Effects of Different Myofascial Release Techniques on Function in Chronic Non-Specific Neck Pain

Background:

Neck pain is a common public-health problem that reduces individual function and burdens health systems. A large proportion of cases have no identifiable specific pathology and are classified as non-specific. When neck pain persists beyond three months without an explanatory structural or neurological pathology, it is defined as chronic non-specific neck pain (CNNP). CNNP is characterized by functional limitation, muscle dysfunction, reduced cervical range of motion, and increased pain sensitivity. Myofascial pain syndrome and myofascial trigger points (MTrP) in the upper-quarter muscles (such as the trapezius, levator scapulae, sternocleidomastoid, rhomboids, infraspinatus, and pectoral muscles) frequently accompany CNNP and play a dominant pathophysiological role.

Current clinical guidelines prioritize non-pharmacological conservative management, including therapeutic exercise and manual therapy. Myofascial release (MFR) techniques are increasingly used to inactivate MTrP and regulate muscle tone. MFR can be delivered manually by a physiotherapist (manual myofascial release, MMR) or applied by the individual using tools such as foam rollers, balls, and massage sticks (self-myofascial release, SMR). Direct comparisons of MMR and SMR, particularly when combined with a structured exercise program, remain scarce in the literature.

Objective:

To comparatively determine the effectiveness of different myofascial release techniques (manual and self-applied), when combined with a structured exercise program, on functional outcomes in individuals with chronic non-specific neck pain.

Setting:

The study will be conducted at Eastern Mediterranean University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Healthy Living Center (SAYMER), Orthopedic Rehabilitation Unit, following ethics approval.

Participants and randomization:

Volunteers diagnosed with CNNP by a specialist physician and meeting the eligibility criteria are enrolled after written informed consent. Participants are allocated by simple randomization into three groups: a Conventional Therapy Group, a Manual Myofascial Release Group, and a Self-Myofascial Release Group.

Interventions:

All three groups receive a common base intervention consisting of a hot pack applied to the cervical region and conventional TENS applied to the most painful region (80 Hz frequency, 100 microsecond pulse duration, asymmetric biphasic rectangular waveform, set to a tingling sensation, for 20 minutes), together with a structured standard exercise program. The structured exercise program includes warm-up (cervical mobility, scapular retraction and depression), stretching of the sternocleidomastoid, upper trapezius, levator scapulae, scalenes, pectoralis major and minor, and suboccipital muscles, diaphragmatic breathing, motor control exercises (chin tuck and craniocervical flexion), scapular stabilization (wall slides, wall walk, serratus punch), strengthening of the middle and lower trapezius, and a cool-down.

In addition to the common base intervention, the Manual Myofascial Release Group receives therapist-applied manual myofascial release, including MTrP ischemic compression and along-fiber myofascial release applied to the suboccipital, upper trapezius, levator scapulae, sternocleidomastoid, rhomboid, infraspinatus, and pectoral muscles, with sustained compression (approximately 90 seconds) combined with passive movements.

In addition to the common base intervention, the Self-Myofascial Release Group performs supervised self-applied myofascial release using a duo-ball, massage balls, and a massage stick/cane, targeting the same upper-quarter muscle groups, with sustained compression (approximately 90 seconds) combined with active movements, under physiotherapist supervision.

All interventions are delivered 3 days per week for 6 weeks. Assessments are performed before treatment, immediately after the first session, and after the final session.

Sample size:

The sample size was based on the primary outcome (pain, measured by the Visual Analog Scale), using data from Kim and Lee (2019) as a reference. A medium effect size (0.25), a 5% significance level (alpha = 0.05), and 80% statistical power (1 - beta = 0.80) were assumed. Using G*Power 3.1.9.2 for 3 groups across 3 measurement times, the minimum required total sample was 72 (24 per group). Allowing for possible dropout, the study is planned with 84 participants (28 per group).

Outcome assessment:

The primary outcome is pain intensity assessed with the Visual Analog Scale at rest, during activity, and at night. Secondary outcomes include pressure pain threshold and tolerance (digital algometer), cervical range of motion (digital goniometer), muscle stiffness (indentometer), craniovertebral angle (photogrammetry), cervical proprioception (cervical joint position error test), cervical muscle strength (hand-held dynamometer), cervical and scapular muscle endurance, disability (Neck Disability Index), neck awareness (Fremantle Neck Awareness Questionnaire), multidimensional biopsychosocial status (Bournemouth Neck Pain Questionnaire and BETY-BQ), sleep quality (Pittsburgh Sleep Quality Index), quality of life (SF-36), and kinesiophobia (NeckPix Scale). Assessment and treatment are performed by the same physiotherapist.

This study is being registered to increase transparency, ensure compliance with international standards, and align with the ethics approval process.

Inclusion criteria

• Neck pain persisting for at least 3 months and diagnosed as chronic non-specific neck pain by a specialist physician
• Aged between 18 and 45 years
• Perceived pain affecting daily living activities (VAS at least 3)
• Presence of myofascial trigger points in the upper-quarter muscles

Exclusion criteria

• Specific serious cervical spine pathology (radiculopathy, myelopathy, severe nerve root compression, spondylosis, and similar)
• History of rheumatologic, neurologic, or systemic disease (for example, acute inflammation, multiple sclerosis, Parkinson's disease, rheumatoid arthritis, fibromyalgia, or cancer)
• History of trauma, fracture, or surgery involving the neck, shoulder, or upper extremity
• Pregnancy or breastfeeding
• Any diagnosed psychiatric disorder (for example, major depression or anxiety disorder) or regular use of psychopharmacological medication
• Use of systemic analgesics, NSAIDs, or muscle relaxants within the last 7 days for pain control
• Any physiotherapy, manual therapy, or injection treatment to the neck region within the last 3 months