effectiveness of muscle energy tecnhique and deep transverse friction massage in the treatment of...

I

EFFECTIVENESS OF MUSCLE ENERGY TECHNIQUE

AND DEEP TRANSVERSE FRICTION MASSAGE IN

THE TREATMENT OF LATERAL EPICONDYLITIS A

COMPARATIVE STUDY

Submitted By

RENJU.V.GOPAL

Dissertation Submitted to the Rajiv Gandhi University of Health Sciences,

Karnataka, Bangalore in partial fulfillment of the requirements for the degree of

MASTER OF PHYSIOTHERAPY IN

MUSCULOSKELETAL DISORDERS AND SPORTS PHYSIOTHERAPY

Under the guidance of

Dr.HARISH.S.KRISHNA

ASSISSTANT PROFESSOR

LAXMI MEMORIAL COLLEGE OF PHYSIOTHERAPY

MANGALORE

2008-2010

II

EFFECTIVENESS OF MUSCLE ENERGY TECHNIQUE

AND DEEP TRANSVERSE FRICTION MASSAGE IN

THE TREATMENT OF LATERAL EPICONDYLITIS A

COMPARATIVE STUDY

Submitted By

RENJU.V.GOPAL

Dissertation Submitted to the Rajiv Gandhi University of Health Sciences,

Karnataka, Bangalore in partial fulfillment of the requirements for the degree of

MASTER OF PHYSIOTHERAPY IN

MUSCULOSKELETAL DISORDERS AND SPORTS PHYSIOTHERAPY

Under the guidance of

Dr. HARISH.S.KRISHNA

ASSISTANT PROFESSOR

LAXMI MEMORIAL COLLEGE OF PHYSIOTHERAPY

MANGALORE

2008-2010

III

DECLARATION BY THE CANDIDATE

I hereby declare that the dissertation titled as EFFECTIVENESS OF

MUSCLE ENERGY TECHNIQUE AND DEEP TRANSVERSE FRICTION

MASSAGE IN THE TREATMENT OF LATERAL EPICONDYLITIS A

COMPARATIVE STUDY is a bonafide and a genuine research work carried out

by me under the guidance of Dr. HARISH.S.KRISHNA.

Date: Signature of the candidate:

Place: Mangalore RENJU.V.GOPAL

Rajiv Gandhi University of Health Sciences, Karnataka

IV

CERTIFICATE BY THE GUIDE

This is to certify that this dissertation entitled EFFECTIVENESS OF

MUSCLE ENERGY TECHNIQUE AND DEEP TRANSVERSE FRICTION


COMPARATIVE STUDY was completed under my supervision. I am satisfied

with the work presented with the work presented by the candidate towards the partial

fulfillment of Masters of Physiotherapy in Musculoskeletal disorders and Sports

Physiotherapy.

Date: Dr. HARISH.S.KRISHNA.

Assistant professor

Place: Mangalore Laxmi Memorial College of

Physiotherapy, Mangalore

V

ENDORSEMENT BY THE PRINCIPAL/ HEAD OF THE

INSTITUTION

This is to certify that this dissertation entitled EFFECTIVENESS OF

MUSCLE ENERGY TECHNIQUE AND DEEP TRNSVERSE FRICTION


COMPARATIVE STUDY is a bonafide and a genuine research work carried out

by RENJU.V.GOPAL under the guidance of Dr. HARISH.S.KRISHNA.

Date: Dr. S.ARUL DHANARAJ

Place: Mangalore Principal & Professor

Laxmi Memorial College of

Physiotherapy, Mangalore

VI

COPYRIGHT

DECLARATION BY THE CANDIDATE

I hereby declare that RAJIV GANDHI UNIVERSITY OF HEALTH

SCIENCES, KARNATAKA, shall have all the rights to preserve, use and

disseminate the dissertation/ theses in print or electronic format for academic/

research purpose.

Date: Signature of the candidate:


Rajiv Gandhi University of Health Sciences, Karnataka

VII

ACKNOWLEDGEMENT

First and foremost I would like to thank God almighty, for his divine grace and

blessing throughout my studies.

I owe to my loving parents my father Mr. N.VENUGOPAL, my mother Mrs. SUDHA

VENUGOPAL and who have made me what I am today with their blessings care

and motivation. I would like to consider special thanks to my sister Mrs. RESMI and

my brother Mr. RAHUL and my dear friend Ms. Sudha for her timely helps, caring

and understanding.

I wish to state my special thanks and credit to my respectable guide and teacher,

Dr.HARISH.S.KRISHNA for his valuable help and guidance, constant

encouragement and keen interest shown in this study and without whom this work

would not have been possible.

I wish to convey my heartfelt thanks to my teacher and principal Dr. S. ARUL

DHANARAJ, Professor and Principal of L.M.CP., Mangalore for his valuable help

and guidance.

I also wish to extend my sincere thanks to my co guide and assistant professor Dr.

Y.V.KALYAN, for always being accessible with his constant help and support

throughout this study.

I would like to express special thanks to Dr. MAGESH GAJAPATHY for his

help and guidance.

VIII

I express my thanks to all the staff members in Laxmi Memorial College of

Physiotherapy for their help and valuable suggestions.

I extend my sincere thanks to Mrs. Sucharita for helping me in statistical analysis.

I wish to express my thanks to Mrs. Neena our computer lecturer & library staff for

their timely help in lending me books and journals for my reference all the time.

My sincere thanks to all the contributors, my friends saber, sweety, sanish, dijish

and my classmates sudha, roshan, jignesh, rashiq, harshith, gaurav and divya.

they all deserve my gratitude.

Last but not the least I would like to thank all the subjects on my study without whom

this task would not have been possible. I thank all who have helped me all the while.

Date: Signature


IX

LIST OF ABBREVIATIONS USED

1. ECRB : Extensor carpi radialis brevis

2. ECRL : Extensor carpi radialis longus

3. MET : Muscle energy technique

4. DTFM : Deep transverse friction massage

5. VAS : Visual analogue scale

6. ANOVA : Analysis Of Variance

7. EFA : Elbow function assessment

8. NS : Not Significant

9. AER : Active External Rotation

10. PER : Passive External Rotation

11. US : Ultrasound

12. M : Male

13. F : Female

14. SS : Statistical significance

15. ADL : Activity daily living

16. Rx : Treatment

X

ABSTRACT

BACKGROUND: Lateral epicondylitis (tennis elbow), one of the common lesion of

the arm is characterized by pain and tenderness in the lateral aspect of the elbow, with

incidence affecting men and women equally. The aim of the study is to assess the

effectiveness of muscle energy technique and deep transverse friction massage in the

treatment of lateral epicondylitis.

METHOD: 30 subjects who were diagnosed by an orthopaedician as lateral

epicondylitis and it is divided into two groups each of 15 subjects. Group A: (n=15):-

Treated with Muscle energy technique with ultrasound. Group B: (n=15):- Treated

with deep transverse friction massage with ultrasound. Patient received treatment for

10 days. The patients pain was assessed by VAS and functional performance was

measured with EFA. Data was collected before treatment (baseline), after 10 sessions,

and follow up done after 3 weeks.

OUTCOME MEASURE AND ITS MEASUREMENT:

The following outcome measures were measured at baseline, After 10 days and After

3 weeks follow up.

1. VAS

2. Elbow function assessment (EFA).

The baseline measurements were compared to data at the end of 10 days and After 3

weeks follow up.

XI

STATISTICAL ANALYSIS:-

One way ANOVA and post hoc analysis (bonferroni test) was used to compare the

outcomes within the group.

Unpaired t test was used to compare VAS and EFA between group A and group B.

RESULTS:

VADS scores of patients in Group A was 6.27 + 1.03, 2.40 + 0.63 and 0.40 + 0.63 at

day 0, day 10 and after 3 weeks. The VAS scores of patients in group B was 5.87

1.12, 3.20 0.56, 3.40 1.95 at day 0, day 10 and after 3 weeks. The EFA scores of

group A was 63.93 + 10.49, 82.27+ 10.21 and 89.97 + 7.20 at day 0, day 10 and after

3 weeks. The EFA scores of patients in group B was 71.80 10.10, 78.20 8.41,

78.47 9.92 respectively.

CONCLUSION:

The MET technique was found to be effective than DTFM for treatment of lateral

epicondylitis as MET caused increased blood circulation to the part, active muscle

contraction and passive stretching causing increased flexibility of the structures. In

contrast DTFM, only scar tissue was broken down which was followed by increased

circulation and therefore neither muscle contraction was facilitated nor flexibility

increased. Hence alternate hypothesis was proved.

.

KEY WORDS: Lateral epicondylitis, US, MET, DTFM, VAS, EFA.

XII

TABLE OF CONTENTS

S.No. Topic Page No.

01. Introduction 1 5

02. Objectives and Hypothesis 6 7

03. Review of Literature 8 14

04. Methodology 15 24

05. Results 25 28

06. Discussion 29 32

07. Conclusion 33

08. Summary 34

09. Bibliography 35 41

10. Annexure 42 59

XIII

LIST OF TABLES

S. No. Topic

Page No.

01.& 02 Age distribution

50

03.

Gender distribution

52

04.

Side distribution 53

05.

Comparison of Visual Analogue Scale (VAS) scores within Group A and Group B.

54

06.

Pair wise comparison of Visual Analogue Scale (VAS) scores Within Group A and within Group B (post hoc analysis-Bonferroni test).

55

07.

Comparison of Elbow Functional Assessment (EFA) scores within Group A and within Group B.

56

08.

Pair wise comparisons of Elbow Functional Assessment (EFA) scores within Group A and within Group B (post hoc Analysis Bonferroni test)

57

XIV

LIST OF FIGURES AND GRAPHS

FIGURES

S. No

Topic

Page No

01 Tools used for the study 20

02 Ultrasound Therapy Method 21

03 Muscle Energy Technique (neutral Position) 22

04 Muscle Energy Technique Method 23

05 Deep Transverse Friction Method 24

GRAPHS

S. No. Topic Page No.

01 Age distribution 51

02 Gender distribution 52

03 Side distribution 53

04 Comparison of Visual Analogue Scale(VAS) scores within Group A and within Group B

54

05 Comparison of Elbow Functional Assessment (EFA)within Group A and within Group B

55

1

INTRODUCTION

Lateral condylitis or tennis elbow was 1 st described by Runge 1873. It is characterized

by pain and tenderness in the lateral aspect of elbow joint. Daily activities such as

shaking hands raising a cup , using a hammer , lifting a showel , dressing and desk or

house work typify the particular movement which initiates the pain. 1

The condition is common in 30 years of age or older with incidence affecting men and

women equally. Dominant arm is commonly affected with a prevalence of 1-3 % in

general population, but this increases to 19% in 30 to 60 of age group.2

Tennis elbow is an over use stress syndrome. The term chronic tennis elbow means

symptoms which are persisting for more than 3 months. Repetitive over use injury of

wrist extensor muscles, prolonged strain on the forearm muscles, direct injury to the

elbow cause pain.3

Tennis elbow patients has pain of sudden or gradual onset , is localized to outer aspects

of elbow, which sometimes travel along the back of the fore arm and may go as far as the

wrist or back of the hand. It may severe enough to go to external aspect if arm up to the

shoulder but its less common, sometimes there is constant ache which gets worse at night

and disturbing the sleep.4

The lesion involving the specialized junctional tissue at the origin of the common

extensor muscle at the lateral epicondyle is proposed as the cause.. Histological studies

have shown that the extensor carpi radialis brevis tendon rather than the lateral

epicondyle is the primary site of pathology.4, 5

2

Extensor carpi radialis brevis has the proximal attachment to lateral collateral ligament

and often to the annular ligament in addition to lateral epicondyle of the humerus . The

Extensor carpi radialis brevis is stretched over the radial head when the elbow is extended

and fully pronated . The Extensor carpi radialis longus and brachioradialis attach above

the lateral epicondyle rather than the common extensor tendon insertion and are less

commonly involved. Extensor digitorum is also largely affected and supinator produces a

moderate increase n the tensile force in common extensor tendon.6, 7

But in the chronic case it is not the lesion causing pain it is due to the formation of a

painful scar which results from repitive injury. The ECRB along with ECRL and EDC

appears to undergo change termed angiofibroblastic hyperplasia because of wrist extensor

overuse rather than inflammation. Inflammatory cells are rarely found in chronic cases.

Instead with repetitive use, microtears and scarring occurs in wrist extensors.5

Local treatments of tennis elbow are numerous like cryotherapy , Ionotophoresis ,

phonotophoresis, electrical stimulation , TENS, fore arm support band , transverse

friction massage stretching, strengthening manipulation are common technique used to

treat tennis elbow. But superiority of any one technique has not been proven. Traditional

modalities such as ice, ultrasound, ionotophoresis and massage have shown mixed result.8

Therapeutic ultrasound is commonly used electrophysical agent many musculoskeletal

conditions, ultrasound is mechanical vibrations which are essentially the same as sound

waves but of higher frequency. ultrasound has the potential to accelerate normal

resolution of inflammation provided the inflammatory stimulus has been provided the

inflammatory stimulus has been removed many studies show benefits of the use of

3

ultrasound in soft tissue and sport injuries , ultrasound therapy is effective in treating

patients with pain and promoting soft tissue healing .2

Pulsed ultrasound is an electrotherapeutic modality that has been used to decrease pain

and increase the rate of healing in many condition example soft tissue injuries,

musculoskeletal pain, arthritic conditions etc.9

With pulsed ultrasound, a less localized warming of the tissue may occur that can lead to

an increase in the extensibility of ligaments, tendons and scar tissue. These effects may

contribute to the reported analgesic action of pulsed ultrasound.10

In a study conducted by binder et al on the effectiveness of ultrasound in the treatment

of lateral epicondylitis , placebo produced improvement in 29 % of patients treated while

ultrasound was effective in 63% of patients treated.11

Though studies show that ultrasound causes some improvement from the base line, the

results are best when used with other modalities or manipulation.

Deep transverse friction massage is also one of the therapeutic approaches for treating

lateral epicondylitis. , massage using friction technique has been used for many years.

The most famous exponent of friction massage was James cyriax, this technique is

principally designed to affect connective tissue of tendon, ligaments and muscles. Deep

transverse friction massage provides therapeutic movement over a small area and one of

the potential advantages of it over other form of massage is that it allows pressure to

applied to greater depth in the tissue.12

4

Deep tansverse friction leads to immediate pain relief - the patient experiences a numbing

effect during the friction and reassessment immediately after the session shows reduction

in pain and increase in strength and mobility. The time to produce analgesia during the

application of transverse friction is a few minutes and the post-massage analgesic effect

may last more than 24 hours.13

DTFM has been claimed to be helpful, as it mobilizes the soft tissue , release and stretch

the tissue which is impaired causing pain and dysfunction.

DTFM produces local vasodilation and also mobilizes the structures in the area. It is an

effective means of treating conditions like tendonitis etc. According to cyriax DTFM

causes traumatic hyperemia which results in increased blood flow and decreases pain. It

also increases tissue perfusion and stimulates mechanoreceptors.12

MET is essentially a mobilization technique using muscular facilitation and and

inhibition. it is effective for musculosketal disorders. Abnormal shortening or lengthening

of muscles occurs in response to injury and pain. MET restores the muscle range and

normality. 14

The majority of MET are isometric but some are isotonic. The physiological principles

upon which MET technique rest are post isometric relaxation and reciprocal inhibition. 14

According to Sherrington s law of reciprocal innervations, contraction of an agonist

muscle reflex inhibits antagonist. The gamma motor neuron discharge to the facilitated

muscle can be reduced by a specific contraction of its antagonist. The stronger the

contraction of antagonist, greater the relaxation of agonist.14

5

The principles of autogenic inhibition may also be employed with MET. Contraction of

the facilitated muscle from the lengthened position generates sufficient tension to activate

golgi tendon endings in the tendon. This reflex inhibits both the gamma and alpha motor

neuron this results in the lengthening of the muscle upon relaxation accurately localized ,

low intensity, isometric contraction of agonist and antagonist segmental muscles are the

most effective for restoring mobility.14

Studies have been done to prove the effectiveness of MET technique for the treatment of

lateral epicondylitis. But no comparative studies with manual therapy technique have

been done in order to prove the superiority of the technique. Hence this study is intended

to compare the effectiveness of DTFM and MET along with ultrasound

6

OBJECTIVES OF THE STUDY

1. To study the effectiveness of Muscle Energy Technique in the treatment of lateral

epicondylitis.

2. To study the effectiveness of Deep Transverse Friction Massage in the treatment of

lateral epicondylitis.

3. To compare the effectiveness of Muscle Energy Tecgnique and Deep Transverse

Friction Massage in the treatment of lateral epicondylitis.

7

HYPOTHESIS

Null Hypothesis (H0):

There will be no significant difference between the effectiveness of MET with ultrasound

and DTFM with ultrasound in the treatment of lateral epicondylitis.

Alternate Hypothesis (H1):

There will be a significant difference between the effectiveness of MET with ultrasound

and DTFM with ultrasound in the treatment of lateral epicondylitis.

8

REVIEW OF LITERATURE

Lateral epicondylitis also known as Tennis Elbow is a common soft tissue condition

frequently associated with overuse injury of the elbow.15, 16 The primary etiological factor

is believed to be a force overload at the aponeurosis of the common extensor origin.16,17,18

Lateral epicondylitis is characterized by an insidious onset of elbow pain that radiates

distally into the forearm, and is brought about by wrist extension with pronation or

supination and is aggravated by gripping.19 The result can be extremely incapacitating

and resistant to treatment.20,21

Allander 22 (1974) reported an annual incidence of 1% to 10% for lateral epicondylitis in

a survey of 15,000. Although accounting for less than 5% of all lateral epicondylitis

clients, 21 tennis players, as a group, exhibit a 40% to 50% chance of having lateral

epicondylitis at some point in time.23, 24

In tennis, pain at the elbow usually results from the backhand stroke. Repetitive backhand

strokes can produce recurrent microtraumatic injury to the forearm extensor musculature

at its lateral epicondylar origin.

A prevalent feature of the syndrome is the production of pain during extension of the

wrist and radial deviation. This movement is performed by the extensor carpi radialis

longus and brevis.25 Decreased muscular performance in lateral epicondylitis have been

proposed to be due to both elbow pain and physical damage to the extensor carpi radialis

brevis muscle.26 Extensor carpi radialis longus and brevis have been implicated in the

dysfunction associated with lateral epicondylitis in EMG studies.27

9

Histological study has shown that extensor carpi radialis brevis tendon rather than the

lateral epicondyle is the primary site of pathology.28 It is due to an overuse syndrome,

which causes microtrauma that results in collagen degeneration and adhesion formation

in extensor carpi radialis longus, extensor carpi radialis brevis and extensor digitorum.29

The most common complaints of individuals with lateral epicondylitis are pain and

decreased grip strength, both of which may affect activities of daily living.21, 30 Pain has

been defined as an unpleasant sensory and emotional experience associated with actual or

potential tissue damage.31 Pain has been classifically reported as the main feature of this

condition.32

Conservative treatment, including cold application, rest, control of inflammation and

reduction of force demands on the muscles, has been the treatment of choice for

individuals with lateral epicondylitis.33, 34, 35

Muscle energy technique (MET) was developed by Fred Mitchell Sr (Mitchell, 1967). IT

targets the soft tissue primarily, although it also makes a major contribution towards joint

mobilization. It is also described as active muscular relaxation technique (Liebenson,

1989, 1990). More recent refinements were derived from the work of people such as

Karel Lewit (Lewit, 1986a) and Veladmir Janda (Janda 1989). The current interest in

MET method crosses all political and therapeutic barriers.36

Experiments demonstrate that drastic changes may be made in the body, soley by

stretching, separating and relaxing superficial fascia in an appropriative manner.37

10

Benny Vaughan (2005) states that application of MET actively assisted engagement of

the muscle while pressure is applied and compression broadening can produce outcomes

of significant results.38

The efficiency of MET in the treatment of severe pain in the muscle and or its insertion

like myofacial pain lateral epicondyle of arm involving supinator, wrist and finger

extensors and or biceps brachii.

MET is particularly effective in patients who have a severe pain from acute somatic

dysfunction or with an injury or a patient with severe spasm.

In this method the patient uses his or her muscle, on request, from a precise controlled

position in a specific direction against an executed counterforce (Mitchell et al, 1979).

MET which involves passive and Active stretching of shortened and often fibrous

structures, contractured or spastic muscle, to strength a physiologically weakened muscle

or a group of muscle, to reduce localized oedema, to relieve passive congestion, and to

mobilize an articulation with restricted mobility.36 It is also effective in patients who have

severe pain from acute somatic dysfunction, such as, a patient with severe muscle spasm

from a fall. (Sandra yale.In:Digiovanna,1991).37

The general consequences are that the use of post isometric relaxation (PIR) is more

useful than Reciprocal inhibition (RI) in normalizing hypertonic musculature. In this

study we utilized PIR type of MET by Karel Lewit (1986 a).The term refers to the effect

of the subsequent relaxation experienced by a muscle or a group of muscle after brief

periods during which an isometric contraction is performed. PIR is achieved by the effect

of a sustained contraction on the golgi tendon organ, since the response to such a

11

contraction seems to be to set the tendon and the muscle to a new length by inhibiting it

(Moritan et al, 1987). Lewit and Simons (1984) agreed that, PIR is a phenomenon

resulting from a neurological loop involving golgi tendon organs.36

Recent study, the procedure of Post-Isometric Relaxation (PIR) the therapist takes the

agonist muscle to its barrier of tension and holds the position; the therapist provides equal

resistance to the client contracting the agonist muscle with about 20% of their strength,

for 7-10 seconds and repeated for 5 times.39

Greenman summarizes the requirements for the use of MET as controlled, balance and

localization. His suggested basic elements include the following.

1. A patient / active muscle contraction.

2. This commences from a controlled position.

3. The contraction is in a specific direction (towards or away from a restricted

barrier).

4. The operator applies distinct counterforce. (to meet, not meet, or to overcome the

patients force).

5. The degree of effort is controlled (sufficient to obtain an effect but not great

enough to induce trauma, or difficulty in controlling the effort.

The usefulness of MET is seen in normalizing abnormal neuromuscular relationship,

improve local circulation and respiratory function and/or normalize restricted /hypertonic

muscles and fascia, mobilize restricted joints.36

12

Post-isometric relaxation techniques such as MET and PNF produce greater changes in

range of motion and muscle extensibility than static or ballistic stretching, immediately

following treatment.40

Lewitt and Simons (1984) found an immediate relief of pain and tenderness after

treatment with post-isometric relaxation technique in subjects with musculoskeletal

dysfunction.41

Soft tissue massage (Deep transverse friction massage) is also one of the therapeutic

approaches for treating lateral epicondylitis. Massage using friction technique has been

used for many years. Deep transverse friction massage (DTFM) is a technique

popularized by Dr. James Cyrix (Cyriax 1975 a, Cyriax 1975 b) for pain and

inflammation relief in musculoskeletal conditions. DTFM is a technique that attempts to

reduce abnormal fibrous adhesions and makes scar tissue more mobile in sub-acute and

chronic inflammatory conditions by realigning the normal soft tissue fibers. According to

him, deep transverse friction causes traumatic hyperemia, which results in increased

blood flow and decrease in pain. It also increases tissue perfusion and stimulates

mechanoreceptors.42

Deep transverse friction massage (DTFM) has been claimed to be helpful in

rehabilitation of tennis elbow via mobilization of soft tissue and possibly release or

stretch any scar tissue impairing normal movement.43

DTFM is stated to be effective for tendinitis as it mechanically induces hyperemia and

thus influence tissue maturation. DTFM realigns collagen fibers to the direction of

tensile force, mobilize scar tissue and produce a temporary pressure paresthesia, as a

13

result there is relative hyperemia at the scar thus acting As a local analgesic. It allows

pressure to be applied to greater that in muscle and it has been advocated in treatment of

muscle strain, tendinitis ligamentatous injuries. Davidson and et al. used light

microscopy and electron microscope and proved that DTFM causes fibroblastic

proliferation and realignment of collagen fibres.42,44,45,46,47

Gibbon and Cohan (1998) added a concept of visco elastic property in the therapeutic

effect of soft tissue massage. Deep transverse friction massage improves visco-elastic

property of muscle and in turn improves function and reduces pain.48

The standard treatment for lateral epicondylitis is therapeutic ultrasound. Ultrasound is a

form of acoustic vibration. Normal frequencies for therapeutic machines are 1MHZ or 3

MHZ.49 Mary Dyson50 (1987) states that treatment with ultrasound can induce

physiological changes which increases the rate of tissue repair after injury and also

reduce pain.

Kliman M D et al (1988)studied that effect of ultrasound therapy in 49 subjects with soft

tissue injuries including tendinitis, epicondylitis, and tenosynovitis. And they concluded

that ultrasound results in decrease in pain and increased pressure tolerance in the soft

tissue injuries.51

Recent study done by Robertson V J (2000) stated that there is little evidence of clinical

effectiveness of therapeutic ultrasound to treat people with pain and musculoskeletal

injuries to promote soft tissue healing.52

14

Young 53 (1996) suggests that non thermal effect may be preferable for tissue repair and

stimulation of blood flow, therefore pulsed ultrasound was selected as a treatment

modality for this study.

Revill et al (1976) has found VAS to be reliable as a measurement of pain intensity.54 A

simple VAS may be sufficient to provide information regarding progressive decrease in

pain.

Sim and Waterfield (1997) argued that continuous scale of pain intensity like VAS is

potentially more sensitive to small degrees of change in intensity.55

Craig Libenson (1996) Huskinsonin 1974 devised the VAS with numerical marks in a

100mm scale.

Sullivan, Susan B O (2001) VAS have been designed as pre-test and post-test outcome

measures.56

Elbow Evaluation Scale is a reliable scale which provides objective data and grading as

well as functional information, hence provides an objective mean of comparing different

treatment options.57

15

METHODOLOGY.

Study design: Experimental study.

Sources of data: A total of 30 patients are taken from A.J.HOSPITAL AND

RESEARCH CENTRE , Kuntikana , Mangalore , OPD of Laxmi memorial college of

physiotherapy, Balmatta, Mangalore and other hospitals in Mangalore. All subjects were

diagnosed as lateral epicondylitis and refered for physiotherapy. Patients were selected

for the study after scrutinizing for inclusion and exclusion criteria. The purpose of the

study was explained to all the subjects and informed consent was taken from each

subject. All the subjects were assessed using a specific Performa. All subjects were

randomly assigned to either Muscle energy techinique (Group A) or Deep Transverse

Friction Massage (Group B). The study was approved by ethical committee of Laxmi

memorial college of physiotherapy, Mangalore.

INCLUSION CRITERIA

1. Age group 30 60 years of both sex.

2. VAS < 7.

3. Positive Mills test and cozens test.

4. Local tenderness on palpation over lateral epicondyle of the humerus.

5. From sub acute to chronic more than 2 months.

16

EXCLUSION CRITERIA

1. Any previous trauma, fracture around elbow, dislocation, bony abnormalities of

elbow.

2. Any other neurological abnormalities.

3. Corticosteroid injection in the preceding 3 months

4. Any other associated systemic illness like metabolic, metastatic, infective

disorders etc.

TOOLS USED FOR THE STUDY:

1. Therapeutic Ultrasound: The device consist of a power source , high frequency

generator and a transducer head The frequency wave was of 1MHZ..

2. Visual Analogue Scale (VAS): The pain VAS is used to evaluate a persons

subjective experience of pain severity. It has well established reliability and

validity in many patient populations and is considered the most sensitive of all

pain ratings scales. The VAS used in this study was a 10 cm line placed

horizontally with the end points marked 0-10. The end points were labelled with

descriptive terms 0 representing no pain and 10 worst pain.

3. Elbow Functional Scale: The patients were assessed using the elbow functional

scale. The scale had categories for identifying the range in which pain is

maximum, the strength in each movement of the elbow, and assessed the ease

with which functional activities were performed. Finally the therapist indicated

how the patients response had improved remained the same or worsened.

4. Ultrasonic gel: As a couplant, for conducting ultrasound waves.

17

5. Cotton.

METHOD OF COLLECTION OF DATA

PROCEDURE:

The patients were evaluated using Elbow Functional scale and VAS. The patients were

informed about the whole procedure, the treatment merits and demerits and a return

consent were obtained from them for voluntary participation in the study. They were

randomly divided in to Group A and Group B of 15 subjects each. The patient were

assessed on elbow functional scale and VAS before the commencement of treatment.

This constituted the base line data. The patient were again assessed after 10 treatment

sessions. The follow-up were taken after 3 weeks.

The total number of subjects participated in the study were 30. These subjects were then

divided randomly into 2 groups, Group A and Group B.

Group A:

Fifteen subjects received Muscle Energy Technique. The method adopted was Lewitts

post-isometric relaxation. During the treatment session the patient were seated in a

considerable height. The forearm extensors were stretched to a pain free limit by keeping

the wrist in flexion, gradually the elbow was extended and forearm was pronated. Mild

isometric contractions of common extensors were performed against resistance. The

patient was asked to use 20% of the strength. The length of the time effort was held upto

10 seconds and were repeated for 5 times with rest for 10 seconds between contractions.

18

Group B:

Fifteen subjects received Deep Transverse Friction Massage. During this

treatment session the patient were seated with elbow well relaxed. The therapist holded

the patients elbow in 900 flexion. DTFM was given to the common extensor tendon at the

point of its origination (lateral epicondyle) with tip of index finger reinforced by the

middle finger. Maximum duration of treatment was 10 minutes.

Both group received therapeutic Ultrasound with intensity ranging from 0.8-2W/cm2 for

4-8 minutes. The patient was seated with the affected limb resting on a couch with the

shoulder in abduction and extension, elbow in 900 flexion. The therapist stands near the

patient applying ultrasound therapy over the painful area in small concentric circles.

Either of the treatment was continuously given for 10 sessions.

OUTCOME MEASURES

The outcome measures are VAS and Elbow Functional Assessment scale. The baseline

measurements are compared to the data at the end of 10 sessions and after 3 weeks.

DATA ANALYSIS

Within Group Analysis: Comparison of VAS and EFA scores at Baseline, 10th day and

after 3 weeks were done separately using one-way ANOVA within Group A and within

Group B. Statistical significance was tested based on p-value (0.05 level). Following one-

way ANOVA Multiple comparison of VAS and EFA scores were done between Baseline

10th day, Baseline after 3 weeks and 10th day after 3 weeks using Bonferroni test

19

(post hoc analysis) and paired student t test within Group A and within Group B.

Statistical significance was tested based on p-value (0.05).

Between Group Analysis: Comparison of VAS and EFA scores at Baseline, 10th day

and after 3 weeks were done separately using unpaired student t test between Group A

and Group B. Statistical significance was tested based on p-value (0.05 level).

20

Figure 1: TOOLS USED FOR THE STUDY.

21

Figure:2 ULTRASOUND THERAPY METHOD:

22

Figure 3: MUSCLE ENERGY TECHNIQUE ( NEUTRAL POSITION)

23

Figure 4: MUSCLE ENERGY TECHNIQUE METHOD:

24

Figure 5: DEEP TRANSVERSE FRICTION MASSAGE METHOD:

25

RESULTS

Table 1and 2:-The age distribution between the groups receiving MET &

Therapeutic Ultrasound (Group A) and Deep Transverse Friction Massage &

Therapeutic Ultrasound (Group B). [Refer Graph 1]

Table 1 shows that in group A there were 7( 46.7%) and in group B 7(46.7%) so total

14(46.7%) individuals were present between the age group of 30 39 years. In group A

there were 5(33.3%) and in group B 7(46.7%) so total 12(40.0%) individuals were

present between the age of 40 49 years. In group A 3(20.0%) and in group B 1(6.7%),

so total 4(13.3%) individuals were present in between the age group of 50 59 years.

Total 30(100%) individuals were taken in this study and were randomly divided into 2

groups of 15 individuals namely group A and group B.

Table 2 shows that mean age with standard deviation of group A was 41.73 8.319 and

the mean age with standard deviation of group B was 40.20 6.19. So there is no

significant difference between the age distribution of group A and group B. ( P = 0.513 ).

Table 3:- The gender distribution between Group A and Group B: [ Refer Graph 2]

Table 3 shows that the female count in group A were7 (46.7 %) and that of the group B

were 6(40.0%), so total 13(43.3%) female individuals were present in this study. The

male count in group A was 8 (53.3%) and that of group B was 9 (60.0%), so total male

count was 17 (56.7%). so overall count of male and female subject in this study was

about 30 (100%).

26

Table 4: - The side distribution between Group A and Group B. [Refer Graph 3]

Table 4 shows that right affected in group A was 8 (53.3%) and that of group B were 6

(40.0%), so total 14 (46.7%) right side affected individuals were present in the study. The

left side affected in group A were 7 (46.7%) and that of group B were 9 (60.0%), so total

16 (53.3%) left side affected individuals were present in the study. So overall count of

right and left side affected individuals in this study was about 30 (100%).

Table 5: - Comparison of VISUAL ANALOGUE SCALE (VAS) scores within

Group A and within Group B. [Refer Graph 4]

The sample size for Group A was taken 15 (N=15). The mean and standard deviation of

Group A for VAS scores at Day 0, Day 10 and After 3 weeks were 6.27 + 1.03, 2.40 +

0.63 and 0.40 + 0.63 respectively. Similarly in group B the sample size was taken 15( N

= 15), mean and standard deviation for VAS scores at Day 0, Day 10 and After 3 weeks

were 5.87 1.12, 3.20 0.56, 3.40 1.95. ANOVA for repeated measures shows that

there is significant decrease in VAS scores from Day 0 to After 3 weeks in both the

groups. [F (2, 56) = 171.9, P < 0.01].

Table 6:- Pair wise comparison of VISUAL ANALOGUE SCALE (VAS) scores

across different periods within Group A and within Group B using post hoc

analysis- Bonferroni test.

The sample size for Group A was taken as 15 (N =15).I, the mean difference of VAS

between Day 0- Day 10, Day 0- After 3 weeks, Day 10- After 3 weeks, were 3.86, 5.86,

2.00, respectively. Standard errors for Day 0- Day 10, Day 0- After 3 weeks, Day 10-

27

After 3 weeks, were 0.27, 0.25and 0.16. The P value between Day 0- Day 10, Day 0-

After 3 weeks, Day 10- After 3 weeks, was 0.00, 0.00, and 0.00 which is highly

significant (P < 0.01). The sample size for Group B was taken as 15 (N =15)., The mean

difference of VAS between Day 0- Day 10, Day 0- After 3 weeks, Day 10- After 3

weeks, were 2.66, 2.46, 0.200. Standard error for Day 0- Day 10, Day 0- After 3 weeks,

Day 10- After 3 weeks, were 0.28, 0.44, and 0.47. The P value between Day 0- Day 10,

Day 0- After 3 weeks, Day 10- After 3 weeks, were 0.00, 0.00 and 0.01 which is highly

significant (P < 0.01). So, multiple comparison shows that difference is highly significant

from Day 0 to Day 10 and Day 10 to After 3 weeks, but the difference from Day 0 to Day

1o and Day 10 to After 3 weeks is significantly higher in group A than group B as [

F(2,56) = 26.58, P < 0.01].

Table 7: - Comparison of ELBOW FUNCTIONAL ASSESSMENT (EFA) scores

within Group A and within Group B. [Refer Graph 5]

The sample size for Group A was taken 15 (N=15). The mean and standard deviation of

Group A for EFA scores at Day 0, Day 10 and After 3 weeks were 63.93 + 10.49, 82.27+

10.21 and 89.97 + 7.20 respectively. Similarly in group B the sample size was taken 15(

N = 15), mean and standard deviation for EFA scores at Day 0, Day 10 and After 3 weeks

were 71.80 10.10, 78.20 8.41, 78.47 9.92. ANOVA for repeated measures shows

that there is significant decrease in EFA scores from Day 0 to After 3 weeks in both the

groups.[ F(2,56)= 121.5.12, P < 0.01].

28

Table 8:- Pair wise comparison of ELBOW FUNCTIONAL ASSESSMENT (EFA)

scores across different periods within Group A and within Group B using post hoc

analysis- Bonferroni test.

The sample size for Group A was taken as 15 (N =15).I, the mean difference of EFA

between Day 0- Day 10, Day 0- After 3 weeks, Day 10- After 3 weeks, were -18.33, -

25.93, -7.60, respectively. Standard errors for Day 0- Day 10, Day 0- After 3 weeks, Day

10- After 3 weeks, were 2.00, 2.01, and 1.37. The P value between Day 0- Day 10, Day

0- After 3 weeks, Day 10- After 3 weeks, was 0.00, which is highly significant (P <

0.01). The sample size for Group B was taken as 15 (N =15)., The mean difference of

EFA between Day 0- Day 10, Day 0- After 3 weeks, Day 15- After 3 weeks, were -6.40,

-6.66,-0.267 . Standard error for Day 0- Day 10, Day 0- After 3 weeks, Day 10- After 3

weeks, was 1.009, 1.43, and 1.10. The P value between Day 0- Day 10, Day 0- After 3

weeks, Day 10- After 3 weeks, was 0.00, 0.001, 1.00 which is highly significant (P <

0.01). So, multiple comparison shows that difference is highly significant from Day 0 to

Day 10 and day 10 to After 3 weeks, but the difference from Day 0 to Day 10 and Day 10

to After 3 weeks is significantly higher in group A than group B as [ F(2,56) = 39.72, P <

0.01].

29

DISCUSSION

30 patients participated in the study after scrutinizing for inclusion and exclusion criteria

patients were randomly divided into group A receiving MET with US and group B

receiving DTFM with US. Patients were in the age group of 35-59. There was no

significant difference between the age distribution of group A and group B, and also

gender seem to have no significant effect on treatment and the results. This was similar to

the studies done by Hamilton58 and Kivi59 which stated that there was no significant

difference in incidence, prevalence and effect of treatment between genders. The

dominant hand was more affected than the non dominant hand which was similar to the

studies done by Hamilton58, Kivi59 and Paugmali60.However no significant difference was

found between sides.

The lateral epicondylitis is initiated by microscopic tears at the common tendon of the

wrist extensors muscles due to chronic overuse. ECRB was found to be primarily affected

and was characterized by dense population of fibroblast, disorganized immature collagen

scar affects normal gliding of muscle fibers and hence active muscle contraction causes

pain.61

As ECRB, ECRL involved any activity which is performed with wrist extension causes a

pain. The activities such as carrying a weight, driving or house hold activities causes

more pain.62

This study was intended to compare the effectiveness of MET and DTFM. When results

were compared MET was found to be more effective, DTFM was also found to have a

30

significant effect only up to end of 10 days of treatment, but no significant effect was

found after 10 treatment sessions to follow up.

Though ultrasound was found to reduce pain and increase rate of healing it was found to

be effective as sole treatment approach. Hence therapeutic ultrasound was given to both

the group of patient in order to reduce pain or inflammatory response after treatment.9

There was affective reduction in pain and ease with which ADL was performed increased

significantly after treatment session with MET and US, even significant difference was

found when follow up was done after 3 weeks. This may be due to, as MET is active

muscular relaxation method, normal blood circulation is restored which wipes out

nocioceptive stimulants from the site of pain which may be reason for significant relief of

pain.14

When post isometric relaxation technique is used, only few fibers are activated and other

fibers are inhibited. As a result of active contraction the fibroblast are broken and are

replaced by superior material. Active contraction is followed by a period of relaxation

during which a passive and non painful stretch is applied and structures are taken to a

new limit, which is said to increase flexibility of the structures. Pain reduction is more

due to the fact that MET address the pathology rather than direct reduction in pain.14

DTFM was also found to have effect on the condition at least up to 10 treatment sessions,

this may be due to the fact, when DTFM is applied fibrous adhesions and scar tissues

were broken down which is followed increase in blood supply to the part and wash out of

exudates.30

31

However the effect with DTFM was found to be limited this may be due to the fact that

when MET was used a generalized effect was obtained as a result of increased blood

circulation, active muscle contraction, passive stretch increasing the flexibility of

structures and muscle strengthening. In contrast in DTFM only the scar tissue was broken

down which was followed by increased circulation and therefore neither muscle

contraction was facilitated nor was flexibility increased.63

As a result Elbow function assessment scores was significantly increased in patients were

MET technique was used. The activities such as use of back pocket, rise from chair, self

care was found to have more improvement wit few sessions of treatment. However pain

during activities such as carrying 10-15 pounds with arm at side and other activities such

as pulling reduced only after 9-10 treatment sessions. However with DTFM, it required

more than 7 sessions for the patients to perform self care activities without pain and there

was only minimum reduction in pain for activities such as carrying 10-15 pounds with

arm at side and pulling.

The EFA scores was significantly increased during follow up session in MET patient and

in patients with DTFM though the patient did not return to baseline value there was mild

increase in pain or remained same as in the end of 10 sessions. But however EFA scores

of patients in group B remained same or even slightly increased this may be due to the

components of EFA scale.

In view of the results obtained, MET is more effective than DTFM. So MET should be

the sole treatment approach in the management of lateral epicondylitis.

32

Limitations:

1. The pain for group B after 10 sessions has increased slightly which is statistically

not significant as well as according to EFA scale elbow functions were better. The

reason for this discrepancy may be due to high subjective reflection of pain which

is measured using VAS or due to inflexibility of EFA scale.

2. Since LE is reported to be a self limiting disorder, in some cases it is not possible

to determine if this self limiting factor led to the improvement of pain levels and

ability to work instead of work administrated.

3. The ultrasound machine was not checked for its accuracy before the treatment.

33

CONCLUSION

The MET technique was found to be effective than DTFM for treatment of

lateral epicondylitis as MET caused increased blood circulation to the part, active muscle





34

SUMMARY

The purpose of this study was to compare the efficacy of MET and DTFM in the

treatment of lateral epicondylitis.30 subjects clinically diagnosed as lateral epicondylitis

were taken after scrutinizing for inclusion and exclusion criteria and were randomly

divided into group A receiving MET with US and group B receiving DTFM with US.

Both the groups received treatment for 10 days. The patients were assessed for pain on

VAS, and function on EFA. The data were taken before commencement of treatment,

after 10 treatment sessions and after 3 weeks.

The above collected data was statistically analyzed using one way ANOVA and post hoc

analysis and unpaired t test was used to compare VAS and EFA scores between group

A and group B. P value was kept at 0.05 for SS.

The MET technique was found to be effective than DTFM for treatment of lateral

epicondylitis as MET caused increased blood circulation to the part, active muscle





\

35

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42

ANNEXURE I

CONSENT FORM

I,______________________________________________________________________

voluntarily declare to participate in the research study EFFECTIVENESS OF

MUSCLE ENERGY TECHNIQUE AND DEEP TRNSVERSE FRICTION

MASSAGE IN THE TREATMENT OF LATERAL EPICONDYLITIS The

researcher has explained me about the study, risks and benefits of participation and has

answered all my questions and queries regarding the study to my satisfaction.

Signature of participant: ____________________________.

Signature of the witness: ____________________________.

Signature of the researcher: __________________________.

Subject is fit/unfit for the study: _______________________.

Guide: _____________________ Co-guide:___________________

Date: ___________________________

43

ANNEXURE II

EVALUATION OF THE PATIENT

PERSONAL DATA

Name :

Age :

Sex :

Date of assessment :

Height :

Weight :

Occupation :

Address :

CHIEF COMPLAINTS:

PAIN SCALE: 0 10

PRESENT HISTORY:

1. Date of onset of symptoms:

2. Onset:

3. Aggravating factor:

4. Relieving factor:

5. Associated symptoms, if any:

6. Tingling:

7. Current medication:

8. Any other complaints:

44

PAST HISTORY:

1. Head/Neck injury:

2. Fractures:

3. Elbow surgery:

4. Any medical history:

ON OBSERVATION: Swelling

Skin colour

Deformity

Posture

ON PALPATION: Tenderness

Temperature

Swelling

Site

PAIN EVALUATION:

Site of pain:

Duration:

Type of pain:

Onset of pain:

Special Tests

Mills Test Resisted middle finger extension Cozens test

45

Provisional Diagnosis:

INVESTIGATION:-

Radiography

Special investigations

Diagnosis:-

Assigned to group:

Treatment administered

Recording chart

PERIODS IN WEEKS

Outcome

measures

Baseline 10th day Follow up

VAS

EFA

46

ANNEXURE III

ELBOW EVALUATION:

Name:

Procedure:

Date:

Elbow: R/L

Dominant: R/L

DATE OF EXAM // // // // //

PAIN ( MAXIMUM POINTS):

5= none (30)

4= slight with continous activity, no

medication (25)

3= moderate with occasional activity, some

medications (15)

2= moderately severe much pain, frequent

medication (10)

1= severe constant pain, markedly limited

activity (5)

0= complete disability (0)

MOTION:

Flexion (17 Points Max.)

Extension (8 Points Max)

Pronation

Supination

47

STRENGTH ( 15 points max.):

5= normal

4= good

3= fair

2= poor

1=trace

0= paralysis

NA= not applicable

MOTION:

Flexion

Extension

Supination

Pronation

INSTABILITY ( 6 points max.):

A/P M/L

None 3 3

Mild 10mm, >100 0 0

FUNCTION ( 12 points max.) 4= normal (1)

3= mild compromise (.75)

2= difficulty (.5)

1= with aid (.25)

0= unable (0)

Na= not applicable

( index-multiply .25)

48

1. Use back pocket

2. Rise from chair

3. Perineal care

4. Wash opposite axilla

5. Eat with utensil

6. Comb hair

7. Carry 10 to 15 pounds with arm at side

8. Dress

9. Pulling

10. Throwing

11. Do usual work , specify work:

12. Do usual sport, specify the sport

PATIENT RESPONSE: 3= much better

2=better

1= same

0= worse

NA= not applicable

COMPLETED B: NAME OF EXAMINER

INDEX: KEY:

95-100= excellent

80-95= good

50 -80= fair

49

ANNEXURE IV

VISUAL ANALOGUE SCALE

0 10

No Pain Max Pain

The Visual Analogue Scale is said to be the best pencil and paper method of assessing

the intensity of clinical pain. It consist of a 10 cm line bounded with verbal descriptors as

no pain at one end and maximum pain at the other end.

50

ANNEXURE V

TABLES

Table 1 & 2: Age Distribution.

GROUPS

AGE

Group A Group B

TOTAL

30-39 7 (46.7%) 7 (46.7%) 14 (46.7%)

40 49 5 (33.3%) 7 (46.7%) 12 (40.0%)

50-59 3 (20.0%) 1 (6.7%) 4 (13.3%)

TOTAL 15 (100%) 15 (100%) 30 (100%)

GROUP MEAN STD.DEVIATION

Group A 41.73 8.319

Group B 40.20 6.190

51

Graph 1: Age Distribution.

52

Table 3: Gender Distribution.

Group A Group B

Total

Sex

N

%

N

%

N

%

Male

8

53.3

9

60.0

17

56.7

Female

7

46.7

6

40.0

13

43.3

Total

15

100

15

100

30

100

Graph 2: Gender Distribution.

53

Table 4: Comparison of AFFECTED SIDES scores within Group A and Group B.

GROUPS

Side

Group A Group B

TOTAL

Right 8 (53.3%) 6 (40.0%) 14 (46.7%)

Left 7 (46.7%) 9 (60.0%) 16 (53.3%)

TOTAL 15 (100%) 15 (100%) 30 (100%)

Graph 3: Comparison of AFFECTED SIDES scores within Group A and Group B

54

Table 5: - Comparison of VISUAL ANALOGUE SCALE (VAS) scores within Group A and within Group B.

Variables

Periods N

Mean

Standard Deviation

Group A 15 6.27 1.033

Group B 15 5.87 1.125

VAS Base line

Total 30 6.07 1.081

Group A 15 2.40 0.632

Group B 15 3.20 0.561

VAS 10th day

Total 30 2.80 0.714

Group A 15 0.40 0.632

Group B 15 3.40 1.957

VAS follow up

Total 30 1.90 2.090

Effect due to duration (day 0 follow up): F (2, 56) = 171.9, p < 0.01, HS

Effects due to Groups on VAS: F (2, 56) = 26.58, p < 0.01, HS.

Graph 4: - Comparison of VISUAL ANALOGUE SCALE (VAS) scores within Group A and within Group B.

55

Table 6: Pair wise comparison of VISUAL ANALOGUE SCALE (VAS)

scores across different periods within Group A and Group B using post

hoc analysis- Bonferroni test.

VAS Period Periods Mean

Std.

Error

p-value Level of significance

10th day 3.867 0.274 .000 HS at p < 0.01 Baseline

Follow up

5.867 0.256 .000 HS at p < 0.01

Group A

10th day Follow up

2.000 0.169 .000 HS at P < 0.01

10th day 2.667 0.287 .000 HS at p < 0.01 Baseline

Follow up

2.467 0.446 .000 HS at p < 0.01

Group B

10th day

Follow up

-.200 0.470 1.000 NS

56

Table 7: - Comparison of ELBOW FUNCTIONAL ASSESSMENT ( EFA) scores within Group A and within Group B.

Variables Periods N

Mean

Standard Deviation

Group A 15 63.93 10.491

Group B 15 71.80 10.108

EFA Base line

Total 30 67.87 10.884

Group A 15 82.27 10.215

Group B 15 78.20 8.419

EFA 10th day

Total 30 80.23 9.427

Group A 15 89.87 7.200

Group B 15 78.47 9.927

EFA follow up

Total 30 84.17 10.306

Effect due to duration (day 0 follow up): F (2, 56) = 121.5, p < 0.01, HS

Effects due to Groups on EFA: F (2, 56) = 39.72, p < 0.01, HS.

Graph 5: - Comparison of ELBOW FUNCTIONAL ASSESSMENT ( EFA) scores within Group A and within Group B.

57

Table 8: Pair wise comparison of ELBOW FUNCTIONAL ASSESSMENT (EFA) scores across different periods within Group A and within Group B using post hoc analysis- Bonferroni test.

EFA Period Periods Mean

Std.

Error

p-value Level of significance

10th day -18.333 2.009 .000 HS at p < 0.01 Baseline

Follow up

-25.933 2.015 .000 HS at p < 0.01

Group A

10th day Follow up

-7.600 1.379 .000 HS at P < 0.01

10th day -6.400 1.009 .000 HS at p < 0.01 Baseline

Follow up

-6.667 1.430 .001 HS at p < 0.01

Group B

10th day

Follow up

-0.267 1.106 1.000 NS

58

ANNEXURE VI

Master Chart 1

VAS EFA

Sr.No. Group Age Gender Side

BaselineAfter10 Follow Baseline

After10 Follow

session up session up 1 1 40 1 1 7 3 1 80 87 92 2 1 49 1 1 7 2 1 76 97 98 3 1 38 2 1 6 2 0 61 82 85 4 1 51 2 2 6 3 1 56 75 80 5 1 42 2 2 4 1 0 63 74 90 6 1 33 2 2 5 3 0 75 96 98 7 1 38 1 1 7 2 1 59 70 82 8 1 32 1 1 8 3 2 47 63 79 9 1 59 2 2 7 2 1 50 80 91 10 1 54 1 1 6 2 0 73 96 98 11 1 36 1 1 7 3 1 80 87 99 12 1 45 1 2 6 3 0 56 79 93 13 1 42 1 2 6 2 0 59 92 95 14 1 33 2 2 7 2 1 61 82 88 15 1 34 2 1 5 3 1 63 74 80

KEY

Group A MET

Gender 1 Male, Gender 2- Female

Side 1- Right, 2- Left.

59

Master Chart 2

VAS EFA Sr.No. Group Age Gender Side

Baseline After10 Follow Baseline After10 Follow session up session up

1 2 53 2 2 6 4 3 73 82 872 2 52 1 2 7 4 6 76 88 783 2 45 1 1 6 4 5 79 83 804 2 54 1 2 4 3 4 84 86 855 2 33 2 1 6 3 5 76 80 806 2 31 2 1 7 3 5 59 65 607 2 30 1 2 5 3 2 62 69 698 2 40 1 1 6 3 5 75 77 789 2 42 1 2 7 4 3 74 80 8110 2 45 1 2 6 3 5 76 79 8011 2 37 2 1 4 3 1 84 89 9212 2 39 2 1 7 3 5 59 65 6313 2 46 1 2 6 2 1 59 69 7214 2 39 1 2 7 3 1 56 72 75

15 2 40 2 2 4 3 0 85 89 97

KEY

Group B- DTFM

Gender 1- Male, Gender 2- Female

Side 1- Right, 2- Left.

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