DISSERTATION SYNOPSIS

SUBMITTED TO

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE

TOWARD PARTIAL FULFILMENT OF

MASTER OF PHYSIOTHERAPY DEGREE COURSE

BY

JYOTI S DEVADIGA

UNDER THE GUIDANCE OF

V S SARAVANAN

VIKAS COLLEGE OF PHYSIOTHERAPY

MARYHILL, AIRPORT ROAD,

KONCHADY, MANGALORE-575008

2009

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE

REGISTRATION OF SUBJECTS FOR DISSERTATION

1. / Name of the candidate and address /

JYOTI S DEVADIGA ,

VIKAS COLLEGE OPHYSIOTHERAPY,
MARYHILL, AIRPORT ROAD,
KONCHADY,
MANGALORE-575008
2. / Name of the Institution / VIKAS COLLEGE OF PHYSIOTHERAPY.
MANGALORE
3. / Course of study and subject / Master of physiotherapy
Physiotherapy in Musculoskeletal Disorders and Sports physiotherapy
4. / Date of admission to Course / 05-04-2010
5. /

Title of the Topic

A COMPARATIVE STUDY BETWEEN THE EFFECT OF TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION AND THE EFFECT OF TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION ALONG WITH MYOFASCIAL RELEASE TECHNIQUE ON TRIGGER POINTS IN TRAPEZITIS

6.
7
8 / Brief resume of intended work
6.1 Need for the study
Myofascial pain syndrome is a common clinical problem of muscle pain caused by trigger
Point , It is a muscle stress syndrome characterized by presence of trigger points in
Muscles . 1,2,3 The problem these syndrome pose lies not in making diagnosis rather it is to
identify the Underlying cause of chronic muscle pain in order to develop specific treatment
plan 1 In myofascial trigger point the soft tissue becomes restricted due to strenuous use of
particular muscle, sustained repeated contraction of the muscle like lifting heavy weight,
keeping the effected muscle shortened for a longer period of time , nutritional deficiency ,
anaemia , hyperurecaemia3
Myofascial pain syndrome is more prevalent in women than in men , patients complain of
Persistant pain ranging in intensity & most frequently found in head neck extremities &
Lowback ,the trapezius muscle is probably the most often beset by myofascioal trigger
Point.4
Management in myofascial pain focuses on releieving pain and correction of the shortened
Muscle by stretching & improving the joint range of motion . 5
Transcutaneous electrical nerve stimulation (TENS) appears to have an immediate effect
in decreasing pain intensity in myofascial trigger point of upper back and neck,high
intensity tens is effective in reducing myofacial Pain . 6,7,8 Literature on effectiveness of
TENS reports wide range of outcome TENS provides initial relief of treatment in 70-80%
Of patients , High frequrency may benefit myofascial pain , currently there is insufficient
Evidence from well-designed control trials to support this use ,.9,10 hence there is a need of
Further study .
Myofascial release technique utilizes the stretching of fascia & muscle to help increase
In range of motion & decrease pain by breaking adhesions in the fascia. 11,12,13,14
Many authors have conducted the individual studies regarding effect of TENS and effect of
Myofascial release technique in management of trapezitis but not many have amalgamated
The effect of TENS and myofascial release technique in management of trapezitis . Due to
The above factors further studies are necessary to evaluvate the most effective and safest
Treatment for the management of trapezitis.
6.2  Review of literature.
1.  Graff Radford SB ReevesJL , Baker RL, conducted study on effect TENS on myofascial trigger points and concluded that high intensity is effective in reducing myofascial pain and these pain reduction does not reflect changes in local trigger point sensitivity .
2.  Kruger LR van der linden WJ cleaton jones pt conducted study on effect of TENS & conservative therapy on myofascial pain dysfunction a single blind trial session was conducted & concluded that TENS did not increase the symptom .
3.  Hou CR, Tsai LC , Cheng kf ,Hong CZ conducted studies on the effect of various therapeutic modalities on myofascial pain in upper trapezius and concluded that hot pack & active ROM along with tens & MFR are most effective in easing myofascial trigger point pain & increasing the cervical range of motion.
4.  Andrew & Fischer conducted studies on the validity & reproduceability of pressure algometer and conclude that it is useful in quantification of deep muscle tenderness , trigger poin , fibrositis , myalgic spots & assessment of sensitivity to pain can be diagnosed by pressure threshold meter (PMT)
5.  John LReeves , Bernadette Jaeger & Steven B Graff Radford conducted study on reliability of pressure algometer in measurement of myofascial trigger point sensitivity which showed high reliability between &within the experimenters when measuring trigger point location .
6.  Tousignant M conducted study on validity of goniometer in cervical range of motion , correlation test was used to evaluvate the criterion validity of goinometer and concluded that it is valid in measurement of cervical flexion &extension
7.  Tousignant M conducted study onervical range of motion device for lateral flexion in patients with neck pain comparision study was done with radiography and concluded that cervical range of motion device showed very good validity for measurement of lateral flexion in population of neck pain.
8.  Phero JC conducted study on effect of TENS &myoneural injection therapy for management of myofascial pain and concluded that TENS therapy is a safe & non invasive technique in treating myofascial pain
9.  Gary Fryer Laura Hodgson conducted study on effect of manual pressure realease technique on trigger point using novel pressure algometer by recording pressure pain threshold and concluded that manual pressure release may be effective in upper trapezius trigger point
10.  Hug Gemmell DC , & Axell Hilland conducted study on immediate effect of tens in treating latent upper trapezius trigger point . a double blind randomized placebo controlled trial was conducted &further concluded that it helps in reduction of pain in treating upper trapezius trigger point.
11.  Fusun Ardic, Merin Sarhes ,oyatopus conducted study effect of TENS &EMS on myofascial trigger points patients were divided in 3 groups , group I was treated with TENS & trapezius stretching exercise , group ii was treated with EMS & trapezius stretching exercise &group iii with trapezius stretching exercise pain intensity with vas ROM &pressure threshold were assessed before &immediately after 2 weeks of treatment ther was significant reduction in vas , increase in ROM & pressure threshold at the end of treatment when compared with control group hence concluded that TENS was more effective immediately after the treatment.
6.3  Objective of the study
The objective of the study is to investigate, in a randomized, prospective study the effect of TENS versus the effect of TENS along with Myofascial Relaese Technique , in patients with trapezitis , on pain reduction and increase incervical joint range of motion.
Specifically, to determine
1.  The effect of TENS on pain reduction and improvement of cervical joint range of motion in trapezitis .
2.  The effect of Myofascial Release Technique on pain reduction and improvement in cervical joint range of motion in trapezitis.

Materials and methods

7.1 Source of data
Data will be collected from patients, who are referred to the outpatient physiotherapy department of Vikas College of Physiotherapy, Mangalore, with diagnosis of trapezitis , after obtaining informed consent.
7.2 Method of collection of data
Hypothesis
1 Null hypothesis (Ho)
There is no significant difference between the effects of TENS and the effect of TENS along with Myofascial Release Technique on patients with trapezitis .
2 Alternative hypothesis (H1)
There is significant difference between the effects of TENS and the effect of TENS along with Myofascial Release Technique on patients with trapezitis.
Research Design
Single factor experimental design will be used for the study.

Sampling method

Random sampling method
Methodology
30 Patients who are diagnosed to have trapezitis will be randomly assigned to one of the two groups. Each group will consist of 15 patients of both genders, Group I will be administered TENS and Group II will be administered TENS and Myofascial Release Technique . Both the groups will be administered the treatment for 6 sessions a week for 2 weeks. In both the groups the TENS will be administred for 20-30mins having frequency of 40-50hz pulse duration of upto50 microsecond at low intensity just above the threshold .
In Group II Myofascial Release technique will be administered with knuckles or forearm with pressure of few kilograms the stretch is provided for atleast 3-5 mins
7.3Inclusion Criteria:
1.  patients with trapezius muscle spasm .
2.  patients willing to partcipate in the study
Exclusion Criteria:
1.  Patients with torticollis
2.  Patients with referd pain to the neck .
3.  Patients who have fever
4.  patients with infective condition around the neck
5.  patients not willing to participate

7.4 Interventions

Group 1:
This will consist of 15 patients of both genders and they will be administred with TENS
amplitude of current at a comfortable low intensity just above the threshold for duration of 20-
30 mins with pulse duration of 50 microsecond & frequency of 40-50 hz
Group 2:
This will consist of 15 patients of both genders and they will beadministred with TENS amplitude of current at a comfortable low intensity just above the threshold for duration of 20-30 mins with pulse duration of 50 microsecond & frequency of 40-50 hz
Later they are administrated myofascial release technique ie slpwly stretch the fascia until reaching barrier restriction , maintain light pressure to stretch the barrier for approximately 3-5 minutes and than release.
Outcome measures:
Before the beginning of the rehabilitation protocol and after 2 weeks of treatment,
All the patients will be evaluated in the following outcome measures.
1.  Pain : 10cm Visual Analogue Scale
2.  Range Of Motion : Goniometer
7.5 The study requires non-invasive investigations and interventions to be conducted on patients. The investigations to be conducted include physical examination of cervical spine inspection, palpation, joint range of motion with the help of goniometer, special tests, etc.
Interventions in the treatment that are used for this study are TENS & Myofascial Release Technique
7.6 Ethical clearance has been obtained from the ethical committee of our institution to carry out the investigations and interventions on patients necessary for this study.

List of references

1.  Gerwin RD ; Review of myofascial pain & fybromyalgia – Factors that promote their persistence
2.  Chang Zern Hon MD – Myofascial trigger point
3.  Travell &Simon’s text on Myofascial pain & dysfunction
4.  Roswer Park cancer institute &state of university of new york at buffalo , school of medicine & biomedical sciences
5.  Fleckenstein J ,Zaps D, Ruger LJ et al Discripecy between perceived effectiveness of treatment method in myofascial pain syndrome
6.  Luke D Rickards International journal of osteopathic Medicine March 2007
7.  Journal of body work and movement therapy
8.  Valdimir Kay , MD :- TENS e-medicine
9.  Johnson MI, Ashton CH, Thompson JW, in depth study of lon term users of TENS Implication for clinical use of TENS.pain mar1991
10.  Cheing GL, Hui-Chan CW, TENS non parallel anti nociceptive effects on chronic clinical pain &acute experimental pain. Archphys Med Rehabil.March1999,80
11.  Steven B , Graff Radford , Department of anaesthology , pain management centre UCLA school of medicine, Los Angeles.
12.  American congress of Rehabilitation medicine and American academy of physical medicine and rehabilitation
13.  John F Barnes 1990, Myofascial release , The search of excellence 10th edition
14.  Robert I Cantu, Alan J ,Grodin 2001 Myofascial manipulation Theory &clinical application 2nd ed .Aspen publisher
15.  Digiovanna, Eillen ,Stanley Schiowitz Dennis J Dowling 2005 An Osteopathic approach to diagnosis &treatment (third edition )
16.  Starkey Chad Myofascial release Therapeutic Modaliti ed3 2004
17.  Digovanna ;barnes & Cantu Robert I Gordin Alan 2001 Myofascial manipulation , Theory & clinical application
18.  South African hounal of surgery
19.  J. Ortho Sports Phy Ther 2006 April
20.  www. Pubmed .com
21.  Angela Forster , Nigel Palastaanga Clayton’s Electrotherapy ninth edition 20010
22.  John Low ,Ann Reed , Mary Dyson ; Electrotherapy Explained Principles and practice
23.  Janet –G Travell , David G Simons Myofascial dysfunction . The triegger point manual , The Upper extremity volume -1 williams & wilkins publisher
Signature of the candidate
Remarks of the Guide
Name and designation of
11.1  Guide : V S SARAVANAN M.P.T.
11.2  Signature :
11.3  Co-guide :
11.4  Signature :
11.5  Head of Department : S. NATARAJAN M.P.T.
11.6  Signature :
12.1  Remarks of the chairman and principal
12.2 Signature :