Rajivgandhiuniversity of Health Science

RAJIVGANDHIUNIVERSITY OF HEALTH SCIENCE

BANGALORE, KARNATAKA

ANNEXURE

Proforma for registration of subjects for dissertation:-2010-2011

1 / Name and address of candidate / Godase Ambrushi Tukaram
Alva’s College of Physiotherapy,
Moodbidri,
574227.
2 / Name of institution / Alva’s College of Physiotherapy,
Moodbidri,
574227.
3 / Course of study and subject / Master of physiotherapy
(Musculoskeletal disorders and sports physiotherapy).
4 / Date of admission to the course / 15/6/2010.
5 / Title of study: A comparative study on the effectiveness of trigger point release technique with ultrasound therapy Versus ultrasound therapy alone in reducing myofascial pain of levator scapulae.

6. BRIEF RESUME OF INTENDED WORK

Myofascial pain syndrome (MPS) is nothing but myofascial trigger point which occurs within taut bands which runs parallel to the orientation of fiber in affected muscle. Taut band may be palpated as a nodular zone of increased consistency. Trigger point was first introduced by Steindler (1940), an American Orthopedic Surgeon1.

Myofascial trigger point is a hyperirritable spot and associated with taut band of skeletal muscles which has tender point and painful on compression or stretch and because of that more typical referred pain pattern is produced1

In myofascial trigger point pain is a main feature and it has two types these are active and latent trigger points.Active is with a spontaneous pain and latent is a sensitive spot that cause discomfort in response to compression1.

It is found that 1/5 of healthy individuals has trigger points in levator scapula without even being conscious of it.Its incidence is more in female than in male, which is associated with headache, stiffness, pain, restricted movements, etc.Levator scapula is also one of the most common trigger point found in the research studies.Myofascial pain syndrome is one among the common disorder in the world population. It seems to occur more with increasing age until mid life1.

Myofascial trigger points are caused due to chronic overload of the muscle which occurs with repetitive activities or that maintain the muscle in a shortened position, acute overload of muscle such as slipping and catching own self, picking up an object that has an unexpected weight, poorly conditioned muscles compared to muscles that are exercised on a regular basis, postural stresses such as sitting for prolonged periods of time, especially if the workstation is not ergonomically correct, and leg length differences and poor body mechanics with lifting and other activities4.
For treatment of myofascial trigger points different modes of treatment are available. These are manual therapy, spray and stretch, local anesthetics, thermotherapy, electrical therapy, ultrasound therapy and contract relax active and passive stretch techniques, dry needling or Injection, etc 4.

Ultrasound is an effective modality widely used for soft tissue injuries. When ultrasound waves travels through the tissue percentage of it is absorbed which leads to the generation of heat. The controlled heat can produce desirable effects like pain relief, decrease in joint stiffness and healing of broken dense soft tissues5.

Trigger point release technique is a soft tissue manipulation done to desensitize trigger points, improve circulation and thereby aid in pain reduction1.

6.1 NEED OF STUDY

For treatment of myofascial trigger points different modes of treatment are available, as already mentioned. These are manual therapy, spray and stretch, local anesthetics, thermotherapy, ultrasound therapy and contract relax active and passive stretch techniques, etc 4.

Ultrasound therapy and myofascial trigger point release are the two often used treatments. Ultrasound has proved to be effective in reducing pain in myofascial pain syndrome. Likewise, myofascial release technique is also an effective means of treating and reducing myofascial pain. An attempt is made in this study to analyse the combined effects of ultrasound with myofascial trigger point release techniques in reducing pain in MPS of levator scapulae.

This study is essential as most of the population suffer from this problem.The result of this study will help the physiotherapists to treat the myofascial pain of levator scapulaemore effectively12.

NULL HYPOTHESIS

H01-Myofascial trigger point release technique with ultrasound is not significantly effective in reducing myofascial pain of levator scapulae.

H02-Ultrasound therapy is not significantly effective in reducing myofascial pain of levator scapulae.

H03-There is no significant difference between Myofascial trigger point release technique with ultrasoundand ultra sound alone in reducing myofascial pain of levator scapulae

EXPERIMENTAL HYPOTHESIS:

H1-Myofascial trigger point release technique with ultrasound is significantly effective in reducing myofascial pain of levator scapulae.

H2-Ultrasound therapy is significantly effective in reducing myofascial pain of levator scapulae.

H3- There is a significant difference between Myofascial trigger point release technique with ultrasound and ultra sound alone in reducing myofascial pain of levator scapulae

6.2 REVIEW OF LITERATURE

DundarU., et al., (2010) did a study to investigate the effectiveness of ultrasound in cervical myofascial pain. This study was a Randomized control trial in which 55 volunteers are included in the study. They made 2 groups (27 and 28). All patients evaluated with NDI. They concluded that ultrasound therapy is effective in cervical pain trigger points5.

Aguilera F.J, Martin D.P., et al., (2010) in their case study used a female patient of 27 years old, effectiveness of ischemic compression for deliberate the blockage of blood in trigger point area to increase local blood flow. Their results show that application of ischemic compression is effective in presence of myofascial trigger point pain in neck11.

Aguilera FJ et al., (2009) did a study to determine the effect of ischemic compression and ultrasound on upperneck back muscle. This study was a Randomized control trial in which 66 volunteers diagnosed with latent Myofascial trigger points of levator scapulae and Trapezius and upper back neck muscles participated. The study concluded both treatmentsshowed immediate effect on pain reduction on latent myofascial trigger points6.

Serbely J.Z., et al., (2007) conducted a study to determine the therapeutic ultrasound modulates pain sensitivity of myofascial trigger points. This study was a Randomized control trial in which 44 subjects (22 males and 22 females) with trigger point in levator scapulae and neck muscles. This study concluded therapeutic exposure to ultrasound reduces short term trigger point sensitivity9.

Gemmell H. et al., (2007) did a study to determine immediate effect of ischemic compression, trigger point release technique and ultrasound on pain. This study was a Randomized control trial study in which 2 treatment groups with 15 subjects in each group participated. It concluded that ischemic compression is superior that sham ultrasound7.

Luke D. Rickards et al., (2006)in a systemic review of 23 randomized control trials on effectiveness of non invasive treatment for myofascial trigger point concluded in their results that there is significant evidence for short term effectiveness of laser therapy on pain intensity and immediate benefits of TENS but the evidence for effectiveness of frequency modulated electrical muscle stimulation, high voltage galvanic stimulation, interferential current is limited. The use of ultrasound also showed little or no effect. Evidence for physical and manual therapies is moderate; owing to heterogeneity in the chosen group in the study12.

Penas C.F. et al., (2006) did a pilot study to compare the effect of single treatment of ischemic compression with transverse friction massage for myofascial trigger point in neck pain. In their study they included 40 subjects (17 men and 23 women with age group 19-38 years). This study concluded ischemic compression technique and transverse massage technique were equally effective in reducing pain and tenderness of neck muscles10.

Hanten W.P.,et al., (2000) examined the effect of home program of ischemic compression pressure with 40 volunteers (23 female and 17 male) with active myofascial trigger points in neck and upper back. Subjects were randomly divided into 2 groups (1st group ischemic compression and 2nd group sustained stretch). The results showed that ischemic compression and sustained stretch release technique are effective at home program8.

6.3 OBJECTIVES OF THE STUDY:

1) To study the effect of trigger point release technique with ultrasound therapy onmyofascial pain of levator scapulae muscle.

2) To study theeffect ofultrasound alone in reducing myofascial pain of levator scapulae.

3) To compare the effect of trigger point release with ultra sound and ultrasound alone in reducing myofascial pain of levatorscapulae.

7. MATERIALS AND METHODOLOGY:

7.1 SOURCE OF DATA:

Alva’s outpatient Department, Moodbidri.

Alva’s outpatient Department, Karkala

7.2 METHOD OF COLLECTION OF DATA

research design –Thestudy is experimental in nature.( Comparative study)

Sample design – Simple random sampling

SAMPLE SIZE

Total sample – 30

Group A - 15 patient (experimental groupI)

Group B - 15 patients(experimental group II)

INCLUSION CRITERIA

Age: 20- 30 years.

Gender: male and female

Active and palpable MTrps on one side of the levator scapulae muscle.

Willingness to participate.

EXCLUSION CRITERIA

Less than 20 years,

Greater than 30 years,

Cervical disc degeneration involvement,

Neck or shoulder surgery within past year,

Clinical evidence of radiculopathy or myelopathy,

Fracture or dislocation of cervical vertebrae,

Cognitive deficits,

Tumors,

Open wounds – in cervical region,

Skin infection (dermatitis).

PROCEDURE:

A total of 30 subjects will be selected for the study from the population who fulfilled the selection criteria using simple random sampling and assigned intotwo equal groups - Experimental group I and Experimental group II randomly. Patient will be thoroughly explained about the purpose of the study, risk and benefits involved in the process to obtain informed consent.

Then patient will be evaluated for pain intensity using Visual Analogue Scale before the treatment(pretest score) and the treatment will be given for both the groups once a day for 7 days and post treatment scores will be collected at the end of seventh day. .

GROUP-I

TRIGGER POINT RELEASE TECHNIQUE WITH ULTRASOUND THERAPY

After thepre-test analysis of pain the experimental group-I willreceive trigger point release technique with ultra sound therapy once a day for a period of seven day

The trigger point will be localized using manual drag method

In Trigger point release technique

Ischemic compression
Unilateral stretching

After locating the trigger point, a firm digital compression will be applied with a single finger pad.The pressure given will be gentle at the beginning and then gradually progress deeper into tissues till it clocks approximately up to 4 kilograms of force. It will be performed very slowly to accommodate the patient's pain threshold level.

The Ischemic compression will be maintained for 5 second and released for 2-3 seconds. Small amount of talcum powder will be applied over the trigger point, before the procedure, in order to reduce the noxious skin friction. After this method subjects will be brought to the position of comfort, following which unilateral stretching of levator scapulae will be done.

After this trigger point release, the subjects will receive ultrasound therapy.Patient will be made to sit on a chair with shoulders in relaxed position. The area will be cleaned and Ultrasound therapy with a frequency of 1 MHZ will be given by direct contact method in a pulse mode 1:1 with an intensity of 0.25 - 0.75 w/cm2 for 8 minutes, duration once a day for a period of seven days.

The post-test measurement of pain will be collected at the end of seventh day.

GROUP-II

ULTRA SOUND THERAPYALONE
After the pre-treatment analysis of pain the experimental groupII patients will receiveUltrasound.

Patient will be made to sit on a chair with shouldersin relaxed position. The area will be cleaned and Ultrasound therapy with a frequency of 1 MHZ will be given by direct contact method in a pulse mode 1:1 with an intensity of 0.25 - 0.75 w/cm2 for 8 minutes, duration once a day for a period of seven days. The post-treatment measurement of pain will be collected at the end of the seventh day.

MATERIALS NEEDED FOR STUDY

Ultrasound therapy unit

Ultrasound Gel

Pencil, paper,recording sheets and other stationary items.

Visual Analogue Scale chart

Talcum powder

Chairs

STATISTICAL METHOD

The intra group comparison of myofascial pain will be analyzed using Paired ‘t’ test

The inter group comparison of myofascial pain will be analyzed using Independent‘t’ test

7.3 Does this study require investigations or interventions to be conducted on patients or other humans or animals?

Yes, the study requires intervention to be done on patients.

7.4 Does this study have ethical clearance?

Yes, permission is obtained from ethical committee of the college to carry out this study.

LIST OF REFERENCES:

McCain G.A., fibromyalgia and myofascial pain syndromes, Wall P.D,text book of pain, 3rd Ed., London, Churchill Livingstone, 1994, 475-494.
Chaitow L.et al.,Acupuncture treatment of fibromyalgia and myofascial pain, Baldry P., fibromyalgia syndrome, 2nd Ed, London Churchill Livingstone, 2005, 113-28.
Thomas M., et al., fibromyalgia pain Kenner R., pain management secrets, New Delhi, Jaypee brothers, 1998, 98-100.
Kisner C., et al.,Joint connective tissue and bone disorders and management,5th Ed, Philadelphia, FA Davis, 2007, 309-27.
Dundar U., et al.,Effectiveness of Ultrasound Therapy in Cervical Myofascial Pain Syndrome: A Double Blind, Placebo-Controlled Study, Turkish journal of Rheumatology, 2010, 13:110-115.
Aguilera F.J., et al., Changes in patient with neck pain after application of compression as trigger point therapy, Journal musculoskeletal rehabilitation 2010, 23(2):101-4.
Gemmell H. et al., Immediate of Ischemic compression trigger point pressure on neck pain upper trapezes trigger points : A randomized control trial , Clinical chiropractic an International journal ., 2008 march, 11:30-36.
Hanten W.P.,et al., Effectiveness of home program of schismatic pressure fallowed by sustained stretch for treatment of myofascial trigger point , Journal of physical therapy association 2000, 26 October, 80 no 10 :997-1003.
Serbely J.Z., et al., Randomized control trials of the antinociceptive effect ultrasound on trigger point sensitivity; novel application in myofascial therapy clinical rehabilitation 2007, May 21, 5:411-17.
Penas C.F. et., al., The immediate effect of Ischemic compression technique transverse friction massage on active and latent myofascial trigger point ; A pilot study , journal and body movement therapies 2006 January , 10; 3-9.
Aguilera F., Martin D.P.,et., al., Immediate effect of ultra sound and Ischemic compression techniques for the treatment of Trapezius latent myofascial trigger point in healthy subject : A randomized control trial study , Journal of manipulative and physiological therapeutics 2009 September :32(7):515-520.
Rickards L.D. The effectiveness non-invasive treatment for active myofascial trigger points: A systematic review of Literature; international journal of Orthopedic medicine, 2006,14 December ;9, 120-136

ANNEXURE – I

Consent of the Subject

I, ______hereby agree to provide my fullest consent and co- operation as a subject for the research work of GODASE AMBRUSHI TUKARAM entitled “A comparative study on the effectiveness of trigger point release technique with ultrasound therapy Versus ultrasound therapy alone in reducing myofascial pain of levator scapulae.”. The possible benefits and risk of the study as well as the procedure and duration of the study have been explained to me. The questions and queries I have posed have been answered to my satisfaction and I am aware that my identity will be kept confidential. I am also aware that I can discontinue the study at anytime if I wish to do so.

Date

Place

Signature of the subject

Signature of the Principal Investigator

Signature
Remarks of Guide
Name and Designation of Guide / Dr.A. Sam ThamburajM.P.T
Principal
Alva’s College of Physiotherapy.
Moodbidri, DK -574227
Signature of Guide
Name and designation of Co-Guide / NOT APPLICABLE
Signature of Co-Guide
Remarks of the Chairman and Principal
Signature of Principal