Effect of muscle energy technique versus Pilates on functional outcomes among physiotherapy students with non-specific neck pain

Abstract

Background

Neck pain is a prevalent musculoskeletal condition that can impact the academic performance and well-being of college students, particularly those in healthcare programs. While both muscle energy technique (MET) and Pilates have shown promise in treating non-specific neck pain, their comparative effectiveness remains unclear.

Aims

This study aimed to evaluate and compare the effects of Pilates and MET on pain, disability, and deep neck flexor strength in physiotherapy students with non-specific neck pain.

Objectives

The objective was to assess the effects of Pilates and MET on pain, disability, and neck flexor strength using the painDETECT Questionnaire and Neck Bournemouth Questionnaire.

Methodology

A total of 32 physiotherapy students were divided into two groups: Group A (Pilates, n = 16) and Group B (MET, n = 16). The painDETECT Questionnaire, Neck Bournemouth Questionnaire, and pressure biofeedback were used to assess pain, disability, and neck flexor strength. Both groups underwent a 3-week intervention, with three sessions per week.

Results

Both groups showed significant improvements in pain, disability, and neck flexor strength (p < 0.05). The MET group had a slightly greater reduction in pain (− 13.51%) compared to Pilates (− 11.27%), while the Pilates group showed marginally better improvement in disability (− 48.00% vs. − 46.53%).

Conclusion

MET and Pilates are both effective in reducing pain, improving disability, and enhancing deep neck flexor strength in students with non-specific neck pain. Both interventions present viable treatment options for managing neck pain in college students.

Introduction

Neck pain is a major public health concern due to its high prevalence and significant socioeconomic impact, making it one of the most common musculoskeletal conditions worldwide. It is more prevalent in middle-aged individuals and affects women more than men [1]. Studies show a wide variation in the incidence of neck pain, ranging from 2443.9 to 6151.2 cases per 100,000 in population [2]. Higher rates were reported among physiotherapy students—26.5% [3]. Non-specific neck pain refers to discomfort in the cervical region without a clear cause, characterized by pain between the first thoracic vertebra and the superior nuchal line. Symptoms can range from stiffness to limited range of motion, often worsened by poor posture or mechanical factors. Causes include muscle dysfunction and, in more severe cases, neurological deficits, requiring proper care and personalized intervention [4].

A key factor in non-specific neck pain is reduced activation of deep cervical muscles, leading to overuse of superficial muscles. Rehabilitation requires a multimodal approach, combining manipulation, mobilization, and exercises to strengthen and stretch the cervical region [4, 5]. Non-specific neck pain is a significant concern among college students, impacting academic performance and well-being. Contributing factors include stress, prolonged screen time, and sedentary behavior [6, 7] The increased use of electronic devices and academic pressures further exacerbate musculoskeletal issues in this population, emphasizing the need for effective interventions [8].

The significant frequency of neck discomfort among college students underlines the requirement for exploring and utilizing evidence-based methods to reduce symptoms and promote quality of life [6]. The prevalence of neck pain rises with age, and the global COVID-19 pandemic has worsened the situation for healthcare students by disrupting routines and negatively affecting lifestyle and mental health [5]. Studies indicate women are more prone to neck pain due to lower physical activity levels [7]. This highlights the need for evidence-based strategies to manage symptoms and improve students’ quality of life.

The painDETECT Questionnaire (PD-Q) is a valuable tool for identifying neuropathic pain components and guiding treatment decisions. It consists of seven questions addressing neuropathic, nociceptive, and unclear pain [9, 10]. Its effectiveness in categorizing pain and evaluating treatment responses makes it essential in clinical practice. By assessing pain symptoms and tracking treatment outcomes, the PD-Q facilitates targeted interventions and offers key insights into managing neck pain in college students [11]. The Neck Bournemouth Questionnaire (NBQ) is particularly helpful for patients with non-specific neck pain. The components are assessed based on patient replies to assess neck discomfort comprehensively. In addition to these approaches, factors such as gender differences, lifestyle choices, and psychological distress greatly influence the occurrence and severity of non-specific neck pain among college students.

Muscle energy technique (MET) involves soft tissue manipulation where patients perform controlled isometric and isotonic contractions. Research has shown that MET effectively reduces pain, increases range of motion, and improves functional outcomes in various musculoskeletal conditions. By targeting muscle contractures and weaknesses through isometric contractions and post-isometric relaxation, MET aims to enhance musculoskeletal function and reduce disability. This method is a promising approach for managing non-specific neck pain among college students through focused muscle contractions and relaxation techniques [12, 13].

Research indicates that Pilates effectively reduces pain and disability in patients with non-specific neck pain [14]. Key principles of Pilates, including core strength, endurance, flexibility, balance, and the mind-body connection, enhance its therapeutic benefits. Modifications to traditional Pilates exercises accommodate diverse musculoskeletal issues, making it suitable for various populations. Incorporating Pilates into rehabilitation programs can help college students with non-specific neck pain improve posture, stability, and overall well-being [15,16,17].

Additionally, the PD-Q is valuable for identifying neuropathic, nociceptive, and unclear pain components, guiding treatment decisions in this population. This research contributes to a comprehensive understanding of non-specific neck pain management, defining care standards for college students and establishing the PD-Q as a diagnostic tool in clinical settings.

Clinical guidelines suggest that using MET and Pilates exclusively for chronic neck pain yields better outcomes [18]. However, there is limited information on their effectiveness for non-specific neck pain. Given the complex nature of non-specific neck pain and the various factors influencing its prevalence among college students, this study examines the effectiveness of MET and Pilates without adjunct therapies. Also, there is insufficient evidence regarding the clinical use of the PD-Q in non-specific neck pain. Therefore, this study aims to compare the effects of muscle energy technique and Pilates on physiotherapy students with non-specific neck pain, utilizing the PD-Q for assessment.

Materials and methods

A total of 32 physiotherapy students with non-specific neck pain were recruited through a convenient sampling method.

Inclusion criteria comprised individuals aged 18 to 25 studying physiotherapy, with non-specific neck pain lasting a minimum of 4 weeks and a PD-Q score ranging from 7 to 18, indicating the absence of neuropathic pain. Exclusion criteria included a history of neck trauma or surgery, the presence of neurological deficits, any musculoskeletal conditions affecting the cervical spine, and participation in any other neck pain treatment within the past 3 months. Outcome measures included the PD-Q to assess neuropathic pain components, the Neck Bournemouth Questionnaire to evaluate neck pain and disability, and pressure biofeedback to assess deep neck flexor muscle strength [19].

The sample size was calculated based on convenience and feasibility, rather than a formal power analysis. The sample size was estimated using similar studies related to neck pain. Participants were randomly assigned to two groups: Group A (see Fig. 1) and Group B (see Fig. 2) using Excel randomization, each following a tailored exercise program. The exercises were performed three times per week for a duration of 3 weeks. A weekly progression was incorporated to ensure gradual improvement in strength and flexibility.

Fig. 1

Group A: Pilates

Fig. 2

Group B: Muscle energy technique

Group A (Pilates)

This group followed a 3-week Pilates program comprising exercises such as head nod, chin tucking, arm opening, roll up, and breaststroke. Each session lasted 45 min and focused on strengthening the neck musculature [20] (see Fig. 1).

Group B (muscle energy technique, MET)

This group underwent a 3-week MET program targeting the trapezius, levator scapulae, and sternocleidomastoid muscles [21]. The sessions involved passive techniques aimed at improving range of motion, functional outcomes, and strength, lasting 3–5 min (see Fig. 2).

Both groups completed three sessions per week for 3 weeks, and no adjunct therapies were provided. Adherence was monitored during sessions and through self-reports. Participants were monitored during the sessions to ensure adherence to the prescribed protocol. Weekly progression was customized based on individual participant performance and tolerance.

Statistical analysis

Data were analyzed using R Studio and Jupyter Notebook (version 7.1). Pre- and post-intervention outcomes within and between the two groups were assessed using appropriate statistical methods, including paired t-tests and independent t-tests. A significance level of p < 0.05 was set as the threshold for statistical significance.

Results

The calculated sample size for this study was approximately 96 participants, with 48 participants required in each group (Group A and Group B) to achieve optimal statistical power. However, due to feasibility and resource constraints, the study comprised 32 participants in total, and there were 2 dropouts. Thus, the sample size of 30 participants was utilized, with 15 participants assigned to each group, and each participant finished the follow-up after 3 weeks (see Fig. 3). Two subjects were not reviewed post intervention citing personal reasons. Hence, the study result was analyzed with 30 subjects. The exercise adherence rate was observed to be excellent. Table 1 displays the demographic details for both groups. Females over numbered males and all baseline values in both the groups were found to be similar.

Fig. 3

Consort flow diagram

Table 1 Demographic data

The demographic details of the individuals in the two groups—the experimental group (MET) and the experimental group (Pilates)—are shown in Table 1.

In-group analysis

Table 2 displays pre-intervention values within the Pilates and MET groups for pain perception, neck function, and pressure biofeedback. Both groups had similar painDETECT Questionnaire scores. The MET group showed higher Neck Bournemouth Questionnaire scores, indicating potentially more severe neck issues. Pressure biofeedback values were slightly higher in the MET group.

Table 2 Pre-values — within-group analysis of Pilates and MET

Table 3 demonstrates the post-intervention outcomes for neck pain variables in the Pilates and MET groups, highlighting significant improvements in pain perception, neck function, and pressure biofeedback for both interventions. This demonstrates the effectiveness of both Pilates and MET in managing non-specific neck pain among physiotherapy students. A comparison of p-values between Tables 2 and 3 indicates the statistical significance of changes from pre- to post intervention. Lower p-values in Table 3 reflect greater improvements in pain, neck function, and muscle strength for both groups.

Table 3 Post-values — within-group analysis of Pilates and MET

Between-group analysis

Table 4 presents the pre-intervention values from the between-group analysis of the Pilates and MET groups, indicating that baseline levels of pain perception, neck function, and pressure biofeedback were comparable across both groups. At the beginning of the study, participants in both groups exhibited similar levels of non-specific neck pain and associated variables, ensuring a balanced starting point for the interventions.

Table 4 Pre-values — between-group analysis of Pilates and MET

Table 5 provides post-intervention data comparing Pilates and MET groups on pain perception, neck function, and pressure biofeedback. Both interventions resulted in similar improvements in managing non-specific neck pain among physiotherapy students. These findings reinforce the clinical value of both Pilates and MET as effective strategies for reducing pain and enhancing functional outcomes in this population.

Table 5 Post-values — between-group analysis of Pilates and MET

Figure 4 displays pre-intervention scores of the painDETECT Questionnaire, pressure biofeedback, and Neck Bournemouth Questionnaire for the Pilates and MET group. It provides a baseline assessment of pain perception, deep neck flexor strength, and neck function.

Fig. 4

In-between analysis of pre-test PDQ, Neck Bournemouth Questionnaire, and pressure biofeedback

Figure 5 displays post-intervention scores of the painDETECT Questionnaire, pressure biofeedback, and Neck Bournemouth Questionnaire for the Pilates and MET group, and it provides a baseline assessment of pain perception, deep neck flexor strength, and neck function.

Fig. 5

In-between analysis of post-test PDQ, Neck Bournemouth Questionnaire, and pressure biofeedback

Comparing Graphs from Figs. 4 and 5 allows for an assessment of the changes in pain perception, deep neck flexor strength, and neck function due to MET therapy.

A decline in painDETECT Questionnaire scores, an increase in pressure biofeedback values, and improved Neck Bournemouth Questionnaire ratings from pre- to post-intervention indicate positive outcomes of MET therapy on non-specific neck pain in physiotherapy students.

Discussion

Clinical guidelines recommend MET and Pilates for managing chronic neck pain, but there is limited evidence on their effectiveness for non-specific neck pain. Non-specific neck pain is complex and influenced by multiple factors, including posture, stress, and physical inactivity. This study addresses the gap in research by evaluating the effects of MET and Pilates on physiotherapy students with non-specific neck pain, without the use of adjunct therapies. The use of the PD-Q is a key aspect of this study, as it provides a more detailed assessment of pain by distinguishing between nociceptive and neuropathic components. This approach highlights the need for a better understanding of the neuropathic components in non-specific neck pain, which often involves a combination of mechanical and neuropathic pain. Accurately assessing these components can lead to more personalized treatment strategies. This study, which focuses on physiotherapy students, offers valuable insights into a population often overlooked in research but potentially more vulnerable to neck pain due to academic pressures, poor posture, and high stress levels.

The findings show that both MET and Pilates led to significant improvements. MET demonstrated a greater reduction in pain (− 15.81%), while Pilates resulted in more substantial functional improvements (− 48.00% on the Neck Bournemouth Questionnaire). These results suggest that MET may be more effective for pain reduction, while Pilates offers better outcomes for functional recovery. The inclusion of the PD-Q helps explain the pain reduction observed, providing a comprehensive view of both pain and functional recovery in this population.

This study contributes to the understanding of non-specific neck pain by using a multidimensional assessment approach, combining the PD-Q with functional outcome measures. The use of MET and Pilates in this study, in the absence of adjunct therapies, adds to the body of evidence supporting their effectiveness for non-specific neck pain. While clinical guidelines emphasize their use for chronic cases, this study demonstrates that these interventions can also benefit students dealing with non-specific neck pain. Future research should explore the long-term effects of these interventions and further investigate the role of the PD-Q in evaluating treatment outcomes.

Furthermore, while this study demonstrated the efficacy of MET and Pilates, the psychological impact of these treatments remains an area for future exploration. Given that non-specific neck pain can have both physical and psychological implications, interventions like Pilates, which focus on mindfulness, breathing, and body awareness, could also have positive effects on mental well-being. Future research could investigate the role of psychological factors, such as stress or anxiety, in the management of neck pain and whether MET or Pilates can alleviate these aspects as well. While both MET and Pilates have proven to be effective interventions for managing non-specific neck pain, this study has certain limitations. A sample size of 30 participants (15 in each group) was selected based on feasibility and resource constraints while ensuring methodological rigor. Although this sample size is smaller than the ideal for maximum statistical power, the use of validated tools such as the PD-Q and NBQ ensured reliable and comprehensive assessments.

Despite these limitations, the study demonstrated statistically significant improvements, highlighting the meaningful impact of these interventions on pain reduction, functional outcomes, and neck flexor strength in physiotherapy students. This study offers several clinical implications. Both MET and Pilates are effective treatment options for managing non-specific neck pain in physiotherapy students. MET is particularly beneficial for pain reduction, while Pilates provides greater advantages for functional recovery. Physiotherapists can apply these techniques into treatment plans based on individual patient needs, focusing on either pain relief or functional improvement. Moreover, the use of the PD-Q equips physiotherapists with a valuable tool for assessing pain comprehensively and tailoring interventions to address specific pain mechanisms.

The findings from this study provide strong evidence for the effectiveness of both MET and Pilates in managing non-specific neck pain in physiotherapy students. The comparative results highlight the strengths of each technique, and the use of the PD-Q contributes valuable insights into pain assessment. Future research with larger sample sizes is recommended to validate and expand on these findings. Moreover, exploring the long-term effects of MET and Pilates could provide a more holistic understanding of their benefits. Additionally, investigating the psychological impact of these interventions—particularly Pilates’ emphasis on mindfulness and body awareness—could offer valuable insights into the comprehensive management of non-specific neck pain. Such research would further support the integration of MET and Pilates into clinical practice and guide more personalized treatment strategies for diverse populations.

Conclusion

This study demonstrates that both MET and Pilates are effective in improving deep neck flexor strength, reducing pain, and enhancing functional outcomes in physiotherapy students with non-specific neck pain. The use of the pain Detect questionnaire (PD-Q), Neck Bournemouth Questionnaire (NBQ), and pressure biofeedback provided a comprehensive assessment of participant's conditions and the intervention's impact. MET was particularly effective in reducing pain, while Pilates showed greater improvements in functional capacity. These findings align with clinical practice guidelines, which recommend using both MET and Pilates for managing musculoskeletal pain, including non-specific neck pain.

Clinicians can confidently incorporate MET and Pilates into treatment plans based on the patient’s primary goal pain relief or functional improvement. Clinical guidelines support the use of both interventions as part of a comprehensive treatment approach for non-specific neck pain. Given the distinct benefits of each technique, combining MET and Pilates may offer a well-rounded strategy, addressing both pain and functional recovery in patients with non-specific neck pain.

Limitations and future scope

• 1. Limited literature exists specifically for patients with neck pain, which presents a gap in research support.

• 2. Future studies could benefit from a larger sample size to enhance the reliability of findings.

• 3. Involvement of various patient populations suffering from NSNP

• 4. Further research should employ the PD-Q to classify pain based on its pathophysiology.

• 5. Greater awareness and utilization of the PD-Q are needed in clinical practice.

• 6. Pressure biofeedback has potential as both a diagnostic and treatment tool in managing neck pain.

• 7. Longer intervention periods should be considered for more comprehensive outcome assessments.

• 8. Development of more neck-specific Pilates exercises is necessary to improve treatment efficacy.

Clinical implications of the study

• 1. Tailored exercise programs were developed for both the Pilates and MET groups to address individual needs (Appendix Tables 6 and 7).

• 2. The intervention specifically excluded conventional therapies, focusing solely on the prescribed exercises.

• 3. Pilate’s exercises were designed and targeted specifically for managing neck pain in the intervention.

• 4. The PD-Q was utilized to classify pain based on its underlying pathophysiology.

• 5. The exercise regimen was carefully structured and dosed according to the specific requirements of the study.

Appendix

Table 6 Tailored exercise program for Group A: Pilates

Table 7 Tailored exercise program for Group B: Muscle energy technique