RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA.
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1. / NAME OF THE CANDIDATE AND ADDRESS / K. SAKTHIVEL116, 5TH MAIN ROAD,
NEAR RAM MANDHIR BUS STOP, BEHIND LAXMI PRINTERS, CHAMARAJPET,
BANGALORE-560018.
2. / NAME OF THE INSTITUTION / KEMPEGOWDA INSTITUTE OF PHYSIOTHERAPY
3. / COURSE OF STUDY AND SUBJECT / M.P.T. (MUSCULO SKELETAL DISORDERS AND SPORTS PHYSIOTHERAPY)
4. / DATE OF ADMISSION TO COURSE / 1ST JUNE 2007
5. / TITLE OF THE TOPIC
A STUDY ON THE EFFECTIVENESS OF THE DIGITAL ISCHEMIC PRESSURE VERSUS ULTRA SOUND THERAPY ON TRIGGER POINTS IN TENNIS ELBOW.
6.
6.1 / BRIEF RESUME OF THE INTENDED WORK :
PURPOSE OF THE STUDY
Tennis elbow (Lateral epicondylitis) pain and tenderness over the lateral epicondyle of the elbow more accurately, the bony insertion of the common extensor tendon is a common complaint among tennis player’s but even more common complaint in non players among who perform repetitive wrist extension (Apley’s, 2001)
Early intervention is needed for optimal recovery. Various conservative treatment choices like Trigger point therapy, Ultrasound therapy, LASER therapy, Myofascial release, Bracing, ICE, Ionotoporosis, Acupuncture, Massage, etc are available.
The study is intended to find the effectiveness of digital ischemic pressure versus ultrasound therapy on Triggerpoints in Tennis elbow.
6.2 / REVIEW OF LITERATURE
Tennis elbow (Lateral epicondylitis, Lateral elbow stress syndrome) is a lesion affecting the origin of the tendons of the muscles that extends the wrist. (Robert Donatelli, Michael J. Wooden, 1994)
Tennis elbow (or) lateral epicondylitis is described as pain originated from lateral epicondyle usually from myofascial trigger points in the supinator muscles. (Janet G Travell and David G Simons, 1983)
Tennis elbow is clinically characterized by pain over the lateral aspect of the elbow and radiating pain down the forearm. The pain aggravated by any activity that puts tension on the forearm extensor muscle origin such as active dorsi flexion of the wrist while grasping an object, and passive flexion of the wrist against resistance. The tennis elbow syndrome is characterized by an insidious onset of pain that is brought on by wrist extension with pronation or supination and is aggravated by gripping. The pain and tenderness are felt at the area of the lateral epicondyle. Tennis elbow is by no means limited to those who play tennis, indeed it can develop as a sequel to local injury and to any repetitive over use activity that involves the forearm extensor muscle. (Robert B. Salter MD, 1999)
The primary pathological process is a degeneration of the extensor tendon in the first 1-2cm distal to its attachment to the extensor origin at the lateral epicondyle. This area has a poor blood supply which, when combined with excessive use, may lead to degenerative changes in the tendon. (Peter Brukner and Karim Khan, 1993)
The peak incidence is between the ages of 40 and 50 years but this condition may affect any age group. It is an insidious onset of pain which occurs 24-72 hours after unaccustomed activity involving repeated wrist extension. (Peter Brukner and Karim Khan, 1993)
The epicondylar pain often diagnosed as tennis elbow is frequently composite pain that is referred in part from the supinator, the extensor carpi radialis longus, and the extensor digitorum. Patient complain of pain when they attempt a firm grip with hand in ulnar deviation, eg. During shaking hands pain is more likely to be felt if forceful supintion or pronation are added to the movement. (Peter Brukner and Karim Khan, 1993)
The application of electrotherapeutic modalities encourages healing process. Soft tissue therapy is performed at the site of the lesion and to adjacent tight thickened tissues. (Peter Brukner and Karim Khan, 1993)
Digital Ischemic pressure involves the application of direct pressure perpendicular to the skin towards the center of a muscle with sufficient pressure to evoke temporary Ischemic reaction. The aim of this Technique is to stimulate the tension monitory receptors within muscle to induce relaxation to provide an analgesic response in soft tissue by eliciting a release of pain mediating substance and to deactivate symptomatic trigger points. Common sites of active trigger point will respond well to this technique. (Peter Brukner and Karim Khan 1993)
Ischemic compression application of sustained pressure to the Trigger point with sufficient force and for a long enough time to inactivate it. This process is continued up to 1 min. (Janet G Travell and David G Simons, 1983)
Application of ultrasound is an effective means of inactivating trigger points. Intensity of 0.5 watt/cm2 using a slow dwell technique with circular motion that completes one circle in 1 or 2 sec is effective in treating trigger point. The circle is tight enough to provide a small overlap over the trigger point in the center of the circle. (Janet G Travell and David G Simons, 1983)
6.3 / OBJECTIVE OF THE STUDY
1. To compare the effectiveness of Digital ischemic pressure versus Ultrasound therapy on Trigger points in reducing pain as measured by Visual Analogue Scale (VAS) in Tennis elbow.
2. To compare the effectiveness of Digital ischemic pressure versus Ultrasound therapy on trigger points in Tennis elbow in evaluating the grip strength using Hand Held Dynamometer.
6.4
6.5 / INCLUSION CRITERIA
Ø Patients between 20 to 60 years of age.
Ø Patients with either sex.
Ø Patient who are positive for Mill’s test and Cozen’s Test
EXCLUSION CRITERIA
Ø Pregnancy
Ø Pace maker
Ø Infection
Ø Deep Vein Thrombosis (DVT)
Ø Malignancy
Ø Post radiation therapy
Ø Rhematoid arthritis
Ø Neuro muscular disease
Ø Cervical spine upper limb problems
Ø Tuberculosis
Ø Anaesthetic area
7. / SOURCE OF DATA
Patients referred to Out Patient Department of Kempegowda institute of physiotherapy from Kempegowda institute of Medical Sciences and Research Centre. Those who fulfill the inclusion and exclusion criteria.
7.1 / METHOD OF COLLECTION OF DATA
Sample Size
Period of Study
Study Design
Sample method / :
:
:
: / 60 (30 in each group)
1 year
Comparative study
Random sampling method
First prepare 60 chits (30 in each group) place them in box, shuffle at each time and ask the patient to pick one chit and whatever the method selected is allocated to that patient. Do not replace the selected chits back into the box.
7.2 / METHODS:
Ø Patient informed consent form will be taken and assessed, explain about the treatment.
Ø Check for inclusion and exclusion criteria with positive Mill’s test and Cozen’s test.
Ø The patients referred from Kempegowda Institute Medical Sciences and Research Centre are allocated in to 2 groups alternatively group A and group B.
Ø Group A will receive Digital Ischemic pressure on Trigger points.
Ø Group B will receive Ultrasound therapy on Trigger points.
Ø Treatment will be given 5 times weekly for 2 successive weeks.
Ø Pain will be measured using Visual Analogue Scale before treatment and after 2 weeks of treatment.
Ø Grip strength will be measured using Hand Held Dynamometer before treatment and after 2 weeks of treatment.
Ø The values will be compared and studied to see the effectiveness of treatments statistically.
7.3 / STUDY VARIABLES
1. Pain as measured by Visual Analogue Scale (VAS)
2. Grip strength as measured by Hand Held Dynamometer.
8. / STATISTICAL ANALYSIS
This will be done using students ‘t’ test and Chi-Square Test for drawing valid conclusion.
9. / DOES STUDY NEED INTERVENTION ON HUMAN SUBJECTS ?
Yes, an intervention on human subjects is needed.
10. / HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION.
Ethical clearance has been obtained from the institution concerned certificate has been enclosed.
11. / RFFERENCE :
1. Apley’s system of Orthopaedics and Fractures, Louis Solomon, David J. Warwick, Selvadurai Nayagam, Arnol-2001. pp.310.
2. Robert Donatelli, Michael J: Wooden, Orthopaedic physical therapy churchill Livingstone USA, 1994. pp.210-215.
3. Janet G. Travell, David G. Simons, Myofascal pain and Dysfunction, Williams and Wilkins, USA, Vol-1 1983. pp.86-90.
4. Robert B. Salter, MD Textbook of disorders D and injuries of the musculo skeletal system; Williams and Wilkins; 1999. pp 295-296.
5. Brukner P, Khan K, Clinical Sports Medicine Sydney: McGraw-Hill; 1993.
pp. 123-124.
6. Bechtal, C.D: Griptest: The use of a dynamometer with adjustable handle spacing J. Bone Joint Surg. Aus. 1954. 36: 820-832.
7. Mathiowetz, V.K. weber G. Volland; and N. Kashman Reliability and validity of grip and pinch strength evaluations J. Hand Surg. Am. 9: 222-226; 1984.
8. David J. Magee, Orthopeadic, physical Assessment 2006, Saunders Elsevier USA. pp.380-420.
9. Van Swearingen JM : Measuring wrist muscle strength J. Orthop. Sports phys. Ther 4: 217, 1983.
10. Oh rbach R, Gale E, Pressure Pain thresholds, Clinical assessment, and Differential diagnosis : Reliability and Validity in patients with myogenic pain, 39: 157-69. 1989.
11. Hong. C.Z. Chen Y.C. Pon C.H. and Yu J. immediate effects of various physical medicine modalities on pain threshold of an active myofascial trigger points.
J. Musculoskeletal pain, 1(2) : 37-53, 1993.
12. Roles, N.C., and R.H. Mandsley: Radial tunnel syndrome resistant tennis elbow as a nerve entrapment J. Bone joint surg. 54:499-508, 1972.
13. Johnlow and Ann Reed, Electrotherapy explained principles and practice Butterworth – Heinemann: Oxford 1998. pp.148-175.
14. Brigs CA, Ellioh BG : Lateral Epicondylotis A review of structures associated with tennis elbow Anatclin 7: 149, 1995.
15. Holds worth L.K. Anderson D.M. Effectiveness of ultrasound used with a hydrocortisone coupling medium or epicondylitis clasp to treat lateral epicondylitis: Pilot study physiotherapy, 1993, 79, 19-24.
12 / REMARKS OF THE GUIDE : / THIS STUDY IS NEEDED FOR ASSESSING THE EFFECTIVENESS OF THE DIGITAL ISCHEMIC PRESSURE VERSUS ULTRASOUND THERAPY ON TRIGGER POINTS IN TENNIS ELBOW.
13. / NAME AND DESIGNATION OF :
13.1 GUIDE :
13.2 SIGNATURE :
13.3 CO-GUIDE :
13.4 SIGNATURE :
13.5 HEAD OF THE DEPARTMENT:
13.6 SIGNATURE : /
S. SHANMUGAM. M.P.T.
Assistant Professor, K.I.P.T.
Dr. H.B. SHIVA KUMAR M.B.B.S. M.S. (Ortho)
Associate Professor
Department of Orthopeadics
K.I.M.S. & R.C.
Prof. R. BALASARAVANAN M.P.T.
K.I.P.T.
14. / 14.1 REMARKS OF THE CHAIRMAN AND PRINCIPAL :
14.2 SIGNATURE : / FOR KIND APPROVAL
Prof. R. BALASARAVANAN M.P.T.
KIPT
KEMPEGOWDA INSTITUTE OF PHYSIOTHERAPY
K.R. Road, V.V. Puram, Bangalore-560004.
Ph : 080-26619960
CONSENT FORM
I ______residing at ______do hereby give my consent of take part in the proposed study conducted by Kempegowda Institute of Physiotherapy. I have decided to volunteer myself for the study on my own will and was not compelled by any individual or group of people and my consent is not for any monetary benefits.
The treatment procedure is fully explained to me by ______in the language best known to me and I am aware that being subjected to this study. I will have to give more time for assessments and treatment; and these assessments do not interfere with benefits.
I have the right to refuse my consent/ or with draw from it any time during the course of the study without adversely affecting my treatment.
By signing the consent form I understand that I agree all the terms and conditions of the institution and I shall not make this institution liable for an ill health / lack of improvement. The matter in this consent form was read by me/read to me by an interpreter and I fully understood the subject matter.
SIGNATURE OF PATIENT SIGNATURE OF INTERPRETER
(Not required if the volunteer read and
sign the consent form by him/her self)
SIGNATURE OF THE INVESTIGATOR