KARNATAKA, BANGALORE
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION1. / Name of the Candidate
And Address
(in block letters): / S. NISHAD
LAXMI MEMORIAL COLLEGE OF PHYSIOTHERAPY, AJ TOWERS, BALMATTA, MANGLORE
2. / Name of the Institute : / LAXMI MEMORIAL COLLEGE OF PHYSIOTHERAPY, MANGLORE
3. / Course of study and subject : / MASTER OF PHYSIOTHERAPY (MPT) (MUSCULOSKELETAL DISORDERS AND SPORTS)
4. / Date of Admission to Course : / 14-07-2012
5. / Title of the topic: / “A STUDY TO COMPARE THE EFFECT OF MYOFASCIAL TRIGGER POINT RELEASE AND MUSCLE ENERGY TECHNIQUE ON PAIN IN GASTROCNEMIUS MUSCLE IN SUBJECTS WITH CHRONIC DEGENERATIVE DISEASE OF KNEE JOINT”
6. / Brief Resume of the Intended Work:
NEED FOR THE STUDY
The knee complex is an important part of the human gait system performing a significant role in human motion. The knee complex consist of three major compartments namely the medial compartment, lateral compartment and the patella-femoral compartment.1
The knee joint is critical for walking and contributes to the movement of lower extremity . It is also an important weight bearing joint and has to hope with forces invoved in walking, running, bending, jumping, squatting and lifting objects. It also works in conjuction with the hip joint and ankle joint assisting in static and erect posture. So not only does the knee participate in the mobility of the knee joint but also provides stability. This makes it the most commonly injured joint in the body.1
A Majority of the elderly population who suffer from degenerative joint disease are more prone to develop myofascial pain, spasm and trigger points around the surrounding muscles of the affected joint . Muscles of most commonly affected are the calf muscles namely the Gastrocnemius.4
The gastrocnemius help to support knee during stance phase and also helps to decelerate tibial advancement during stance phase. When the triceps surae is weak, the tibialis posterior, peronei, and long toe flexors are ineffective hindfoot plantarflexors. This leads to inability to decelerate the tibia and therefore, flexion of the knee persist throughout stance phase. The patient may attempt to compensate with increased quadriceps activity during a larger portion of stance phase.2
Degenerative joint disease of the knee is a major cause for musculoskeletal problems leading to activity limitation. The incidence of degenerative joint disease in India as of 2006-2007 was recorded to be 56.6% in a community survey among elderly population greater than sixty years of age.3
Muscle energy technique (MET) is a non – invasive technique which can be used to lenghthen a shortened, contracted or spastic muscle; to strengthen a physiologically weakened muscle or group muscles ; to reduce localized edema to relieve passive congestion and to mobilize an articulation with restricted mobility.6
The term “Myo” means “ Relating to muscle” . Fascia is a sheet or band of fibrous connective tissue separating or binding together muscles and organs. It also forms tendons and ligaments. Myofascial release is a body work technique that focus on bodys fascia, a connective system that weaves through entire body. It is promoted to restore flexibility and relieve pain. Poor posture, injury, illness or stress can negatively affect the bodys alignment and cause fascia to become restricted. Myofascial release practitioner uses variety of technique including gross or “ Cross- hand” stretches, skin rolling , j-strecthes , fascial glide, pulls, trigger point release. Myofascial release consist of gentle form of stretching and manual compression to connective tissue and releasing bond between it and muscle. This is usually done by applying shear, compression, or tension in various direction or skin rolling.5
Therefore this study aims to find out which of the two techniques will be more effective in relieving pain in gastrocnemius muscle in patients with chronic degenerative disease of the knee.
HYPOTHESIS:
Null Hypothesis(H0):
There will be no significant difference between effectiveness of myofascial release and muscle energy technique on pain in gastrocnemius muscle in chronic degenerative disease of knee joint
Alternative Hypothesis (H1):
There will be significant difference between effectiveness of myofascial release and muscle energy technique on pain in gastrocnemius muscle in chronic degenerative disease of knee joint
6.1 REVIEW OF LITERATURE
William .c. sheil (2008) – The knee complex comprises of three major components altogether which plays an important role in our daily living activities such as walking, running , stair climbing, and squatting and other activities of daily living.7
Mahajan 2005- Degenerative joint disease is characterized by progressive erosion of articular cartilage and bone overgrowth at the joint margins. Cartilage integrity requires balance between synthesis and degradation of matrix components. Chondrocytes react to various mechanical and chemical stresses in order to stabilize and restore the tissue.8
Janet travel – A majority of the elderly population who suffer from Degenerative joint disease of knee joint are more prone to develop myofascial pain , spasm and trigger points around the surrounding muscles of the affected joints. Muscles most commonly affected are the calf muscles namely the Gastrocnemius.4
ITOCH - The gastrocnemius help to support knee during stance phase and also helps to decelerate tibial advancement during stance phase. When the triceps surae is weak, the tibialis posterior, peronei, and long toe flexors are ineffective hindfoot plantarflexors. This leads to inability to decelerate the tibia and therefore, flexion of the knee persist throughout stance phase. The patient may attempt to compensate with increased quadriceps activity during a larger portion of stance phase.2
Rene cailliet 1992- Degenerative joint disease of knee and hip is major cause of musculoskeletal pain , the single most relevant cause for impairment and activity limitation. Knee joint is common area for degenerative joint disease and subjects exhibit characteristic pattern of decrement in function.9
Rebecca marshall et al (2002) Evaluating the effectiveness of myofascial release to reduce pain in people with myofascial pain syndrome and the conclusion was myofascial release may help reduce the severity and intensity of muscle pain in people with myofascial pain syndrome.18
Smanitto 2006- Both the static stretching group and the myofascial group showed increases the flexibility of athletes range of mtion . Myofascial release is a very good tool to greatly increase range of motion , the same amount as static stretching as well as decrease pain and myofascial trigger points associated with chronic myofascial pain syndrome.13
Simons et al 1992 Some patients will find a trigger point muscle, particularly the trigger point are accessible site and a few will describe some sort of technique they have developed to relieve pain, which usually invoves the application of pressure to the trigger point.24
Reeves et al (1986) in terms of outcome measures the pressure algometre has been shown to be reliable in measuring trigger point sensitivity.15
Leon chaitow 1991 – Muscle energy technique are useful in the treatment of trigger points and achieving the restoration of hypomobile joints range of motion.6
Gill Webster 2001 – described the mechanism and physiology of muscle energy technique as being due to stretch receptors called Golgi tendon organs that are located in the agonist muscle. These receptors react to overstretching of the muscle inhibiting further muscle contraction . This is naturally protective reaction, preventing rupture and has a lengthening effect due to the sudden relaxation of the entire muscle under stretch. In more technical terms, a strong muscle contraction against equal counterforce triggers the Golgi tendon organ. The afferent nerve impulses from the Golgi tendon organs enters the dorsal root of the spinalcord and meets with an inhibitory motor neurone. This stops the discharge of the efferent motor neurone impulse and therefore prevents further contraction , the muscle tone decreases, which in turn results in the agonist relaxing and lengthening.11
Anna Maria Carlsson(2003) The visual analogue scale (VAS) is a simple and frequently used method for the assessment of variations in intensity of pain. In clinical practice the percentage of pain relief, assessed by VAS, is often considered as a measure of the efficacy of treatment. However, as illustrated in the present study, the validity of VAS estimates performed by patients with chronic pain may be unsatisfactory. Two types of VAS, an absolute and a comparative scale, were compared with respect to factors influencing the reliability and validity of pain estimates. As shown in this study the absolute type of VAS seems to be less sensitive to bias than the comparative one and is therefore preferable for general clinical use. Moreover, the patients appear to differ considerably in their ability to use the VAS reliably. When assessing efficacy of treatment attention should therefore be paid to several complementary indices of pain relief as well as to the individual's tendency to bias his estimates.17
Kinser AM -Algometers are devices that can be used to identify the pressure and/or force eliciting a pressure-pain threshold. It has been noted in pressure-pain threshold studies that the rate at which manual force is applied should be consistent to provide the greatest reliability. This study tested the reliability and construct validity of an algometer (1000-Hz sampling rate) by manually applying pressure on a force plate (500-Hz sampling rate).25
6.2 OBJECTIVES OF STUDY
1. To determine the effectiveness of myofascial release is reducing the pain in gastrocnemius pain chronic degenerative disease of knee joint
2. To determine the effectiveness of Muscle energy technique in reducing the pain in gastrocnemius pain in chronic degenerative disease of knee joint.
3. To compare the effectiveness of myofascial release and Muscle energy technique in reducing the pain in gastrocnemius pain in chronic degenerative disease of knee joint
/
MATERIALS AND METHODS:
This study is conducted among subjects with degenerative joint disease of knee who attending the AJIMS Outpatient department and LMCP OSut patient department , A.J tower out patient department, Manglore.STUDY DESIGN: Comparative study
7.1 SOURCE OF DATA:
The sample for this study is drawn from subjects with degenerative joint disease of knee who are referred for physiotherapy to the out-patient department of AJIMS and LMCP , A.J tower .Mangalore.
SAMPLE SIZE :40 Subjects will be randomly selected and included for this study comprising of both male and female subjects in the age group of 40-60 years.
7.2 METHOD OF COLLECTION OF DATA
SAMPLING TECHNIQUE:
Simple randomized sampling technique
INCLUSION CRITERIA:
· Patients with degenerative joint disease of knee
· Patients with symptomatic pain in the gastronomies muscle
· Both gender of age groups 40-60years.
EXCLUSION CRITERIA:
· Old fractures of hip or knee
· Infective diseases of the knee
· Cardio- pulmonary problem
· Neurological problems
· Previous knee surgeries
· Patellar dislocations
MATERIALS AND TOOLS REQUIRED:
1. Vas scale
2. Syringe algometre
TECHNIQUE OF APPLICATION:
Patients fulfilling the above criteria were selected for participating in this study. Patients will be fully explained about the procedure and an informed.
Consent was obtained from subject participating in this study.
Patients in the first group were treated with the Myofascial trigger point release techniques and the second group of Patients with muscle energy techniques.
Common physiotherapy treatments was given to both group , ie Inteferential therapy, Short Wave Diathermy, Wax Therapy, TENS.etc. Home Exercise program was given to both groups and reviews were taken at each visit.
A total of 40 patients will be taken for this study, the first group consist of 20 patients, The second group in this study 20 patients.
Before giving intervention technique each of the patients will be asked to first score their pain level on the visual analogue scale. Then a syringe algometre will be used to quantify their level of pain in the gastrocnemius .The subjects in both group asked to come daily for 1 week.
The follow up were done for both group before and after giving the treatment.
Palpation of Gastronomies Muscle (Janet Travel 1992):
The Patients foot is Plantar flexed and muscle is contracted. The Gastronomies is examined by pincer palpation if subcutaneous tissues are sufficiently slack and adipose layer is not too thick. The patient lies either recumbent or kneeling on a chair seat.
In recumbent position, the patient lies on the side that place the Gastrocnemiuss head in uppermost position.
Lateral head is smaller and usually easier to grasp for pincer palpation. The thumb is inserted between its medial border and fibula with the finger in the midline groove between the bellies of the Gastronomies.
Patient foot placed in more neutral position or slight plantar flexion to slacken the muscle partially.
Muscle Energy Technique (Leon Chaitow 1996):
Patient lies supine with feet extending over the edge of the table. The therapist’s left hand cradles the Achilles tendon just above the heel avoiding pressure on the tendon. The heel lies in the palm of the hand, fingers curving around it. The therapist’s hand is placed so that fingers rest on dorsum of foot with thumb on sole lying on medial margin.
Starting from restriction barrier, ask patient to plantar flex not more than 20 deg against unyielding resistance with appropriate breathing. This effort isometric ally contracts gastrocnemius. Hold for 7-10 seconds.
On slow release, on exhalation the foot/ankle is dorsiflexed slightly and painlessly beyond new barrier with patient assistance. Pattern is repeated until no further gain is achieved (backing off to mid range for next contraction) if chronic.
Myofascial Release Technique (Lucy Whyte Ferguson 2006)
The patient lies prone with the knee extended. Trigger point release is performed on the gastrocnemiuso trigger while rocking the ankle into greater and lesser dorsiflexion thus stretching the taut bands of muscle.
In supine position, patient’s foot is placed on therapist chest or abdomen and dorsiflexed to a varying degree to stretch the call muscles while trigger point compression applied.
Tools:
Syringe Algometer:-
The pressure algometer probe tip is usually held stationary and pressure is steadily increased from zero until a pressure pain threshold (PPT) is elicited. In order to explore the extent of surface markings of abnormally tender regions in more detail an improved method is proposed whereby the pressure algometer is not kept still. It is slid over the tissues at a predetermined downward pressure and velocity to produce compressive, tensile and shear stress within underlying tissues. It is moved over surrounding non-tender regions until it reaches the surface overlying an abnormally tender region where a PPT is evoked. The probe is removed immediately and the skin marked. When this is repeated from different directions, the boundary of the surface markings of a tender region will appear in corresponding detail. Provided that this ‘sliding pressure algometer’ produces sufficiently similar amounts of stress when applied on separate occasions, it can be used to monitor the progress of a condition or the effects of treatment. To reduce cost and increase availability, this pressure algometer may be made of a plastic syringe converted into a gas-tight chamber. Dr Alexander John