were included in the study. This device uses a laser pointer fixed to helmet or headband. Targets were 40 cm of diameter with concentric circles in 1 cm increments, divided into 4 quadrants which intersect at zero [18].
Patients with who did not met the inclusion criteria were excluded from the study:
Congenital anomalies of cervical spine or first rib.
Posterior ponticle or cervical rib.
Thoracic outlet syndrome.
Contraindications to mobilisation to any person that were currently taking either anti-inflammatory or pain relieving medication at that time. The whole procedure was explained and written consent was taken from all the patients participated in the study.
Randomisation
Subjects who matched the inclusion criteria were randomly assigned to both the groups A and B using chit method of randomisation. The allocation was conducted by the primary investigator at the baseline. Group A was given MET along with Proprioceptive Training (n-20) and Group B was given First Rib Maitland Mobilisation along with Proprioceptive Training (n-20). Measurements were taken for age, height, Body Mass Index (BMI) for all subjects. All patients underwent baseline measurement for pain, disability and head position sense.
Procedure
Group A- MET: [Table/Fig-1] shows patients were given post-isometric relaxation for restricted first rib in sitting position and therefore the affected elevated first rib, opposite foot of therapist was placed on the table and patient non affected arm is ‘dropped’ on the therapist flexed knee. The practitioner’s conjointly flexes the elbow on the non-affected side placed anterior to shoulder with the hand supporting the patient facet of head. Then therapist makes contact with the tubercle of the first rib with fingers or thumb of affected side (patient) disposing of available soft tissue slack as steady force is applied in inferior direction. The therapist eases his flexed leg and uses his supported hand to encourage patient’s neck into a side flexion and rotation to affected side thus unloading the scalene tension thereon side and encourage the first rib to move anteriorly and inferiorly. The contact thumb or fingers on the rib tubercle/shaft takeout there slack, and therefore the patient was asked to inhale and hold breath for few seconds and at a similar time gently presses your head towards non affected side against hand. This 5-7 second contraction can activate the scalene muscle. On releasing the breath, restriction barrier is taken out of soft tissues as all the movements that were done before the contractions were repeated and 2 or 3 repetitions usually results in greater rib stabilisation and functional balance [19].
Group B-Maitland Mobilisation: [Table/Fig-2] shows first rib Maitland Mobilisation, the physiotherapists placed her thumbs anterior to muscle belly of the trapezius muscle and therefore the direction of pressure will be inclined a bit towards the feet yet as being postero-anteriorly directed. Patient lies supine whereas physiotherapists standing at the facet being treated and apply the pressure in the oscillating anterior posterior and caudal movement on all components of the primary rib that are palpable [20].
Both groups were given proprioceptive training as shown in [Table/Fig-3] which incorporates head relocation practice, gaze stability, eye follow, eye head coordination. All active movements of the cervical spine (flexion, extension, rotation, and lateral flexion) were used. Occulomotor adaptation exercises were used to maintain postural stability which was carried out through various stages by asking the patient to perform eye movement with head neutral in both directions then visually focusing on a target while rotating the head in both directions horizontal as well as vertical. Head eye coordination with rotation of both the eyes and head in opposite directions. Exercises were progressed by increasing vary of movements, speed and alteration of visual targets [21].
Occulomotor adaptation exercise.
Hot fomentation was given in the form of commercially available hydro collator packs over the painful area in cervical region before the treatment whereas the temperature of the hydro collator unit was set at 71°C and six to eight layers of the towel were set and was given for 10-20 minutes [22]. The treatment protocol was given for three sessions per week for four weeks [23].
Statistical Analysis
Data were analysed using SPSS 21 version (SPSS Inc., Chicago, IL, USA). Mean and standard deviation of all the variables were measured. The level of significance was set at p<0.05. ANOVA and student’s t-test was used to compare the intergroup difference in analysing the data collected for all variables.
Results
A total of 67 patients were assessed and 40 patients who fulfilled the inclusion criteria were randomly allocated to either group. Two participants from Group A left the study out due to personal reasons and two participants from Group B withdrew because they could not comply with the treatment and assessment schedule for which 4 new patients were treated for the analysis of 40 participants.
Mean comparison of age, weight and BMI was done for both the groups. Intergroup analysis showed no significant difference in both group, p>0.05 [Table/Fig-4].
Mean comparison of age, weight and BMI.
| Variables | Mean±SD Group A (Muscle energy technique) | Mean±SD Group B (Maitland mobilisation) | t-value | p-value |
|---|
| Age | 37.50±8.88 | 38.10±9.06 | 0.212 | 0.834NS |
| Weight | 69.95±5.48 | 68.50±7.07 | 0.725 | 0.473NS |
| BMI | 25.51±2.31 | 26.24±2.69 | 0.920 | 0.363NS |
p-value <0.05 or .001 (significant or highly significant respectively)
p-value >0.05 (non-significant)
NS: Non-significant
The result of the study showed that group A had 70.9% of improvement at the end of 4th week and group B had 28.47% of improvement. Group A Experimental group showed highly significant improvement by 42.43% in comparison to group B p<0.001 [Table/Fig-5].
Mean comparison for both groups on pain.
| Pain | Groups | Mean±SD | t-value | p-value |
|---|
| Baseline | MET (Group A)Mobilisation (Group B) | 44.65±3.9043.90±3.34 | 0.654 | 0.517 |
| 2nd week | MET (Group A)Mobilisation (Group B) | 32.00±4.2436.55±4.81 | 3.17 | 0.003 |
| 4th week | MET (Group A)Mobilisation (Group B) | 12.95±4.0631.40±5.63 | 11.89 | <0.001**HS |
p-value <0.05 or .001 (significant or highly significant respectively)
p-value >0.05 (non-significant)
NS: Non-significant
[Table/Fig-6] shows the intragroup analysis for pain variable of MET group A and their p values showed highly significant difference at end of 4th week p<0.05.
Intragroup analysis for pain variable of MET group A.
| MET group | Pain | Mean±SD | t-value | p-value |
|---|
| Pair 1 (Difference of means from baseline to 2nd week) | Baseline2nd week | 44.65±3.8932.00±4.24 | 18.773 | 0.028 |
| Pair 2 (Difference of means from 2nd week to 4th week) | 2nd week4th week | 32.00±4.2412.95±4.06 | 19.767 | 0.019 |
| Pair 3 (Difference of means from baseline to 4th week) | Baseline4th week | 44.65±3.8912.95±4.06 | 34.973 | 0.001** |
If p-value <0.05 or .001 (significant or highly significant respectively)
If p-value >0.05 (not significant)
[Table/Fig-7] shows the intragroup analysis for pain variable of Mobilisation group and their p-values showed significant difference at end of 4th week p<0.05.
Intragroup analysis for pain variable of mobilisation group.
| Mobilisation group | Pain | Mean±SD | t-value | p-value |
|---|
| Pair 1 (Difference of means from baseline to 2 week) | Baseline2nd week | 43.90±3.3436.55±4.81 | 11.17 | 0.046 |
| Pair 2 (Difference of means from 2nd to 4th week) | 2nd week4th week | 36.55±4.8131.40±5.63 | 8.66 | 0.044 |
| Pair 3 (Difference of means from baseline to 4th week) | Baseline4th week | 43.90±3.3431.40±5.63 | 13.60 | 0.021* |
The intergroup analysis for neck disability measured by NDI showed that there was a highly significant improvement seen in MET group A as compared to group B at 4th week, p<0.001 [Table/Fig-8].
Mean comparison for both groups on Neck disability.
| Disability | Groups | Mean±SD | t-value | p-value |
|---|
| Baseline | MET (Group A)Mobilisation (Group B) | 17.60±2.6817.25±1.71 | 0.492 | 0.626 |
| 2nd week | MET (Group A)Mobilisation (Group B) | 12.60±2.4114.75±1.99 | 3.07 | 0.004* |
| 4th week | MET (Group A)Mobilisation (Group B) | 6.45±2.3312.60±1.67 | 9.61 | <0.001**HS |
p-value <0.05 or .001 (significant or highly significant respectively)
p-value >0.05 (non-significant)
NS: Non-significant
[Table/Fig-9] shows the intragroup analysis for disability component for MET group A showed highly significant difference at the end of 4th week p<0.05.
Intragroup analysis for disability component for MET group A.
| MET group | Disability | Mean±SD | t-value | p-value |
|---|
| Pair 1 (Difference of means from baseline to 2 week) | Baseline2nd week | 17.60±2.6812.60±2.42 | 12.583 | 0.020 |
| Pair 2 (Difference of means from 2nd week to 4th week) | 2nd week4th week | 12.60±2.426.45±2.33 | 11.725 | 0.009 |
| Pair 3 (Difference of means from baseline to 4th week) | Baseline4th week | 17.60±2.686.45±2.33 | 17.714 | 0.001** |
If p-value <.05 or .001 (significant or highly significant respectively)
If p-value >0.05 (not significant)
[Table/Fig-10] shows the intragroup analysis for disability component for Mobilisation group B showed significant difference at the end of 4th week p<0.05.
Intragroup analysis for disability component for Mobilisation group B.
| Mobilisation group | Disability | Mean±SD | t-value | p-value |
|---|
| Pair 1 (Difference of means from baseline to 2 week) | Baseline2nd week | 17.25±1.7114.75±1.99 | 8.483 | 0.039 |
| Pair 2 (Difference of means from 2nd week to 4th week) | 2nd week4th week | 14.75±1.9912.60±1.67 | 11.831 | 0.021 |
| Pair 3 (Difference of means from baseline to 4th week) | Baseline4th week | 17.25±1.7112.60±1.67 | 14.235 | 0.010* |
If p-value <0.05 or .001 (significant or highly significant respectively)
If p-value >0.05 (not significant)
The result of our study also revealed that head position sense in group A showed 67% improvement at the end of 4th week and group B showed 28% improvement at the end of 4th week. But group A showed highly significant improvement by 39% in comparison to group B [Table/Fig-11].
Mean comparison for both groups on Head position sense.
| Head position sense | Groups | Mean±SD | t-value | p-value |
|---|
| Baseline | METMobilisation | 12.00±1.6211.35±1.62 | 1.52 | 0.137 |
| 2nd week | METMobilisation | 8.55±1.479.15±1.68 | 1.05 | 0.303 |
| 4th week | METMobilisation | 4.60±1.578.03±1.63 | 6.53 | <0.001**HS |
p-value <0.05 or .001 (significant or highly significant respectively)
p-value >0.05 (non-significant)
NS: Non significant
[Table/Fig-12] shows the intragroup analysis for head position sense for MET group A showed highly significant difference at the end of 4th week p<0.05.
Intragroup analysis for head position sense for MET group A.
| MET group | Head position sense right | Mean±SD | t-value | p-value |
|---|
| Pair 1 (Difference of means from baseline to 2nd week) | Baseline2nd week | 12.00±1.628.55±1.47 | 17.39 | 0.041 |
| Pair 2 (Difference of means from 2nd to 4th week) | 2nd week4th week | 8.55±1.474.60±1.57 | 12.67 | 0.023 |
| Pair 3 (Difference of means from baseline to 4th week) | Baseline4th week | 12.00±1.624.60±1.57 | 17.39 | 0.001** |
If p-value <0.05 or .001 (significant or highly significant respectively)
If p-value >0.05 (not significant)
[Table/Fig-13] shows the intragroup analysis of head position sense for Mobilisation group B showed significant difference at the end of 4th week p<0.05.
Intragroup analysis of head position sense for Mobilisation group B.
| Mobilisation group | Head position sense right | Mean±SD | t-value | p-value |
|---|
| Pair 1 (Difference of means from baseline to 2nd week) | Baseline2nd week | 11.35±1.629.15±1.68 | 8.904 | 0.040 |
| Pair 2 (Difference of means from 2nd to 4th week) | 2nd week4th week | 9.15±1.688.03±1.63 | 4.682 | 0.021 |
| Pair 3 (Difference of means from baseline to 4th week) | Baseline4th week | 11.35±1.628.03±1.63 | 12.801 | 0.015* |
If p-value <0.05 or .001 (significant or highly significant respectively)
If p-value >0.05 (not significant)
The intergroup analysis for pain, neck disability and head position sense using unpaired t-test showed that there was a significant improvement in MET group A as compared to group B p<0.001.
Discussion
Mechanical neck pain is most commonly seen in people involved in occupation like computer sitting, desk job, students and administrative tasks with sedentary life style [24], occupational stress, heavy lifting and prolonged demanding work [25]. In a sitting working position, neck extensor muscles would be stretched while flexors muscles are tend to become weak during long working hours of sustained forward position of head and neck [26].
The study was done to compare the effectiveness of the two techniques that is First Rib Muscle Energy Technique in group A and Maitland Mobilisation in group B in chronic mechanical neck pain patients. The subjects of this study had similar baseline values for all dependent variables which indicate that all groups had homogenous distribution of patients.
The results of this study revealed that both the groups improved significantly at the end of the 4th week. Whereas the group A had shown better results in reducing pain, disability and improving head position sense than group B.
In this study the within group analysis of group A, the Mc gill pain questionnaire showed that there was a significant improvement in pain of 42.43% at the last day of 4th week of treatment. The results acquired for pain decrease in the MET group could be similar to pilot study by Sachdeva S et al., where pain intensity reduced MET over the neck and showed the conceivable mechanism for decrease in pain intensity in MET group which can be attributed to hypoalgesic effect. It also leads to reduction of pain by the inhibitory Golgi tendon reflex, initiated and isometric contraction that prompts reflex relaxation of the muscle and activation of muscle and joint mechanoreceptors prompts sympathatic excitation evoked by somatic efferent’s and localised activation of peri aqueductal gray matter that assume job in diminishing modulation of pain. Nociceptive inhibition at that point happens at the dorsal horn of the spinal cord, as simultaneous gating of nociceptive impulses in the dorsal horn, due to mechano-receptor stimulation [27].
The after effect of the study led by Selkow NM et al., found that momentary effects of MET on pain in individuals with non explicit lumbopelvic pain which concluded that the effects of MET over past 24 hours seems to be most significant [28].
However, in comparison between group A and group B, the group B shows 28% improvement in pain by the Mc gill pain questionnaire at the end of 4th week of treatment. The relative improvement in group B was due to the growing evidence of the hypoalgesic effect of a number of manual therapy techniques. Fryer G et al., also revealed that both spinal manipulation and mobilisation has decreased the thoracic pain sensitivity to pressure, but with mobilisation it is more effective [29].
Both the groups, group A and group B, showed statistically significant improvement in functional disability of 63.3% and 36.9%, respectively at the end of the last day of 4th week. The possible mechanism for improving NDI could be any form of physical therapy intervention brought about significant decrease in neck disability and increase in functional status of the neck supported by Ylinen J et al., [30].
The relatively additional improvement of functional disability in group A was also supported by Colloca L et al., that it may be also be due to the biomechanical effects on the restoration of mobility. Biomechanical effects have been found to be associated with manual therapy in both the groups [31].
Similar results were obtained by Phadke A et al., in a RCT which investigated the effect of MET and static stretching on pain and functional disability of mechanical neck pain patients. It was concluded that MET is better than static stretching for variables VAS and NDI [32].
The study also showed improved head position sense in Group A of 67% at the end of 4th week treatment whereas Group B showed only 28% of improvement. The mechanism of improved proprioception in MET applied to the spine involves various specific leverages and localisation to spinal articulations, which is controlled, purposeful isometric muscle contraction done by the patient. This has been explained to stimulate joint proprioceptors, which focuses on different pattern of afferent activity in proprioceptive impaired region, and initiates the CNS to normalise the proprioceptive and motor coordination from that area.
MET might also produce changes in proprioception, motor programming, and control. Spinal pain disturbs proprioception and motor control, causing decreased awareness of spinal motion and position and cutaneous touch perception [33].
Limitation
This study did not have a control group. There may be a possible interaction between the treatment effects of both groups. Therefore, the results could only explain the relative effectiveness of these two techniques. To find out whether each technique was actually effective in treating mechanical neck pain, additional studies are still required. The long-term effects of the treatment were not explained. The outcome assessor was not blinded, which might have led to measurement bias in the study. Future studies should assess the long-term effects of the interventions and there effects with the presence of control group.
Conclusion
Both groups were found to be effective in reducing pain, disability but the effects of MET was highly significant in response to Maitland Mobilisation. Results of the study also revealed that addition of proprioceptive training along with MET added the efficacy of improving head position sense, and reducing pain and disability in comparison to Maitland Mobilisation. This may also enlighten the relation between first rib restriction and mechanical neck pain due to occupational stresses and bad posture which can be treated by breaking the restriction barrier.
The effects of first rib MET along with proprioceptive training is an effective form of manual therapy in treating patients with chronic mechanical neck pain patients associated with first rib restriction, which proves MET is more effective form of manual therapy in mobilising restricted joints.
p-value <0.05 or .001 (significant or highly significant respectively)p-value >0.05 (non-significant)NS: Non-significantp-value <0.05 or .001 (significant or highly significant respectively)p-value >0.05 (non-significant)NS: Non-significantIf p-value <0.05 or .001 (significant or highly significant respectively)If p-value >0.05 (not significant)p-value <0.05 or .001 (significant or highly significant respectively)p-value >0.05 (non-significant)NS: Non-significantIf p-value <.05 or .001 (significant or highly significant respectively)If p-value >0.05 (not significant)If p-value <0.05 or .001 (significant or highly significant respectively)If p-value >0.05 (not significant)p-value <0.05 or .001 (significant or highly significant respectively)p-value >0.05 (non-significant)NS: Non significantIf p-value <0.05 or .001 (significant or highly significant respectively)If p-value >0.05 (not significant)If p-value <0.05 or .001 (significant or highly significant respectively)If p-value >0.05 (not significant)
[1]. Wang H, Naghavi M, Allen C, Barber RM, Bhutta ZA, Carter A, Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: A systematic analysis for the Global Burden of Disease Study 2015 The Lancet 2016 388(10053):1459-544.10.1016/S0140-6736(16)31012-1 [Google Scholar] [CrossRef]
[2]. Cohen SP, Epidemiology, diagnosis, and treatment of neck pain In Mayo Clinic Proceedings 2015 90(2):284-99.Elsevier10.1016/j.mayocp.2014.09.00825659245 [Google Scholar] [CrossRef] [PubMed]
[3]. Childs JD, Cleland JA, Elliott JM, Teyhen DS, Wainner RS, Whitman JM, Neck pain: Clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association Journal of Orthopaedic & Sports Physical Therapy 2008 38(9):A1-34.10.2519/jospt.2008.0303187580500 [Google Scholar] [CrossRef] [PubMed]
[4]. Côté P, Cassidy JD, Carroll LJ, Kristman V, The annual incidence and course of neck pain in the general population: a population-based cohort study Pain 2004 112(3):267-73.10.1016/j.pain.2004.09.00415561381 [Google Scholar] [CrossRef] [PubMed]
[5]. Thacker D, Jameson J, Baker J, Divine J, Unfried A, Management of upper cross syndrome through the use of active release technique and prescribed exercises Logan College of Chiropractic 2011 Apr [Google Scholar]
[6]. Guzman J, Haldeman S, Carroll LJ, Carragee EJ, Hurwitz EL, Peloso P, Clinical practice implications of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders: from concepts and findings to recommendations Spine 2008 33[4S]:S199-213.10.1097/BRS.0b013e318164464118204393 [Google Scholar] [CrossRef] [PubMed]
[7]. Bergmann DC, Thomas F, Peterson D, The Spine: anatomy, biomechanics, assessment, and adjustive techniques Chiropractic Technique 1993 https://scholar.google.com/scholar?hl=en&as_sdt=0%2C5&q=Bergmann+DC%2C+Thomas+F.+%2C+Peterson+D.+The+Spine%3A+anatomy%2C+biomechanics%2C+assessment%2C+and+adjustive+techniques.+Chiropractic+Technique.+1993.+&btnG= [Google Scholar]
[8]. Michael A, First rib function and the thoracic outlet syndrome Journal of Orthopaedic Medicine 1995 17(2):56-61.10.1080/1355297X.1995.11719787 [Google Scholar] [CrossRef]
[9]. Lindgren KA, Leino E, Subluxation of the first rib: A possible thoracic outlet syndrome mechanism Archives of Physical Medicine and Rehabilitation 1988 69(9):692-95. [Google Scholar]
[10]. Johnson HH, Thoracocostal subluxation syndrome: an often overlooked cause of chest and arm pain Chiropractic Technique 1995 7:134-38.Available from https://scholar.google.com/scholar?hl=en&as_sdt=0%2C5&q=Johnson+HH.+Thoracocostal+subluxation+syndrome%3A+an+often+overlooked+cause+of+chest+and+arm+pain.+Chiropractic+Technique.+1995%3B7%3A134-8.+&btnG= [Google Scholar]
[11]. Feuerherd R, Saliba S, Manual therapy for first-rib dysfunction Athletic Training and Sports Health Care 2013 5(1):05-06.10.3928/19425864-20130104-02 [Google Scholar] [CrossRef]
[12]. Kamkar A, Cardi-Laurent C, Whitney SL, Conservative management of superior subluxation of the first rib Journal of Sport Rehabilitation 1992 1(4):300-16.10.1123/jsr.1.4.300 [Google Scholar] [CrossRef]
[13]. Gibson W, Palsson TS, Coopes E, Wand BM, Travers MJ, Thrust manipulation may not decrease the intensity of chronic low back pain. Letter to the editor regarding “Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis” by Coulter et al The spine journal: official journal of the North American Spine Society 2018 18(10):196110.1016/j.spinee.2018.05.03930442417 [Google Scholar] [CrossRef] [PubMed]
[14]. Chaitow L, Crenshaw K, Muscle energy techniques Elsevier Health Sciences 2006 [Google Scholar]
[15]. Sattar A, Waqas S, Asim HM, Effect of First Rib Mobilization in Mechanical Neck Pain with Radiculopathy for Pain Relief Annals of King Edward Medical University 2018 24(2):768-70. [Google Scholar]
[16]. Hawker GA, Mian S, Kendzerska T, French M, Measures of adult pain: Visual analog scale for pain (vas pain), numeric rating scale for pain (nrs pain), mcgill pain questionnaire (mpq), short-form mcgill pain questionnaire (sf-mpq), chronic pain grade scale (cpgs), short form-36 bodily pain scale (sf-36 bps), and measure of intermittent and constant osteoarthritis pain (icoap) Journal of Arthritis Care and Research 2011 63(S11):S240-52.10.1002/acr.20543 [Google Scholar] [CrossRef]
[17]. Vernon H, Mior S, The Neck Disability Index: A study of reliability and validity Journal of Manipulative and Physiological Therapeutics 1991 Sep 10.1037/t35122-000 [Google Scholar] [CrossRef]
[18]. Kristjansson E, Treleaven J, Sensorimotor function and dizziness in neck pain: implications for assessment and management Journal of Orthopaedic & Sports Physical Therapy 2009 39(5):364-77.10.2519/jospt.2009.283419411769 [Google Scholar] [CrossRef] [PubMed]
[19]. Leon Chaitow, Ken Crenshaw, Sandy Fritz BS, ‘Advanced soft tissue techniques-muscle energy techniques’ Churchill Livingstone Elsevier 3rd editionchapter 6 Pg no. 228-30 [Google Scholar]
[20]. Tuttle N, Posteroanterior movements of the cervical spine (Doctoral dissertation, School of Physiotherapy and Exercise Science, Faculty of Health, Griffith University) [Google Scholar]
[21]. Jull G, Falla D, Treleaven J, Hodges P, Vicenzino B, Retraining cervical joint position sense: the effect of two exercise regimes Journal of Orthopaedic Research 2007 25(3):404-12.10.1002/jor.2022017143898 [Google Scholar] [CrossRef] [PubMed]
[22]. Games KE, Sefton JM, Wilson AE, Whole-body vibration and blood flow and muscle oxygenation: A meta-analysis Journal of Athletic Training 2015 50(5):542-49.10.4085/1062-6050-50.2.0925974682 [Google Scholar] [CrossRef] [PubMed]
[23]. Kumar GY, Sneha P, Sivajyothi N, Effectiveness of muscle energy technique, Ischaemic compression and strain counterstrain on upper trapezius trigger points: A comparative study International Journal of Physical Education, Sports and Health 2015 1(3):22-26. [Google Scholar]
[24]. Barton PM, Hayes KC, Neck flexor muscle strength, efficiency, and relaxation times in normal subjects and subjects with unilateral neck pain and headache Archives of Physical Medicine and Rehabilitation 1996 77(7):680-87.10.1016/S0003-9993(96)90008-8 [Google Scholar] [CrossRef]
[25]. Rezasoltani A, Khaleghifar M, Tavakoli A, Ahmadi A, Minoonejad H, The effect of a proprioceptive neuromuscular facilitation program to increase neck muscle strength in patients with chronic non-specific neck pain World Journ of Sport Sci 2010 3(1):59-63. [Google Scholar]
[26]. Mayoux-Benhamou MA, Revel M, Influence of head position on dorsal neck muscle efficiency Electromyography and Clinical Neurophysiology 1993 33(3):161-66. [Google Scholar]
[27]. Sachdeva S, Yadav J, Gulati M, Pawaria S, To see the effect of first rib muscle energy technique on pain in chronic mechanical neck pain patients-A randomized controlled pilot study International Journal of Medical Science and Diagnostic Research 2019 32(1):75-80. [Google Scholar]
[28]. Selkow NM, Grindstaff TL, Cross KM, Pugh K, Hertel J, Saliba S, Short-term effect of muscle energy technique on pain in individuals with non-specific lumbopelvic pain: A pilot study Journal of Manual & Manipulative Therapy 2009 17(1):E14-E18.10.1179/jmt.2009.17.1.14E20046557 [Google Scholar] [CrossRef] [PubMed]
[29]. Fryer G, Morris T, Gibbons P, Paraspinal muscles and intervertebral dysfunction: part one Journal of Manipulative and Physiological Therapeutics 2004 27(4):267-74.10.1016/j.jmpt.2004.02.00615148466 [Google Scholar] [CrossRef] [PubMed]
[30]. Ylinen J, Takala EP, Nykänen M, Häkkinen A, Mälkiä E, Pohjolainen T, Active neck muscle training in the treatment of chronic neck pain in women: a randomized controlled trial JAMA 2003 289(19):2509-16.10.1001/jama.289.19.250912759322 [Google Scholar] [CrossRef] [PubMed]
[31]. Colloca L, Benedetti F, How prior experience shapes placebo analgesia Pain 2006 124(1-2):126-33.10.1016/j.pain.2006.04.00516701952 [Google Scholar] [CrossRef] [PubMed]
[32]. Phadke A, Bedekar N, Shyam A, Sancheti P, Effect of muscle energy technique and static stretching on pain and functional disability in patients with mechanical neck pain: A randomized controlled trial Hong Kong Physiotherapy Journal 2016 35:05-11.10.1016/j.hkpj.2015.12.00230931028 [Google Scholar] [CrossRef] [PubMed]
[33]. Fryer G, Morris T, Gibbons P, Paraspinal muscles and intervertebral dysfunction: part two Journal of Manipulative and Physiological Therapeutics 2004 27(5):348-57.10.1016/j.jmpt.2004.04.00815195042 [Google Scholar] [CrossRef] [PubMed]