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EFFECTIVENESS OF MUSCLE ENERGY TECHNIQUE
AND DEEP TRANSVERSE FRICTION MASSAGE IN
THE TREATMENT OF LATERAL EPICONDYLITIS A
COMPARATIVE STUDY
Submitted By
RENJU.V.GOPAL
Dissertation Submitted to the Rajiv Gandhi University of Health Sciences,
Karnataka, Bangalore in partial fulfillment of the requirements for the degree of
MASTER OF PHYSIOTHERAPY IN
MUSCULOSKELETAL DISORDERS AND SPORTS PHYSIOTHERAPY
Under the guidance of
Dr.HARISH.S.KRISHNA
ASSISSTANT PROFESSOR
LAXMI MEMORIAL COLLEGE OF PHYSIOTHERAPY
MANGALORE
2008-2010
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EFFECTIVENESS OF MUSCLE ENERGY TECHNIQUE
AND DEEP TRANSVERSE FRICTION MASSAGE IN
THE TREATMENT OF LATERAL EPICONDYLITIS A
COMPARATIVE STUDY
Submitted By
RENJU.V.GOPAL
Dissertation Submitted to the Rajiv Gandhi University of Health Sciences,
Karnataka, Bangalore in partial fulfillment of the requirements for the degree of
MASTER OF PHYSIOTHERAPY IN
MUSCULOSKELETAL DISORDERS AND SPORTS PHYSIOTHERAPY
Under the guidance of
Dr. HARISH.S.KRISHNA
ASSISTANT PROFESSOR
LAXMI MEMORIAL COLLEGE OF PHYSIOTHERAPY
MANGALORE
2008-2010
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DECLARATION BY THE CANDIDATE
I hereby declare that the dissertation titled as EFFECTIVENESS OF
MUSCLE ENERGY TECHNIQUE AND DEEP TRANSVERSE FRICTION
MASSAGE IN THE TREATMENT OF LATERAL EPICONDYLITIS A
COMPARATIVE STUDY is a bonafide and a genuine research work carried out
by me under the guidance of Dr. HARISH.S.KRISHNA.
Date: Signature of the candidate:
Place: Mangalore RENJU.V.GOPAL
Rajiv Gandhi University of Health Sciences, Karnataka
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CERTIFICATE BY THE GUIDE
This is to certify that this dissertation entitled EFFECTIVENESS OF
MUSCLE ENERGY TECHNIQUE AND DEEP TRANSVERSE FRICTION
MASSAGE IN THE TREATMENT OF LATERAL EPICONDYLITIS A
COMPARATIVE STUDY was completed under my supervision. I am satisfied
with the work presented with the work presented by the candidate towards the partial
fulfillment of Masters of Physiotherapy in Musculoskeletal disorders and Sports
Physiotherapy.
Date: Dr. HARISH.S.KRISHNA.
Assistant professor
Place: Mangalore Laxmi Memorial College of
Physiotherapy, Mangalore
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ENDORSEMENT BY THE PRINCIPAL/ HEAD OF THE
INSTITUTION
This is to certify that this dissertation entitled EFFECTIVENESS OF
MUSCLE ENERGY TECHNIQUE AND DEEP TRNSVERSE FRICTION
MASSAGE IN THE TREATMENT OF LATERAL EPICONDYLITIS A
COMPARATIVE STUDY is a bonafide and a genuine research work carried out
by RENJU.V.GOPAL under the guidance of Dr. HARISH.S.KRISHNA.
Date: Dr. S.ARUL DHANARAJ
Place: Mangalore Principal & Professor
Laxmi Memorial College of
Physiotherapy, Mangalore
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COPYRIGHT
DECLARATION BY THE CANDIDATE
I hereby declare that RAJIV GANDHI UNIVERSITY OF HEALTH
SCIENCES, KARNATAKA, shall have all the rights to preserve, use and
disseminate the dissertation/ theses in print or electronic format for academic/
research purpose.
Date: Signature of the candidate:
Place: Mangalore RENJU.V.GOPAL
Rajiv Gandhi University of Health Sciences, Karnataka
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ACKNOWLEDGEMENT
First and foremost I would like to thank God almighty, for his divine grace and
blessing throughout my studies.
I owe to my loving parents my father Mr. N.VENUGOPAL, my mother Mrs. SUDHA
VENUGOPAL and who have made me what I am today with their blessings care
and motivation. I would like to consider special thanks to my sister Mrs. RESMI and
my brother Mr. RAHUL and my dear friend Ms. Sudha for her timely helps, caring
and understanding.
I wish to state my special thanks and credit to my respectable guide and teacher,
Dr.HARISH.S.KRISHNA for his valuable help and guidance, constant
encouragement and keen interest shown in this study and without whom this work
would not have been possible.
I wish to convey my heartfelt thanks to my teacher and principal Dr. S. ARUL
DHANARAJ, Professor and Principal of L.M.CP., Mangalore for his valuable help
and guidance.
I also wish to extend my sincere thanks to my co guide and assistant professor Dr.
Y.V.KALYAN, for always being accessible with his constant help and support
throughout this study.
I would like to express special thanks to Dr. MAGESH GAJAPATHY for his
help and guidance.
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I express my thanks to all the staff members in Laxmi Memorial College of
Physiotherapy for their help and valuable suggestions.
I extend my sincere thanks to Mrs. Sucharita for helping me in statistical analysis.
I wish to express my thanks to Mrs. Neena our computer lecturer & library staff for
their timely help in lending me books and journals for my reference all the time.
My sincere thanks to all the contributors, my friends saber, sweety, sanish, dijish
and my classmates sudha, roshan, jignesh, rashiq, harshith, gaurav and divya.
they all deserve my gratitude.
Last but not the least I would like to thank all the subjects on my study without whom
this task would not have been possible. I thank all who have helped me all the while.
Date: Signature
Place: Mangalore RENJU.V.GOPAL
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LIST OF ABBREVIATIONS USED
1. ECRB : Extensor carpi radialis brevis
2. ECRL : Extensor carpi radialis longus
3. MET : Muscle energy technique
4. DTFM : Deep transverse friction massage
5. VAS : Visual analogue scale
6. ANOVA : Analysis Of Variance
7. EFA : Elbow function assessment
8. NS : Not Significant
9. AER : Active External Rotation
10. PER : Passive External Rotation
11. US : Ultrasound
12. M : Male
13. F : Female
14. SS : Statistical significance
15. ADL : Activity daily living
16. Rx : Treatment
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ABSTRACT
BACKGROUND: Lateral epicondylitis (tennis elbow), one of the common lesion of
the arm is characterized by pain and tenderness in the lateral aspect of the elbow, with
incidence affecting men and women equally. The aim of the study is to assess the
effectiveness of muscle energy technique and deep transverse friction massage in the
treatment of lateral epicondylitis.
METHOD: 30 subjects who were diagnosed by an orthopaedician as lateral
epicondylitis and it is divided into two groups each of 15 subjects. Group A: (n=15):-
Treated with Muscle energy technique with ultrasound. Group B: (n=15):- Treated
with deep transverse friction massage with ultrasound. Patient received treatment for
10 days. The patients pain was assessed by VAS and functional performance was
measured with EFA. Data was collected before treatment (baseline), after 10 sessions,
and follow up done after 3 weeks.
OUTCOME MEASURE AND ITS MEASUREMENT:
The following outcome measures were measured at baseline, After 10 days and After
3 weeks follow up.
1. VAS
2. Elbow function assessment (EFA).
The baseline measurements were compared to data at the end of 10 days and After 3
weeks follow up.
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STATISTICAL ANALYSIS:-
One way ANOVA and post hoc analysis (bonferroni test) was used to compare the
outcomes within the group.
Unpaired t test was used to compare VAS and EFA between group A and group B.
RESULTS:
VADS scores of patients in Group A was 6.27 + 1.03, 2.40 + 0.63 and 0.40 + 0.63 at
day 0, day 10 and after 3 weeks. The VAS scores of patients in group B was 5.87
1.12, 3.20 0.56, 3.40 1.95 at day 0, day 10 and after 3 weeks. The EFA scores of
group A was 63.93 + 10.49, 82.27+ 10.21 and 89.97 + 7.20 at day 0, day 10 and after
3 weeks. The EFA scores of patients in group B was 71.80 10.10, 78.20 8.41,
78.47 9.92 respectively.
CONCLUSION:
The MET technique was found to be effective than DTFM for treatment of lateral
epicondylitis as MET caused increased blood circulation to the part, active muscle
contraction and passive stretching causing increased flexibility of the structures. In
contrast DTFM, only scar tissue was broken down which was followed by increased
circulation and therefore neither muscle contraction was facilitated nor flexibility
increased. Hence alternate hypothesis was proved.
.
KEY WORDS: Lateral epicondylitis, US, MET, DTFM, VAS, EFA.
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TABLE OF CONTENTS
S.No. Topic Page No.
01. Introduction 1 5
02. Objectives and Hypothesis 6 7
03. Review of Literature 8 14
04. Methodology 15 24
05. Results 25 28
06. Discussion 29 32
07. Conclusion 33
08. Summary 34
09. Bibliography 35 41
10. Annexure 42 59
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LIST OF TABLES
S. No. Topic
Page No.
01.& 02 Age distribution
50
03.
Gender distribution
52
04.
Side distribution 53
05.
Comparison of Visual Analogue Scale (VAS) scores within Group A and Group B.
54
06.
Pair wise comparison of Visual Analogue Scale (VAS) scores Within Group A and within Group B (post hoc analysis-Bonferroni test).
55
07.
Comparison of Elbow Functional Assessment (EFA) scores within Group A and within Group B.
56
08.
Pair wise comparisons of Elbow Functional Assessment (EFA) scores within Group A and within Group B (post hoc Analysis Bonferroni test)
57
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LIST OF FIGURES AND GRAPHS
FIGURES
S. No
Topic
Page No
01 Tools used for the study 20
02 Ultrasound Therapy Method 21
03 Muscle Energy Technique (neutral Position) 22
04 Muscle Energy Technique Method 23
05 Deep Transverse Friction Method 24
GRAPHS
S. No. Topic Page No.
01 Age distribution 51
02 Gender distribution 52
03 Side distribution 53
04 Comparison of Visual Analogue Scale(VAS) scores within Group A and within Group B
54
05 Comparison of Elbow Functional Assessment (EFA)within Group A and within Group B
55
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INTRODUCTION
Lateral condylitis or tennis elbow was 1 st described by Runge 1873. It is characterized
by pain and tenderness in the lateral aspect of elbow joint. Daily activities such as
shaking hands raising a cup , using a hammer , lifting a showel , dressing and desk or
house work typify the particular movement which initiates the pain. 1
The condition is common in 30 years of age or older with incidence affecting men and
women equally. Dominant arm is commonly affected with a prevalence of 1-3 % in
general population, but this increases to 19% in 30 to 60 of age group.2
Tennis elbow is an over use stress syndrome. The term chronic tennis elbow means
symptoms which are persisting for more than 3 months. Repetitive over use injury of
wrist extensor muscles, prolonged strain on the forearm muscles, direct injury to the
elbow cause pain.3
Tennis elbow patients has pain of sudden or gradual onset , is localized to outer aspects
of elbow, which sometimes travel along the back of the fore arm and may go as far as the
wrist or back of the hand. It may severe enough to go to external aspect if arm up to the
shoulder but its less common, sometimes there is constant ache which gets worse at night
and disturbing the sleep.4
The lesion involving the specialized junctional tissue at the origin of the common
extensor muscle at the lateral epicondyle is proposed as the cause.. Histological studies
have shown that the extensor carpi radialis brevis tendon rather than the lateral
epicondyle is the primary site of pathology.4, 5
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Extensor carpi radialis brevis has the proximal attachment to lateral collateral ligament
and often to the annular ligament in addition to lateral epicondyle of the humerus . The
Extensor carpi radialis brevis is stretched over the radial head when the elbow is extended
and fully pronated . The Extensor carpi radialis longus and brachioradialis attach above
the lateral epicondyle rather than the common extensor tendon insertion and are less
commonly involved. Extensor digitorum is also largely affected and supinator produces a
moderate increase n the tensile force in common extensor tendon.6, 7
But in the chronic case it is not the lesion causing pain it is due to the formation of a
painful scar which results from repitive injury. The ECRB along with ECRL and EDC
appears to undergo change termed angiofibroblastic hyperplasia because of wrist extensor
overuse rather than inflammation. Inflammatory cells are rarely found in chronic cases.
Instead with repetitive use, microtears and scarring occurs in wrist extensors.5
Local treatments of tennis elbow are numerous like cryotherapy , Ionotophoresis ,
phonotophoresis, electrical stimulation , TENS, fore arm support band , transverse
friction massage stretching, strengthening manipulation are common technique used to
treat tennis elbow. But superiority of any one technique has not been proven. Traditional
modalities such as ice, ultrasound, ionotophoresis and massage have shown mixed result.8
Therapeutic ultrasound is commonly used electrophysical agent many musculoskeletal
conditions, ultrasound is mechanical vibrations which are essentially the same as sound
waves but of higher frequency. ultrasound has the potential to accelerate normal
resolution of inflammation provided the inflammatory stimulus has been provided the
inflammatory stimulus has been removed many studies show benefits of the use of
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ultrasound in soft tissue and sport injuries , ultrasound therapy is effective in treating
patients with pain and promoting soft tissue healing .2
Pulsed ultrasound is an electrotherapeutic modality that has been used to decrease pain
and increase the rate of healing in many condition example soft tissue injuries,
musculoskeletal pain, arthritic conditions etc.9
With pulsed ultrasound, a less localized warming of the tissue may occur that can lead to
an increase in the extensibility of ligaments, tendons and scar tissue. These effects may
contribute to the reported analgesic action of pulsed ultrasound.10
In a study conducted by binder et al on the effectiveness of ultrasound in the treatment
of lateral epicondylitis , placebo produced improvement in 29 % of patients treated while
ultrasound was effective in 63% of patients treated.11
Though studies show that ultrasound causes some improvement from the base line, the
results are best when used with other modalities or manipulation.
Deep transverse friction massage is also one of the therapeutic approaches for treating
lateral epicondylitis. , massage using friction technique has been used for many years.
The most famous exponent of friction massage was James cyriax, this technique is
principally designed to affect connective tissue of tendon, ligaments and muscles. Deep
transverse friction massage provides therapeutic movement over a small area and one of
the potential advantages of it over other form of massage is that it allows pressure to
applied to greater depth in the tissue.12
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Deep tansverse friction leads to immediate pain relief - the patient experiences a numbing
effect during the friction and reassessment immediately after the session shows reduction
in pain and increase in strength and mobility. The time to produce analgesia during the
application of transverse friction is a few minutes and the post-massage analgesic effect
may last more than 24 hours.13
DTFM has been claimed to be helpful, as it mobilizes the soft tissue , release and stretch
the tissue which is impaired causing pain and dysfunction.
DTFM produces local vasodilation and also mobilizes the structures in the area. It is an
effective means of treating conditions like tendonitis etc. According to cyriax DTFM
causes traumatic hyperemia which results in increased blood flow and decreases pain. It
also increases tissue perfusion and stimulates mechanoreceptors.12
MET is essentially a mobilization technique using muscular facilitation and and
inhibition. it is effective for musculosketal disorders. Abnormal shortening or lengthening
of muscles occurs in response to injury and pain. MET restores the muscle range and
normality. 14
The majority of MET are isometric but some are isotonic. The physiological principles
upon which MET technique rest are post isometric relaxation and reciprocal inhibition. 14
According to Sherrington s law of reciprocal innervations, contraction of an agonist
muscle reflex inhibits antagonist. The gamma motor neuron discharge to the facilitated
muscle can be reduced by a specific contraction of its antagonist. The stronger the
contraction of antagonist, greater the relaxation of agonist.14
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The principles of autogenic inhibition may also be employed with MET. Contraction of
the facilitated muscle from the lengthened position generates sufficient tension to activate
golgi tendon endings in the tendon. This reflex inhibits both the gamma and alpha motor
neuron this results in the lengthening of the muscle upon relaxation accurately localized ,
low intensity, isometric contraction of agonist and antagonist segmental muscles are the
most effective for restoring mobility.14
Studies have been done to prove the effectiveness of MET technique for the treatment of
lateral epicondylitis. But no comparative studies with manual therapy technique have
been done in order to prove the superiority of the technique. Hence this study is intended
to compare the effectiveness of DTFM and MET along with ultrasound
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OBJECTIVES OF THE STUDY
1. To study the effectiveness of Muscle Energy Technique in the treatment of lateral
epicondylitis.
2. To study the effectiveness of Deep Transverse Friction Massage in the treatment of
lateral epicondylitis.
3. To compare the effectiveness of Muscle Energy Tecgnique and Deep Transverse
Friction Massage in the treatment of lateral epicondylitis.
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HYPOTHESIS
Null Hypothesis (H0):
There will be no significant difference between the effectiveness of MET with ultrasound
and DTFM with ultrasound in the treatment of lateral epicondylitis.
Alternate Hypothesis (H1):
There will be a significant difference between the effectiveness of MET with ultrasound
and DTFM with ultrasound in the treatment of lateral epicondylitis.
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REVIEW OF LITERATURE
Lateral epicondylitis also known as Tennis Elbow is a common soft tissue condition
frequently associated with overuse injury of the elbow.15, 16 The primary etiological factor
is believed to be a force overload at the aponeurosis of the common extensor origin.16,17,18
Lateral epicondylitis is characterized by an insidious onset of elbow pain that radiates
distally into the forearm, and is brought about by wrist extension with pronation or
supination and is aggravated by gripping.19 The result can be extremely incapacitating
and resistant to treatment.20,21
Allander 22 (1974) reported an annual incidence of 1% to 10% for lateral epicondylitis in
a survey of 15,000. Although accounting for less than 5% of all lateral epicondylitis
clients, 21 tennis players, as a group, exhibit a 40% to 50% chance of having lateral
epicondylitis at some point in time.23, 24
In tennis, pain at the elbow usually results from the backhand stroke. Repetitive backhand
strokes can produce recurrent microtraumatic injury to the forearm extensor musculature
at its lateral epicondylar origin.
A prevalent feature of the syndrome is the production of pain during extension of the
wrist and radial deviation. This movement is performed by the extensor carpi radialis
longus and brevis.25 Decreased muscular performance in lateral epicondylitis have been
proposed to be due to both elbow pain and physical damage to the extensor carpi radialis
brevis muscle.26 Extensor carpi radialis longus and brevis have been implicated in the
dysfunction associated with lateral epicondylitis in EMG studies.27
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Histological study has shown that extensor carpi radialis brevis tendon rather than the
lateral epicondyle is the primary site of pathology.28 It is due to an overuse syndrome,
which causes microtrauma that results in collagen degeneration and adhesion formation
in extensor carpi radialis longus, extensor carpi radialis brevis and extensor digitorum.29
The most common complaints of individuals with lateral epicondylitis are pain and
decreased grip strength, both of which may affect activities of daily living.21, 30 Pain has
been defined as an unpleasant sensory and emotional experience associated with actual or
potential tissue damage.31 Pain has been classifically reported as the main feature of this
condition.32
Conservative treatment, including cold application, rest, control of inflammation and
reduction of force demands on the muscles, has been the treatment of choice for
individuals with lateral epicondylitis.33, 34, 35
Muscle energy technique (MET) was developed by Fred Mitchell Sr (Mitchell, 1967). IT
targets the soft tissue primarily, although it also makes a major contribution towards joint
mobilization. It is also described as active muscular relaxation technique (Liebenson,
1989, 1990). More recent refinements were derived from the work of people such as
Karel Lewit (Lewit, 1986a) and Veladmir Janda (Janda 1989). The current interest in
MET method crosses all political and therapeutic barriers.36
Experiments demonstrate that drastic changes may be made in the body, soley by
stretching, separating and relaxing superficial fascia in an appropriative manner.37
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Benny Vaughan (2005) states that application of MET actively assisted engagement of
the muscle while pressure is applied and compression broadening can produce outcomes
of significant results.38
The efficiency of MET in the treatment of severe pain in the muscle and or its insertion
like myofacial pain lateral epicondyle of arm involving supinator, wrist and finger
extensors and or biceps brachii.
MET is particularly effective in patients who have a severe pain from acute somatic
dysfunction or with an injury or a patient with severe spasm.
In this method the patient uses his or her muscle, on request, from a precise controlled
position in a specific direction against an executed counterforce (Mitchell et al, 1979).
MET which involves passive and Active stretching of shortened and often fibrous
structures, contractured or spastic muscle, to strength a physiologically weakened muscle
or a group of muscle, to reduce localized oedema, to relieve passive congestion, and to
mobilize an articulation with restricted mobility.36 It is also effective in patients who have
severe pain from acute somatic dysfunction, such as, a patient with severe muscle spasm
from a fall. (Sandra yale.In:Digiovanna,1991).37
The general consequences are that the use of post isometric relaxation (PIR) is more
useful than Reciprocal inhibition (RI) in normalizing hypertonic musculature. In this
study we utilized PIR type of MET by Karel Lewit (1986 a).The term refers to the effect
of the subsequent relaxation experienced by a muscle or a group of muscle after brief
periods during which an isometric contraction is performed. PIR is achieved by the effect
of a sustained contraction on the golgi tendon organ, since the response to such a
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contraction seems to be to set the tendon and the muscle to a new length by inhibiting it
(Moritan et al, 1987). Lewit and Simons (1984) agreed that, PIR is a phenomenon
resulting from a neurological loop involving golgi tendon organs.36
Recent study, the procedure of Post-Isometric Relaxation (PIR) the therapist takes the
agonist muscle to its barrier of tension and holds the position; the therapist provides equal
resistance to the client contracting the agonist muscle with about 20% of their strength,
for 7-10 seconds and repeated for 5 times.39
Greenman summarizes the requirements for the use of MET as controlled, balance and
localization. His suggested basic elements include the following.
1. A patient / active muscle contraction.
2. This commences from a controlled position.
3. The contraction is in a specific direction (towards or away from a restricted
barrier).
4. The operator applies distinct counterforce. (to meet, not meet, or to overcome the
patients force).
5. The degree of effort is controlled (sufficient to obtain an effect but not great
enough to induce trauma, or difficulty in controlling the effort.
The usefulness of MET is seen in normalizing abnormal neuromuscular relationship,
improve local circulation and respiratory function and/or normalize restricted /hypertonic
muscles and fascia, mobilize restricted joints.36
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Post-isometric relaxation techniques such as MET and PNF produce greater changes in
range of motion and muscle extensibility than static or ballistic stretching, immediately
following treatment.40
Lewitt and Simons (1984) found an immediate relief of pain and tenderness after
treatment with post-isometric relaxation technique in subjects with musculoskeletal
dysfunction.41
Soft tissue massage (Deep transverse friction massage) is also one of the therapeutic
approaches for treating lateral epicondylitis. Massage using friction technique has been
used for many years. Deep transverse friction massage (DTFM) is a technique
popularized by Dr. James Cyrix (Cyriax 1975 a, Cyriax 1975 b) for pain and
inflammation relief in musculoskeletal conditions. DTFM is a technique that attempts to
reduce abnormal fibrous adhesions and makes scar tissue more mobile in sub-acute and
chronic inflammatory conditions by realigning the normal soft tissue fibers. According to
him, deep transverse friction causes traumatic hyperemia, which results in increased
blood flow and decrease in pain. It also increases tissue perfusion and stimulates
mechanoreceptors.42
Deep transverse friction massage (DTFM) has been claimed to be helpful in
rehabilitation of tennis elbow via mobilization of soft tissue and possibly release or
stretch any scar tissue impairing normal movement.43
DTFM is stated to be effective for tendinitis as it mechanically induces hyperemia and
thus influence tissue maturation. DTFM realigns collagen fibers to the direction of
tensile force, mobilize scar tissue and produce a temporary pressure paresthesia, as a
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result there is relative hyperemia at the scar thus acting As a local analgesic. It allows
pressure to be applied to greater that in muscle and it has been advocated in treatment of
muscle strain, tendinitis ligamentatous injuries. Davidson and et al. used light
microscopy and electron microscope and proved that DTFM causes fibroblastic
proliferation and realignment of collagen fibres.42,44,45,46,47
Gibbon and Cohan (1998) added a concept of visco elastic property in the therapeutic
effect of soft tissue massage. Deep transverse friction massage improves visco-elastic
property of muscle and in turn improves function and reduces pain.48
The standard treatment for lateral epicondylitis is therapeutic ultrasound. Ultrasound is a
form of acoustic vibration. Normal frequencies for therapeutic machines are 1MHZ or 3
MHZ.49 Mary Dyson50 (1987) states that treatment with ultrasound can induce
physiological changes which increases the rate of tissue repair after injury and also
reduce pain.
Kliman M D et al (1988)studied that effect of ultrasound therapy in 49 subjects with soft
tissue injuries including tendinitis, epicondylitis, and tenosynovitis. And they concluded
that ultrasound results in decrease in pain and increased pressure tolerance in the soft
tissue injuries.51
Recent study done by Robertson V J (2000) stated that there is little evidence of clinical
effectiveness of therapeutic ultrasound to treat people with pain and musculoskeletal
injuries to promote soft tissue healing.52
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Young 53 (1996) suggests that non thermal effect may be preferable for tissue repair and
stimulation of blood flow, therefore pulsed ultrasound was selected as a treatment
modality for this study.
Revill et al (1976) has found VAS to be reliable as a measurement of pain intensity.54 A
simple VAS may be sufficient to provide information regarding progressive decrease in
pain.
Sim and Waterfield (1997) argued that continuous scale of pain intensity like VAS is
potentially more sensitive to small degrees of change in intensity.55
Craig Libenson (1996) Huskinsonin 1974 devised the VAS with numerical marks in a
100mm scale.
Sullivan, Susan B O (2001) VAS have been designed as pre-test and post-test outcome
measures.56
Elbow Evaluation Scale is a reliable scale which provides objective data and grading as
well as functional information, hence provides an objective mean of comparing different
treatment options.57
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METHODOLOGY.
Study design: Experimental study.
Sources of data: A total of 30 patients are taken from A.J.HOSPITAL AND
RESEARCH CENTRE , Kuntikana , Mangalore , OPD of Laxmi memorial college of
physiotherapy, Balmatta, Mangalore and other hospitals in Mangalore. All subjects were
diagnosed as lateral epicondylitis and refered for physiotherapy. Patients were selected
for the study after scrutinizing for inclusion and exclusion criteria. The purpose of the
study was explained to all the subjects and informed consent was taken from each
subject. All the subjects were assessed using a specific Performa. All subjects were
randomly assigned to either Muscle energy techinique (Group A) or Deep Transverse
Friction Massage (Group B). The study was approved by ethical committee of Laxmi
memorial college of physiotherapy, Mangalore.
INCLUSION CRITERIA
1. Age group 30 60 years of both sex.
2. VAS < 7.
3. Positive Mills test and cozens test.
4. Local tenderness on palpation over lateral epicondyle of the humerus.
5. From sub acute to chronic more than 2 months.
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EXCLUSION CRITERIA
1. Any previous trauma, fracture around elbow, dislocation, bony abnormalities of
elbow.
2. Any other neurological abnormalities.
3. Corticosteroid injection in the preceding 3 months
4. Any other associated systemic illness like metabolic, metastatic, infective
disorders etc.
TOOLS USED FOR THE STUDY:
1. Therapeutic Ultrasound: The device consist of a power source , high frequency
generator and a transducer head The frequency wave was of 1MHZ..
2. Visual Analogue Scale (VAS): The pain VAS is used to evaluate a persons
subjective experience of pain severity. It has well established reliability and
validity in many patient populations and is considered the most sensitive of all
pain ratings scales. The VAS used in this study was a 10 cm line placed
horizontally with the end points marked 0-10. The end points were labelled with
descriptive terms 0 representing no pain and 10 worst pain.
3. Elbow Functional Scale: The patients were assessed using the elbow functional
scale. The scale had categories for identifying the range in which pain is
maximum, the strength in each movement of the elbow, and assessed the ease
with which functional activities were performed. Finally the therapist indicated
how the patients response had improved remained the same or worsened.
4. Ultrasonic gel: As a couplant, for conducting ultrasound waves.
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5. Cotton.
METHOD OF COLLECTION OF DATA
PROCEDURE:
The patients were evaluated using Elbow Functional scale and VAS. The patients were
informed about the whole procedure, the treatment merits and demerits and a return
consent were obtained from them for voluntary participation in the study. They were
randomly divided in to Group A and Group B of 15 subjects each. The patient were
assessed on elbow functional scale and VAS before the commencement of treatment.
This constituted the base line data. The patient were again assessed after 10 treatment
sessions. The follow-up were taken after 3 weeks.
The total number of subjects participated in the study were 30. These subjects were then
divided randomly into 2 groups, Group A and Group B.
Group A:
Fifteen subjects received Muscle Energy Technique. The method adopted was Lewitts
post-isometric relaxation. During the treatment session the patient were seated in a
considerable height. The forearm extensors were stretched to a pain free limit by keeping
the wrist in flexion, gradually the elbow was extended and forearm was pronated. Mild
isometric contractions of common extensors were performed against resistance. The
patient was asked to use 20% of the strength. The length of the time effort was held upto
10 seconds and were repeated for 5 times with rest for 10 seconds between contractions.
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18
Group B:
Fifteen subjects received Deep Transverse Friction Massage. During this
treatment session the patient were seated with elbow well relaxed. The therapist holded
the patients elbow in 900 flexion. DTFM was given to the common extensor tendon at the
point of its origination (lateral epicondyle) with tip of index finger reinforced by the
middle finger. Maximum duration of treatment was 10 minutes.
Both group received therapeutic Ultrasound with intensity ranging from 0.8-2W/cm2 for
4-8 minutes. The patient was seated with the affected limb resting on a couch with the
shoulder in abduction and extension, elbow in 900 flexion. The therapist stands near the
patient applying ultrasound therapy over the painful area in small concentric circles.
Either of the treatment was continuously given for 10 sessions.
OUTCOME MEASURES
The outcome measures are VAS and Elbow Functional Assessment scale. The baseline
measurements are compared to the data at the end of 10 sessions and after 3 weeks.
DATA ANALYSIS
Within Group Analysis: Comparison of VAS and EFA scores at Baseline, 10th day and
after 3 weeks were done separately using one-way ANOVA within Group A and within
Group B. Statistical significance was tested based on p-value (0.05 level). Following one-
way ANOVA Multiple comparison of VAS and EFA scores were done between Baseline
10th day, Baseline after 3 weeks and 10th day after 3 weeks using Bonferroni test
-
19
(post hoc analysis) and paired student t test within Group A and within Group B.
Statistical significance was tested based on p-value (0.05).
Between Group Analysis: Comparison of VAS and EFA scores at Baseline, 10th day
and after 3 weeks were done separately using unpaired student t test between Group A
and Group B. Statistical significance was tested based on p-value (0.05 level).
-
20
Figure 1: TOOLS USED FOR THE STUDY.
-
21
Figure:2 ULTRASOUND THERAPY METHOD:
-
22
Figure 3: MUSCLE ENERGY TECHNIQUE ( NEUTRAL POSITION)
-
23
Figure 4: MUSCLE ENERGY TECHNIQUE METHOD:
-
24
Figure 5: DEEP TRANSVERSE FRICTION MASSAGE METHOD:
-
25
RESULTS
Table 1and 2:-The age distribution between the groups receiving MET &
Therapeutic Ultrasound (Group A) and Deep Transverse Friction Massage &
Therapeutic Ultrasound (Group B). [Refer Graph 1]
Table 1 shows that in group A there were 7( 46.7%) and in group B 7(46.7%) so total
14(46.7%) individuals were present between the age group of 30 39 years. In group A
there were 5(33.3%) and in group B 7(46.7%) so total 12(40.0%) individuals were
present between the age of 40 49 years. In group A 3(20.0%) and in group B 1(6.7%),
so total 4(13.3%) individuals were present in between the age group of 50 59 years.
Total 30(100%) individuals were taken in this study and were randomly divided into 2
groups of 15 individuals namely group A and group B.
Table 2 shows that mean age with standard deviation of group A was 41.73 8.319 and
the mean age with standard deviation of group B was 40.20 6.19. So there is no
significant difference between the age distribution of group A and group B. ( P = 0.513 ).
Table 3:- The gender distribution between Group A and Group B: [ Refer Graph 2]
Table 3 shows that the female count in group A were7 (46.7 %) and that of the group B
were 6(40.0%), so total 13(43.3%) female individuals were present in this study. The
male count in group A was 8 (53.3%) and that of group B was 9 (60.0%), so total male
count was 17 (56.7%). so overall count of male and female subject in this study was
about 30 (100%).
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26
Table 4: - The side distribution between Group A and Group B. [Refer Graph 3]
Table 4 shows that right affected in group A was 8 (53.3%) and that of group B were 6
(40.0%), so total 14 (46.7%) right side affected individuals were present in the study. The
left side affected in group A were 7 (46.7%) and that of group B were 9 (60.0%), so total
16 (53.3%) left side affected individuals were present in the study. So overall count of
right and left side affected individuals in this study was about 30 (100%).
Table 5: - Comparison of VISUAL ANALOGUE SCALE (VAS) scores within
Group A and within Group B. [Refer Graph 4]
The sample size for Group A was taken 15 (N=15). The mean and standard deviation of
Group A for VAS scores at Day 0, Day 10 and After 3 weeks were 6.27 + 1.03, 2.40 +
0.63 and 0.40 + 0.63 respectively. Similarly in group B the sample size was taken 15( N
= 15), mean and standard deviation for VAS scores at Day 0, Day 10 and After 3 weeks
were 5.87 1.12, 3.20 0.56, 3.40 1.95. ANOVA for repeated measures shows that
there is significant decrease in VAS scores from Day 0 to After 3 weeks in both the
groups. [F (2, 56) = 171.9, P < 0.01].
Table 6:- Pair wise comparison of VISUAL ANALOGUE SCALE (VAS) scores
across different periods within Group A and within Group B using post hoc
analysis- Bonferroni test.
The sample size for Group A was taken as 15 (N =15).I, the mean difference of VAS
between Day 0- Day 10, Day 0- After 3 weeks, Day 10- After 3 weeks, were 3.86, 5.86,
2.00, respectively. Standard errors for Day 0- Day 10, Day 0- After 3 weeks, Day 10-
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27
After 3 weeks, were 0.27, 0.25and 0.16. The P value between Day 0- Day 10, Day 0-
After 3 weeks, Day 10- After 3 weeks, was 0.00, 0.00, and 0.00 which is highly
significant (P < 0.01). The sample size for Group B was taken as 15 (N =15)., The mean
difference of VAS between Day 0- Day 10, Day 0- After 3 weeks, Day 10- After 3
weeks, were 2.66, 2.46, 0.200. Standard error for Day 0- Day 10, Day 0- After 3 weeks,
Day 10- After 3 weeks, were 0.28, 0.44, and 0.47. The P value between Day 0- Day 10,
Day 0- After 3 weeks, Day 10- After 3 weeks, were 0.00, 0.00 and 0.01 which is highly
significant (P < 0.01). So, multiple comparison shows that difference is highly significant
from Day 0 to Day 10 and Day 10 to After 3 weeks, but the difference from Day 0 to Day
1o and Day 10 to After 3 weeks is significantly higher in group A than group B as [
F(2,56) = 26.58, P < 0.01].
Table 7: - Comparison of ELBOW FUNCTIONAL ASSESSMENT (EFA) scores
within Group A and within Group B. [Refer Graph 5]
The sample size for Group A was taken 15 (N=15). The mean and standard deviation of
Group A for EFA scores at Day 0, Day 10 and After 3 weeks were 63.93 + 10.49, 82.27+
10.21 and 89.97 + 7.20 respectively. Similarly in group B the sample size was taken 15(
N = 15), mean and standard deviation for EFA scores at Day 0, Day 10 and After 3 weeks
were 71.80 10.10, 78.20 8.41, 78.47 9.92. ANOVA for repeated measures shows
that there is significant decrease in EFA scores from Day 0 to After 3 weeks in both the
groups.[ F(2,56)= 121.5.12, P < 0.01].
-
28
Table 8:- Pair wise comparison of ELBOW FUNCTIONAL ASSESSMENT (EFA)
scores across different periods within Group A and within Group B using post hoc
analysis- Bonferroni test.
The sample size for Group A was taken as 15 (N =15).I, the mean difference of EFA
between Day 0- Day 10, Day 0- After 3 weeks, Day 10- After 3 weeks, were -18.33, -
25.93, -7.60, respectively. Standard errors for Day 0- Day 10, Day 0- After 3 weeks, Day
10- After 3 weeks, were 2.00, 2.01, and 1.37. The P value between Day 0- Day 10, Day
0- After 3 weeks, Day 10- After 3 weeks, was 0.00, which is highly significant (P <
0.01). The sample size for Group B was taken as 15 (N =15)., The mean difference of
EFA between Day 0- Day 10, Day 0- After 3 weeks, Day 15- After 3 weeks, were -6.40,
-6.66,-0.267 . Standard error for Day 0- Day 10, Day 0- After 3 weeks, Day 10- After 3
weeks, was 1.009, 1.43, and 1.10. The P value between Day 0- Day 10, Day 0- After 3
weeks, Day 10- After 3 weeks, was 0.00, 0.001, 1.00 which is highly significant (P <
0.01). So, multiple comparison shows that difference is highly significant from Day 0 to
Day 10 and day 10 to After 3 weeks, but the difference from Day 0 to Day 10 and Day 10
to After 3 weeks is significantly higher in group A than group B as [ F(2,56) = 39.72, P <
0.01].
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29
DISCUSSION
30 patients participated in the study after scrutinizing for inclusion and exclusion criteria
patients were randomly divided into group A receiving MET with US and group B
receiving DTFM with US. Patients were in the age group of 35-59. There was no
significant difference between the age distribution of group A and group B, and also
gender seem to have no significant effect on treatment and the results. This was similar to
the studies done by Hamilton58 and Kivi59 which stated that there was no significant
difference in incidence, prevalence and effect of treatment between genders. The
dominant hand was more affected than the non dominant hand which was similar to the
studies done by Hamilton58, Kivi59 and Paugmali60.However no significant difference was
found between sides.
The lateral epicondylitis is initiated by microscopic tears at the common tendon of the
wrist extensors muscles due to chronic overuse. ECRB was found to be primarily affected
and was characterized by dense population of fibroblast, disorganized immature collagen
scar affects normal gliding of muscle fibers and hence active muscle contraction causes
pain.61
As ECRB, ECRL involved any activity which is performed with wrist extension causes a
pain. The activities such as carrying a weight, driving or house hold activities causes
more pain.62
This study was intended to compare the effectiveness of MET and DTFM. When results
were compared MET was found to be more effective, DTFM was also found to have a
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30
significant effect only up to end of 10 days of treatment, but no significant effect was
found after 10 treatment sessions to follow up.
Though ultrasound was found to reduce pain and increase rate of healing it was found to
be effective as sole treatment approach. Hence therapeutic ultrasound was given to both
the group of patient in order to reduce pain or inflammatory response after treatment.9
There was affective reduction in pain and ease with which ADL was performed increased
significantly after treatment session with MET and US, even significant difference was
found when follow up was done after 3 weeks. This may be due to, as MET is active
muscular relaxation method, normal blood circulation is restored which wipes out
nocioceptive stimulants from the site of pain which may be reason for significant relief of
pain.14
When post isometric relaxation technique is used, only few fibers are activated and other
fibers are inhibited. As a result of active contraction the fibroblast are broken and are
replaced by superior material. Active contraction is followed by a period of relaxation
during which a passive and non painful stretch is applied and structures are taken to a
new limit, which is said to increase flexibility of the structures. Pain reduction is more
due to the fact that MET address the pathology rather than direct reduction in pain.14
DTFM was also found to have effect on the condition at least up to 10 treatment sessions,
this may be due to the fact, when DTFM is applied fibrous adhesions and scar tissues
were broken down which is followed increase in blood supply to the part and wash out of
exudates.30
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31
However the effect with DTFM was found to be limited this may be due to the fact that
when MET was used a generalized effect was obtained as a result of increased blood
circulation, active muscle contraction, passive stretch increasing the flexibility of
structures and muscle strengthening. In contrast in DTFM only the scar tissue was broken
down which was followed by increased circulation and therefore neither muscle
contraction was facilitated nor was flexibility increased.63
As a result Elbow function assessment scores was significantly increased in patients were
MET technique was used. The activities such as use of back pocket, rise from chair, self
care was found to have more improvement wit few sessions of treatment. However pain
during activities such as carrying 10-15 pounds with arm at side and other activities such
as pulling reduced only after 9-10 treatment sessions. However with DTFM, it required
more than 7 sessions for the patients to perform self care activities without pain and there
was only minimum reduction in pain for activities such as carrying 10-15 pounds with
arm at side and pulling.
The EFA scores was significantly increased during follow up session in MET patient and
in patients with DTFM though the patient did not return to baseline value there was mild
increase in pain or remained same as in the end of 10 sessions. But however EFA scores
of patients in group B remained same or even slightly increased this may be due to the
components of EFA scale.
In view of the results obtained, MET is more effective than DTFM. So MET should be
the sole treatment approach in the management of lateral epicondylitis.
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32
Limitations:
1. The pain for group B after 10 sessions has increased slightly which is statistically
not significant as well as according to EFA scale elbow functions were better. The
reason for this discrepancy may be due to high subjective reflection of pain which
is measured using VAS or due to inflexibility of EFA scale.
2. Since LE is reported to be a self limiting disorder, in some cases it is not possible
to determine if this self limiting factor led to the improvement of pain levels and
ability to work instead of work administrated.
3. The ultrasound machine was not checked for its accuracy before the treatment.
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33
CONCLUSION
The MET technique was found to be effective than DTFM for treatment of
lateral epicondylitis as MET caused increased blood circulation to the part, active muscle
contraction and passive stretching causing increased flexibility of the structures. In
contrast DTFM, only scar tissue was broken down which was followed by increased
circulation and therefore neither muscle contraction was facilitated nor flexibility
increased. Hence alternate hypothesis was proved.
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34
SUMMARY
The purpose of this study was to compare the efficacy of MET and DTFM in the
treatment of lateral epicondylitis.30 subjects clinically diagnosed as lateral epicondylitis
were taken after scrutinizing for inclusion and exclusion criteria and were randomly
divided into group A receiving MET with US and group B receiving DTFM with US.
Both the groups received treatment for 10 days. The patients were assessed for pain on
VAS, and function on EFA. The data were taken before commencement of treatment,
after 10 treatment sessions and after 3 weeks.
The above collected data was statistically analyzed using one way ANOVA and post hoc
analysis and unpaired t test was used to compare VAS and EFA scores between group
A and group B. P value was kept at 0.05 for SS.
The MET technique was found to be effective than DTFM for treatment of lateral
epicondylitis as MET caused increased blood circulation to the part, active muscle
contraction and passive stretching causing increased flexibility of the structures. In
contrast DTFM, only scar tissue was broken down which was followed by increased
circulation and therefore neither muscle contraction was facilitated nor flexibility
increased. Hence alternate hypothesis was proved.
\
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35
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42
ANNEXURE I
CONSENT FORM
I,______________________________________________________________________
voluntarily declare to participate in the research study EFFECTIVENESS OF
MUSCLE ENERGY TECHNIQUE AND DEEP TRNSVERSE FRICTION
MASSAGE IN THE TREATMENT OF LATERAL EPICONDYLITIS The
researcher has explained me about the study, risks and benefits of participation and has
answered all my questions and queries regarding the study to my satisfaction.
Signature of participant: ____________________________.
Signature of the witness: ____________________________.
Signature of the researcher: __________________________.
Subject is fit/unfit for the study: _______________________.
Guide: _____________________ Co-guide:___________________
Date: ___________________________
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43
ANNEXURE II
EVALUATION OF THE PATIENT
PERSONAL DATA
Name :
Age :
Sex :
Date of assessment :
Height :
Weight :
Occupation :
Address :
CHIEF COMPLAINTS:
PAIN SCALE: 0 10
PRESENT HISTORY:
1. Date of onset of symptoms:
2. Onset:
3. Aggravating factor:
4. Relieving factor:
5. Associated symptoms, if any:
6. Tingling:
7. Current medication:
8. Any other complaints:
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44
PAST HISTORY:
1. Head/Neck injury:
2. Fractures:
3. Elbow surgery:
4. Any medical history:
ON OBSERVATION: Swelling
Skin colour
Deformity
Posture
ON PALPATION: Tenderness
Temperature
Swelling
Site
PAIN EVALUATION:
Site of pain:
Duration:
Type of pain:
Onset of pain:
Special Tests
Mills Test Resisted middle finger extension Cozens test
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45
Provisional Diagnosis:
INVESTIGATION:-
Radiography
Special investigations
Diagnosis:-
Assigned to group:
Treatment administered
Recording chart
PERIODS IN WEEKS
Outcome
measures
Baseline 10th day Follow up
VAS
EFA
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46
ANNEXURE III
ELBOW EVALUATION:
Name:
Procedure:
Date:
Elbow: R/L
Dominant: R/L
DATE OF EXAM // // // // //
PAIN ( MAXIMUM POINTS):
5= none (30)
4= slight with continous activity, no
medication (25)
3= moderate with occasional activity, some
medications (15)
2= moderately severe much pain, frequent
medication (10)
1= severe constant pain, markedly limited
activity (5)
0= complete disability (0)
MOTION:
Flexion (17 Points Max.)
Extension (8 Points Max)
Pronation
Supination
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47
STRENGTH ( 15 points max.):
5= normal
4= good
3= fair
2= poor
1=trace
0= paralysis
NA= not applicable
MOTION:
Flexion
Extension
Supination
Pronation
INSTABILITY ( 6 points max.):
A/P M/L
None 3 3
Mild 10mm, >100 0 0
FUNCTION ( 12 points max.) 4= normal (1)
3= mild compromise (.75)
2= difficulty (.5)
1= with aid (.25)
0= unable (0)
Na= not applicable
( index-multiply .25)
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48
1. Use back pocket
2. Rise from chair
3. Perineal care
4. Wash opposite axilla
5. Eat with utensil
6. Comb hair
7. Carry 10 to 15 pounds with arm at side
8. Dress
9. Pulling
10. Throwing
11. Do usual work , specify work:
12. Do usual sport, specify the sport
PATIENT RESPONSE: 3= much better
2=better
1= same
0= worse
NA= not applicable
COMPLETED B: NAME OF EXAMINER
INDEX: KEY:
95-100= excellent
80-95= good
50 -80= fair
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49
ANNEXURE IV
VISUAL ANALOGUE SCALE
0 10
No Pain Max Pain
The Visual Analogue Scale is said to be the best pencil and paper method of assessing
the intensity of clinical pain. It consist of a 10 cm line bounded with verbal descriptors as
no pain at one end and maximum pain at the other end.
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50
ANNEXURE V
TABLES
Table 1 & 2: Age Distribution.
GROUPS
AGE
Group A Group B
TOTAL
30-39 7 (46.7%) 7 (46.7%) 14 (46.7%)
40 49 5 (33.3%) 7 (46.7%) 12 (40.0%)
50-59 3 (20.0%) 1 (6.7%) 4 (13.3%)
TOTAL 15 (100%) 15 (100%) 30 (100%)
GROUP MEAN STD.DEVIATION
Group A 41.73 8.319
Group B 40.20 6.190
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51
Graph 1: Age Distribution.
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52
Table 3: Gender Distribution.
Group A Group B
Total
Sex
N
%
N
%
N
%
Male
8
53.3
9
60.0
17
56.7
Female
7
46.7
6
40.0
13
43.3
Total
15
100
15
100
30
100
Graph 2: Gender Distribution.
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53
Table 4: Comparison of AFFECTED SIDES scores within Group A and Group B.
GROUPS
Side
Group A Group B
TOTAL
Right 8 (53.3%) 6 (40.0%) 14 (46.7%)
Left 7 (46.7%) 9 (60.0%) 16 (53.3%)
TOTAL 15 (100%) 15 (100%) 30 (100%)
Graph 3: Comparison of AFFECTED SIDES scores within Group A and Group B
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Table 5: - Comparison of VISUAL ANALOGUE SCALE (VAS) scores within Group A and within Group B.
Variables
Periods N
Mean
Standard Deviation
Group A 15 6.27 1.033
Group B 15 5.87 1.125
VAS Base line
Total 30 6.07 1.081
Group A 15 2.40 0.632
Group B 15 3.20 0.561
VAS 10th day
Total 30 2.80 0.714
Group A 15 0.40 0.632
Group B 15 3.40 1.957
VAS follow up
Total 30 1.90 2.090
Effect due to duration (day 0 follow up): F (2, 56) = 171.9, p < 0.01, HS
Effects due to Groups on VAS: F (2, 56) = 26.58, p < 0.01, HS.
Graph 4: - Comparison of VISUAL ANALOGUE SCALE (VAS) scores within Group A and within Group B.
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Table 6: Pair wise comparison of VISUAL ANALOGUE SCALE (VAS)
scores across different periods within Group A and Group B using post
hoc analysis- Bonferroni test.
VAS Period Periods Mean
Std.
Error
p-value Level of significance
10th day 3.867 0.274 .000 HS at p < 0.01 Baseline
Follow up
5.867 0.256 .000 HS at p < 0.01
Group A
10th day Follow up
2.000 0.169 .000 HS at P < 0.01
10th day 2.667 0.287 .000 HS at p < 0.01 Baseline
Follow up
2.467 0.446 .000 HS at p < 0.01
Group B
10th day
Follow up
-.200 0.470 1.000 NS
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Table 7: - Comparison of ELBOW FUNCTIONAL ASSESSMENT ( EFA) scores within Group A and within Group B.
Variables Periods N
Mean
Standard Deviation
Group A 15 63.93 10.491
Group B 15 71.80 10.108
EFA Base line
Total 30 67.87 10.884
Group A 15 82.27 10.215
Group B 15 78.20 8.419
EFA 10th day
Total 30 80.23 9.427
Group A 15 89.87 7.200
Group B 15 78.47 9.927
EFA follow up
Total 30 84.17 10.306
Effect due to duration (day 0 follow up): F (2, 56) = 121.5, p < 0.01, HS
Effects due to Groups on EFA: F (2, 56) = 39.72, p < 0.01, HS.
Graph 5: - Comparison of ELBOW FUNCTIONAL ASSESSMENT ( EFA) scores within Group A and within Group B.
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Table 8: Pair wise comparison of ELBOW FUNCTIONAL ASSESSMENT (EFA) scores across different periods within Group A and within Group B using post hoc analysis- Bonferroni test.
EFA Period Periods Mean
Std.
Error
p-value Level of significance
10th day -18.333 2.009 .000 HS at p < 0.01 Baseline
Follow up
-25.933 2.015 .000 HS at p < 0.01
Group A
10th day Follow up
-7.600 1.379 .000 HS at P < 0.01
10th day -6.400 1.009 .000 HS at p < 0.01 Baseline
Follow up
-6.667 1.430 .001 HS at p < 0.01
Group B
10th day
Follow up
-0.267 1.106 1.000 NS
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ANNEXURE VI
Master Chart 1
VAS EFA
Sr.No. Group Age Gender Side
BaselineAfter10 Follow Baseline
After10 Follow
session up session up 1 1 40 1 1 7 3 1 80 87 92 2 1 49 1 1 7 2 1 76 97 98 3 1 38 2 1 6 2 0 61 82 85 4 1 51 2 2 6 3 1 56 75 80 5 1 42 2 2 4 1 0 63 74 90 6 1 33 2 2 5 3 0 75 96 98 7 1 38 1 1 7 2 1 59 70 82 8 1 32 1 1 8 3 2 47 63 79 9 1 59 2 2 7 2 1 50 80 91 10 1 54 1 1 6 2 0 73 96 98 11 1 36 1 1 7 3 1 80 87 99 12 1 45 1 2 6 3 0 56 79 93 13 1 42 1 2 6 2 0 59 92 95 14 1 33 2 2 7 2 1 61 82 88 15 1 34 2 1 5 3 1 63 74 80
KEY
Group A MET
Gender 1 Male, Gender 2- Female
Side 1- Right, 2- Left.
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Master Chart 2
VAS EFA Sr.No. Group Age Gender Side
Baseline After10 Follow Baseline After10 Follow session up session up
1 2 53 2 2 6 4 3 73 82 872 2 52 1 2 7 4 6 76 88 783 2 45 1 1 6 4 5 79 83 804 2 54 1 2 4 3 4 84 86 855 2 33 2 1 6 3 5 76 80 806 2 31 2 1 7 3 5 59 65 607 2 30 1 2 5 3 2 62 69 698 2 40 1 1 6 3 5 75 77 789 2 42 1 2 7 4 3 74 80 8110 2 45 1 2 6 3 5 76 79 8011 2 37 2 1 4 3 1 84 89 9212 2 39 2 1 7 3 5 59 65 6313 2 46 1 2 6 2 1 59 69 7214 2 39 1 2 7 3 1 56 72 75
15 2 40 2 2 4 3 0 85 89 97
KEY
Group B- DTFM
Gender 1- Male, Gender 2- Female
Side 1- Right, 2- Left.
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