RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE,KARNATKA

PROFORMA FOR REGISTRATION OF SUBJECTS

FOR DISSERTATION

1 / NAME OF THE CANDIDATE AND ADDRESS / NAVIN KUMAR CHAUDHARY,
LAHAN -3 (MATIYARWA).
DIST-SIRAHA, ZONE-SAGARMATHA , NEPAL
2 / NAME OF THE INSTITUTION / ACHARYA INSTITUTE OF HEALTH SCIENCES&COLLEGE OF PHYSIOTHERAPY,
BANGALORE-32
3 / COURSE OF STUDY AND SUBJECT / MASTER OF PHYSIOTHERAPY IN MUSCULOSKELETAL DISORDERS AND SPORTS PHYSIOTHERAPY.
4 / DATE OF ADMISSION TO COURSE / 09/06/2009
5 / TITLE OF THE TOPIC / EFFECTS OF MANUAL PHYSICAL THERAPY TO THE CERVICAL SPINE IN THE MANAGEMENT OF LATERAL EPICONDYLALGIA.
6 / BRIEF RESUME OF THE INTENDED WORK :
6.1NEED FOR STUDY:
Lateral epicondylalgia,also referred to as lateral epicondylitis or tennis elbow, is a common musculoskeletal disorder frequently encountered by physicaltherapist1.The syndrome occurs more frequently in occupations involving repetitive wrist movement2,3.Lateral epicondylalgia is characerised by an insidious onset of pain at the lateral elbow,tenderness to palpation of the wrist extensors, and restricted movement of the wrist with consequences of altered function and disability4.The syndrome most commonly afflicts individuals between the ages of 45 and 50 and usually affects the dominant arm5.Although lateral epicondylalgia has been purported to be an overuse disorder of the common extensor tendon, with the extensor carpi radialis brevis muscle being the most commonly involved6,7,8,9.Several pathophysiological mechanism has been proposed, including degenerative changes in tendon structures,radial nerve entrapement syndrome,somato sympathetic dysfunction and somatic pain referral from articular structure of the cervical spine10,11,12,13.In management,joint mobilization techniques directed at the elbow region have been demonstrated to improve pain-free and grip strength in short term14,15.Studies with long term outcome have not been reported.
It has been purported that cervico thoracic spine dysfunction may contribute to the etiology of lateral epicondylalgia16.Hence, the effects of manual therapy directed at the cervical and thoracic spine in patients with lateral epicondylalgia is also sparse17.Hence , the purpose of this study is to evaluate the effects of manual therapy of cervical spine in the management of patients with lateral epicondylalgia.
6.2 REVIEW OF LITERATURE :
1. vicenzino b,et al(2007)18 investigated joint manipulation in the management of lateral epicondylalgia.They demonstrated that joint manipulation directed at the elbow and wrist as well as the cervical and thoracic spinal regions results in clinical alterations in pain and motor system.Following these treatment,they concluded that this treatment gives good recovery to lateral epicondylalgia.
2. Slater h, et al(2006)19 conducted the study of effects of mobilization with movement(MWM) technique for lateral epicondylalgia in 24 patients.In this study they concluded that MWM technique achieved analgesia and enhancing grip force from lateral epicondylalgia.
3. Fernandez-carnero J, et al(2008)20, in this case study they investigated the immediate effects of a single cervical spine manipulation and a manual contact intervention(MCI) on pressure pain thresholds(PPTs) and thermal pain thresholds over the elbow region and pain-free grip(PFG) force in patients with lateral epicondylalgia(LE) for 10 patients using repeated measures crossover, single-blinded randomized study.From this study they concluded that application of a manipulation at the cervical spine produced an immediate bilateral increase in PPT in patients with LE.
4. Paungmali A, et al (2003)14, in investigation of this case study they examined that the effects of mulligan’s mobilization with movement technique for lateral epicondylalgia for 7 women and 17 men using placebo,control and repeated measures.From this study they demonstrated that an initial hypoalgesic effect and concurrent sympathoexcitation on lateral epicondylalgia following treatment of MWM technique.
5. Rompe JD, et al (2001)17, they compared the effects of extracorporeal shockwave therapy(ESWT) alone with a combination of ESWT and manual therapy of the cervical spine in treating unilateral chronic epicondylitis of the elbow in 30 patients using prospective and matched single-blind control trial study design.
From this comparative treatment study,they concluded that ESWT may be an effective conservative treatment method for unilateral chronic epicondylitis.
6. Herd CR, et al (2008)21 in their randomized and non-randomized study design evaluated the effects of mulligan’s mobilization with movement technique for lateral epicondylalgia in13 subjects.They concluded that mulligan’s mobilization with movement technique in providing immediate,short and long-term benefits.In addition,positive results were demonstrated with manipulative therapy directed at the cervical spine.
7 / 6.3 OBJECTIVE OF THE STUDY
To determine the effectiveness of Manual physical therapy to the cervical spine in the management of lateral epicondylalgia.
HYPOTHESES OF STUDY:
NULL HYPOTHESIS:
There is no significant effects of manual physical therapy to the cervical spine in the management of lateral epicondylalgia.
ALTERNATE HYPOTHEIS:
There is significant effects of manual physical therapy to the cervical spine in the management of lateral epicondylalgia.
MATERIALS AND METHOD :
7.1 SOURCE OF DATA:
·  Acharya physiotherapy clinic and rehabilitation centre,Bangalore.
7.2METHOD OF COLLECTION OF DATA:
STUDY DESIGN:
·  Experimental study design.
SAMPLE SIZE
·  30 subjects
SAMPLE DESIGN:
·  Convenient sampling.
MATERIAL USED :
·  chair
·  VAS(visual analogue scale)
·  ultra sound machine
INCLUSION CRITERIA :
·  Gender:both male and female.
·  Age:35-50
·  .Pain during palpation of the lateral epicondyle .
·  .pain with resisted wrist extension .
·  . pain with resisted middle finger extension .
EXCLUSION CRITERIA :
·  multiple diagnosis (shoulder pathology,cervical spine radiculopathy ).
·  fibromyalgia
·  cns disorder
·  diabeties
·  painfull elbow which is undergone to surgery.
·  bilateral upper extremity symtoms .
·  Radial tunnel syndrome ,such as pain to palpation over the radial tunnel and pain with full pronation of forearm .
DURATION OF THE STUDY :
·  3 months(12wks)
7.3 INTERVENTION OF THE STUDY
30 subjects will be selected and equally assigned in to experimental group(n=15) and control group(n=15).The experimental group will receive local management(LM) plus manual therapy for cervical region whereas control group will receive local management (LM) with placebo technique.
Experimental group:
In this experimental group,local management (ultra sound therapy ) will be applied at the lateral epicondylitis.After this treatment manual physical therapy technique also will be given in cervical region by following method.Patient’s unilateral arm will be positioned as an abduction of shoulder and internal rotation,and occasionally the addition of elbow extension.One of the therapist’s hands depressed the scapula while the other cradled the occiput and neck above c5,c6.A grade ш,passive lateral glide movement will be applied by the hand cradling the neck & occiput21,22.
Control group:
In this group, ultrasound therapy will be given at the lateral epicondylitis.Afterwards,it will be involved the same interaction and communication between the therapist and patient as in the lateral glide technique.It will be reproduced the manual contact and setting up procedure used in the treatment but without the application of a grade ш lateral glide movement.This subjects arm shall be positioned such that the hand rested on the abdomen
OUT COME MEASURES:
·  pain will be measured by visual analogue scale
DATA ANALYSIS:
Differences of pre and post evaluating sessions will be analysed for statistical significance by using of an independent T test.
7.4 ETHICAL CLEARANCE:
Ethical clearance for the study has been obtained from the ethical committee of acharya institution.
8 / LIST OF REFERENCES:
1.Noteboom T,Cruver R, Keller J, Kellogg B, Nitz AJ. Tennis elbow: a review. J orthop sports phys ther. 1994;19:357-366.
2.Dimberg L. The prevalence and causation of tennis elbow (lateral humeral epicondylitis) in a population of workers in an engineering industry. Ergonomics. 1987;30:573-579.
3.Feuerstein M, Huang GD, Haulfer AJ, Miller Jk. Development of a screen for predicting clinical outcomes in patients with work-related upper extremity disorders. J Occup Environ med.2000;42:749-761.
4.wright A,thurnwald P ,smith J. An evaluation of mechanical and thermal hyperalgesia in patients with lateral epicondylalgia.pain clin,1992;5:221-227.
5.Haker E .lateral epicondalgia :diagonosis ,treatment and evaluation .crit Rev phys med .1993;5:129-154.
6.kaufman RL.Conservative chiropractic care of lateral epicondylitis.J Manupulative physiol ther .2000;23:619-622.
7. Peters T ,Baker CL,Jr.Lateral epicondylitis .Clin sports.Med.2001;20:549-563.
8.pienimaki TT .Conservative treatment and of treatment
Rehabilitation of tennis elbow:a review article.Crit Rev phys Rehabil med. 2000;12 213-228.
9. Pienimaki TT,Tarvainen TK siira Pt, Vanharanta H. progressive strengthening and stretching exercises, and ultrasound for chronic lateral epicondylitis. Physiotherapy,1996;82:522-530.
10. Smith J,O’callaghan J, Vicenzino B,Thurnwald P, Wright A.The influence of regional sympathetic blockade with guanethidine on hyperalgesia in patients with lateral epicondylalgia. J musculoskel pain. 1999;7:55-71.
11.Vicenzino B, Collins D, Wright A.The initial effects of cervical spine manipulative physiotherapy treatment on the pain and dysfunction of lateral epicondylalgia. Pain.1996;68:69-74.
12. Wright A, Thurnwald p, O’callaghain j, Smidt N, Vicenzino B, Hyperlalgesia in tennis elbow patients. J musculoskel pain.1994;2:83-97.
13.Yaxley GA, Jull GA. Adverse tension in the neural system.A preliminary study of tennis elbow.Aust J physiother.1998;39:15-22.
14. Paungmali A, O’Leary s, souvlis T,Vicenzino B. Hypoalgesic and sympathoexcitatory effects of mobilization with movement for lateral epicondylalgia. Phys Ther 2003;83:374-383.
15. Vicenzino B ,paungmali A, Buratoski S, Wright A. specific manipulative therapy treatment for chronic lateral epicondylalgia produced uniquely characteristic hypoalgesia. Man the 2001;6:205-212.
16. Lee DG.Tennis elbow: a manual therapist’s perspective J orthop sports phys Ther.1986;8:134-142.
17.Rompe JD, Riedel C, Betz U, fink C. chronic lateral epicondylitis of the elbow: A prospective study of low-energy shock wave therapy and low-energy shockwave therapy plus manual therapy of the cervical spine.Arch phys med rehabil.2001; 82:578-582.
18. Slater H, et al. The effects of a manual therapy technique in experimental lateral epicondylalgia.2006 may;11 (2):107-17.
19. Fernandez-carnero J.et al. The immediate hypoalgesic and motor effects after a single cervical spine manipulation in subjects with lateral epicondylalgia. 2008 nov-dec;31(9):675-81.
20. Herd CR, et al.A systematic review of the effectiveness of manipulative therapy in treating lateral epicondylalgia.2008;16(4)225-37.
21. Elvey R, Treatment of arm pain associated with abnormal brachial plexus tension, Aust J. physiother,32 (1986)225-230.
22. Maitland G, vertebral manipulation, butterworths,Sydney.1986.
9. / SIGNATURE OF THE CANDIDATE :
10. / REMARKs OF THE GUIDE:
11. / NAME AND DESIGNATION OF :
11.1 GUIDE:
11.2 SIGNATURE:
11.3 CO-GUIDE:(IF ANY):
11.4 SIGNATURE:
11.5 HEAD OF DEPARTMENT:
11.6 SIGNATURE:
12 / 12.1 REMARKS OF THE CHAIRMAN &PRINCIAL:
12.2 SIGNATURE: