Introduction

Pain in the anatomic region of neck is known as mechanical neck pain which is primarily caused by overuse of normal anatomical structure, secondary to injury and deformity of anatomical structure. Also, mechanical neck pain can be defined as generalized neck pain provoked by sustained neck postures, neck movement and pain on palpation of cervical musculature without pathologies. Restrictions of the neck movement occur and forced movement on the neck may worsen the pain. Mechanical neck pain is also known as nonspecific neck pain. It is common complaint which affects 45-54% of general population. The incidence of neck pain is higher in women (15%) than men (9%). High prevalence of neck pain was reported in desk job workers. 1 year prevalence of neck pain and work related neck pain was reported as 43.3% and 28.3%. To compare the effect of Maitland and Mulligan mobilization with Myofascial release on mechanical neck pain with decreased temporomandibular joint mobility. Total 45 subjects were selected and divided into three groups by random sampling method. This study concludes that Maitland mobilization and Mulligan mobilization are effective in mechanical neck pain with TMJ disability. Neck pain is a common musculoskeletal disorder and one of the most common causes of disability and absence from work (Helland, 1980). Mechanical neck pain is nonspecific disorder of the cervical spine, characterized by pain and discomfort exacerbated by neck movement, present in periods of remission and exacerbation. Cervical pain is the fourth leading cause of disability in adults. Epidemiologic studies estimate an annual prevalence of 30 to 50% in general population, and a systematic review reports the average frequency of 37.2%. Annually, 11.5% of economically active population experience of limitation resulting from cervical pain, affecting the quality of life and causing significant socioeconomic impact. It has been shown that individuals with chronic neck pain exhibit structural and functional changes including weakness and cervical flexor and extensor muscles imbalance, a decrease in the cervical range of motion, as well as proprioceptive deficits and compromise of postural control. Those changes are thought to be assigned to the reflex inhibition associated with pain, causing damage to muscular function and favoring the chronification of mechanical neck pain (Alomar, 2007).

Based on the duration of neck pain, the international association for the study of pain Kumar and Elavarasi (2016) proposed a classification as: acute neck pain which usually lasts <7 days, subacute neck pain lasting for more than 7 days but <3 months and chronic neck pain with the duration of 3 months or more. Neck pain is most common in people with a working age group of 20-50 years and people employed in various jobs for example people who spend most of their working day at a desk with neck bent forward posture. It is a common complaint which affects 45-54% of the general population. The incidence of neck pain is higher in women 15% than men 9%. Women have the highest incidence at age of 45 and men at the age of 60. High prevalence of neck pain was reported in desk job workers. 1 year prevalence of NP and work related neck pain was reported as 43.3% and 28.3%. 18 survey which was done in Kolkata on mechanical neck pain patients found that 67% of patients presented with associated upper limb pain without neurological deficit.

Ahn (2007); Nitsure and Welling (2014) stated that Temporomandibular disorders are defined as musculoskeletal conditions that involve the masticatory muscles, the temporomandibular joint and associated structures. Temporomandibular disorder is a generic term referring to painful or dysfunctional conditions of the mastication muscles, joints and structures related to it, with the cervical spine among them. It has an impact on the quality of life, affecting daily living activities, work capacity and social life. They present an economic burden for society. Common signs and symptoms of temporomandibular disorder are localized pain in the stomatognathic region, headaches, difficulty with chewing, tinnitus, dizziness or noise during jaw opening and closing. Popping clicking and muscle tenderness is common condition that occurs at temporomandibular joint. Mechanically, the large amplitude of jaw opening or closing is associated with neck extension or flexion (Balthazard, 2020). It can be concluded that 90% of the patients with cervical pain were found to have temporomandibular disorders. Study suggests a relationship between temporomandibular disorders and patients who present cervical pain and postural changes.

The peak incident of temporomandibular dysfunction is seen in adults 20-40 yrs. It is common condition affect up to 60-70% of the population and woman are more likely affect then male. In the United States, TMD affect 5-12% of population. Ahn (2007); Balthazard (2020) found that Myofascial release is effective in treating temporomandibular dysfunction previous study proved that Myofascial release in reduces pain, tenderness and improve function of temporomandibular joint. Fascia is located between the skin and the underlying structure of muscle and bone, it is a seamless web of connective tissue that covers and connects the muscles, organs and skeletal structures in our body. Muscle and fascia are united forming the Myofascial system (Shah & Bhalara, 2012).

Inter relationship of temporomandibular joint (orofacial area) and cervical spine at neurophysiological and neuroanatomical level are documented earlier. The co-existence of temporomandibular sign, functional limitation, trigger point and hyperalgesia in the cervical region confirmed. Forward head position is capable for producing alteration in temporomandibular joint. Rodriguez-hoguet et al. Provides evidence that MFR could be better than a multimodal physiotherapy program for short-term improvement of pain and pain thresholds in patients with neck pain (Calisgan, 2018). Thus, the purpose of this study is to compare the effect of Maitland and Mulligan mobilization with Myofascial release on cervical range of motion, pain, craniovertebral angle and temporomandibular joint mobility.

Materials and Methods

Sample type and size, subject selection criteria

The study was approved by SGT University. All study procedures were done in Physiotherapy OPD of the SGT hospital with patient consent. In the beginning 90 patients were selected for the study and 20 patients were excluded. 15 came with tension type headache and 5 with cervical pain radiating to the shoulder and arm which added them to the exclusion criteria. Inclusion criteria included complain of insidious onset of neck pain that have lasted for less than 12 weeks, subjects having mouth opening less than 35 mm and craniovertebral angle less than 45 with age of 21-45 years both male and female subjects were included. Participants not undergoing any medical treatment and subject with decreased temporomandibular mobility were included in the study. Then remaining 70 subjects were ready to take part in the study and again 25 patients were excluded because they did not match the inclusion criteria. So, on screening only 45 subjects were remaining which were eligible for the study. Remaining 45 students were randomly divided into three groups, Group A, Group B and Group C.

Intervention

1) To Group A patients Maitland mobilization with myofascial release were given. 2) To Group B patients Mulligan mobilization with myofascial release were given. 3) To Group C isometric exercise with hot pack and therapeutic ultrasound was given.

Procedure

Before starting the treatment procedure, All the subjects selected for the study had undergone assessment which was done by the Physician and then patient was re assessed by the Physiotherapist. Subjects were divided into three groups by random sampling method i.e., Group A, Group B and Group C. Treatment was given to the subjects for 5 times a week for two weeks, for 45 minutes of duration. Treatment was briefly explained to the subjects by the Physiotherapist. Total treatment time was 45 minutes. Patient was in supine lying or sitting position according to the requirement of treatment and subjects comfort during treatment.

Group A (Maitland mobilization and myofascial release)

15 participants received Maitland mobilization to the cervical spine and Myofascial release on the temporomandibular joint for a period of two weeks (five days a week, one session per day) along with Myofascial release participants. Position of the patient was Prone and the therapist was standing at the level of the head of the patients with his thumbs in opposition placed at the level of the facet or the spinous process of the corresponding cervical vertebra Figure 1. A PA oscillatory pressure was applied, through the thumbs, over the process of the hypo mobile vertebra.: Grades I and II were given where pain occurred before the motion barrier; and grades III and IV given where the motion barrier was encountered before pain. This oscillatory mobilization was performed at a rate of 2–3 oscillations per second with metronome control and a frequency of 3–4 mobilization of the joint lasting approximately 30s each. Myofascial release (kneading) was applied on the masseter muscle. Kneading of masseter and temporal muscles will applied in circular motion and intensified pressure, three fingers are used to perform kneading on masseter, and whole palm of hand and fingers was used for temporal muscle and kneading is given for 5-15 minutes.

Group B (Mulligan mobilization and myofascial release)

15 participants received Mulligan SNAGs along with myofascial release for a period of five sessions per week for two weeks. Mulligan mobilization (cervical SNAG) was given to patient in a seated position with one thumb placed on spinous process or articular pillar of the upper vertebra of the implicated functional spinal unit, sustained passive accessory intervertebral movement superioanteriorly along the facet plane applied by therapist Figure 2.

This glide was maintained during the range of motion; then therapist released the glide when patient returned to starting position. The mobilization was repeated five times per session for a period of two weeks. Myofascial release (kneading) is applied on the masseter muscle. Kneading of masseter and temporal muscles was applied in circular motion and intensified pressure, three fingers are used to perform kneading on masseter, and whole palm of hand and fingers is used for temporal muscle and kneading is given for 5-15 minutes. The rest time is one minute between each treatment time.

Group C (Isometric exercise, ultrasound and hot pack)

Isometric exercises of cervical was performed in the seated position by resisting at the forehead toward cervical flexion, extension, lateral flexion and rotation (Five days a week, one session per day). For 10 seconds, with 15 seconds breaks between holds, and 10-15 repetitions (Figure 3). Resisted isometric exercises on temporomandibular joint was given for protrusion extrusion and lateral deviation was given counter-force for a duration starting from 5 seconds to 30 seconds, 10 times in one session. Ultrasound was given on the temporomandibular joint for 8 minutes on pulsed mode with the pulsed width 0.8 watt/cm² (five days a week, one session per day).

Results and Discussion

Total 90 subjects were selected for the study. Out of 90 subjects,20 patients were excluded due to tension type headache and radiating pain then from remaining 70 subjects 25 further excluded due to their nonmatching characteristics. Only 45 subjects were lying under the inclusion criteria on which study was done. This study has shown some good results. There was a significant difference in Pain between all three groups. This study shows that the help of Maitland and Mulligan mobilization, pain has been decreased in all three groups but in Group A it shows more significant result than other 2 groups Table 1. This study also shown some positive results when myofascial release technique was given to the temporomandibular joint to increase the mouth opening. MFR has given to all the three groups and there was improvement in all the three groups but group A had shown the best results Table 2.

This study has also shown some positive effects of mobilization (SNAGs) on forward head posture. SNAGs were given to all the three groups and have shown positive result in correcting the FHP but group B has shown the most significant improvement in forward head posture Table 3. This study also shows significant improvement in increasing Range of motion in mechanical neck pain patients. Mobilization were given to all the three groups and there is improvement in all the three groups but group A has shown the most significant effect in flexion extension Table 5; Table 4.

Neck pain is a very common condition nowadays. It leads to Disability. It includes neck pain which is non-radiating in nature but is confined to the cervical occipital or posterior scapular areas. Shehri (2018) suggested in his study that Maitland mobilization shows significant effect on Craniovertebral angle and mulligan mobilization shows significant effect on Craniovertebral angle and also shows positive result on pain. Gautam (2014) suggested in his study that Maitland mobilization has shown better effect on Pain, Range of motion and neck disability. This study was executed to check the effect of Maitland Mobilization and Mulligan mobilization along with Myofascial release on pain, Range of Motion, Craniovertebral Angle and mouth opening in mechanical neck pain with decrease temporomandibular joint mobility.

Castro (2020) suggested in his study that Maitland mobilization shows significant effect on pain and range of motion and mouth opening in mechanical neck pain. This study has shown very positive results on all the variables. It is suggested in this study that Maitland and mulligan both mobilization plays a major role in reducing the pain while giving on the cervical spine in the condition of mechanical neck pain. This study shows that with the help of Maitland and Mulligan mobilization, pain has been decreased in all the three groups but in group A it shows more significant result than other 2 groups. Ganesh (2015) suggested in his study that Maitland and mulligan mobilization shows very significant result in reducing pain. However in his suggested it is also mentioned that these mobilizations are less effective in mouth opening. Mouth opening is a very common and important function. Reduced mouth opening is a common clinical problem. There are so many reasons which cause this problem. Normal range of mouth opening around 30-50mm. But if it comes to reduced to 20mm.this situation is described as reduced mouth opening.

Pierson (2011) suggested in his study that Myofascial release on temporomandibular joint shows positive result in mouth opening. She also included in her study that Myofascial release has shown significant results on pain also. This technique is also very helpful in reducing pain and helps in increasing joint range of motion to some extent. This study also shown some positive results when Myofascial release technique was given to the temporomandibular joint to increase the mouth opening. MFR has given to all the three groups and there was improvement in all the three groups but group A had shown the best results. The Craniovertebral angle is defined as the intersection of a horizontal line passing through the C7 spinous process and a line joining the midpoint of the tragus of the ear to the skin overlying the C7 spinous process. This angle is used to assess any abnormal head posture (Forward Head Posture). Forward head posture (FHP) is a disturbed neck posture in which hyper extension of the upper cervical vertebrae and forward translation of the cervical vertebrae occur.

Kim (2015) suggested in her study that mobilization and SNAGs plays very important role in correcting the forward head posture. This study has also shown some positive effects of Mobilization (SNAGs) on forward head posture. SNAGs were given to all the three groups and have shown positive result in correcting the FHP but group B has shown the most significant improvement in forward head posture. Lee (2013) suggested in his study that Maitland and mulligan mobilization play major role in increasing range of motion (Flexion, Extension) in mechanical neck pain. This study also shows significant improvement in increasing range of motion in mechanical neck pain patients. Mobilization were given to all the three patients and there is improvement in all the three groups but group A has shown the most significant effect in flexion extension.

Limitation

There is a variety of causes behind mechanical neck pain (postural abnormalities, neck trauma, smoking, psychological problems, etc) that might also affect the results of the study. Some patients were excluded from the study for different reasons, and this problem reduced the strength of this study. Study time was quite less. 2 weeks were not good enough to get the significant result.

Conclusion

The study compared the effect of Maitland mobilization and Mulligan mobilization along with myofascial release on pain, range of motion, craniovertebral angle and mouth opening in mechanical neck pain with decreased temporomandibular joint mobility. Pain decreased in all three groups, range of motion increased in all the groups, mouth opening also increased in all three groups and craniovertebral angle improved in all here group. This study showed that all the variables have improved significantly with Maitland and Mulligan mobilization in mechanical neck pain. So, it was concluded that mobilization (Mulligan & Maitland) is very effective in mechanical neck pain.

Conflict of Interest

The authors declare that they have no conflict of interest for this study.

Funding support

The authors declare that they have no funding support for this study.