· web viewdhanusha, nepal 2. name of the institution and address k.t.g. college of physiotherapy...
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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA
ANNEXURE-II
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1. Name of the candidate and
address
SUBODH KUMAR MAHATO
Durgatol, Hariharpur-1,
Dhanusha, Nepal
2. Name of the Institution and
address
K.T.G. COLLEGE OF PHYSIOTHERAPY
Hegganahalli Cross, Vishwaneedam Post,
Sunkadakatte Via Magadi Road,
Bangalore – 560091
3. Course of study and subject MASTER OF PHYSIOTHERAPY
(Musculoskeletal Disorders and Sports
Physiotherapy )
4. Date Of Admission To Course 10/08/2013
5. Title of The Topic:
“COMPARATIVE EFFECT BETWEEN HOLD RELAX VERSUS
ISCHEMIC COMPRESSION TECHNIQUES ON UPPER TRAPEZIUS
MYOFACIAL TRIGGER POINT- A SINGLE BLIND STUDY”
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6. Brief resume of the intended work:
6.1 Need for the study:
Myofascial Trigger points (MTP) which comes under the non articular category of
musculoskeletal disorder are discrete, focal, hyperirritable spots in a taut band of
skeletal muscle causing pain on compression and also can produce referred pain,
tenderness, motor dysfunction and autonomic phenomena.1,2 The pain is usually a
deep and dull aching which can be both exquisite and continuous depending on the
circumstances and the anatomy.3 The mechanism of activation of the MTP is
hypothesized as the result from injured or overloaded muscle fibers, leading to
involuntary shortening of sarcomere and loss of oxygen and nutrient supply with
increased metabolic demand on local tissues.2
Clinically MTP are classified as active or latent where an active MTP is tender to
palpation with a referred pain pattern felt remote from the site causing pain at rest
and latent MTP restrict movement or cause muscle weakness causing pain when
pressure is applied directly over the point rather causing spontaneous pain.4 Pain
pressure threshold is the least stimulus intensity at which patient perceives pain and
measured by pressure algometer.5
It usually originates in skeletal muscles and/or their fascia2 and the most common
sites are the muscles involved in maintaining posture: upper trapezius, levator
scapulae, sternocleidomastoid, scalenes, and quadrates lumborum muscle. However,
it also can be located in fascia, ligaments and tendons.6 MTP mostly seen in upper
trapezius muscle as it works constantly to keep the head and neck vertical and normal
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antigravity function of upper trapezius getting overstressed by any position or activity
in which trapezius helps to carry the weight of arms for prolong period like
telephoning or sitting without armrest support. It is associated with the motor
endplate zone which is also known as the innervation zone where the α-motor neuron
divides into a number of branches and synapses onto trapezius muscle fibres. Hence,
it leads to shortening of sarcomere of trapezius muscle and affects the flexibility of
muscle decreasing the cervical range of motion followed with trapezius pain and
altering pain pressure threshold.7,1
MTP treatment methods can be divided into invasive and non-invasive methods.
Among the invasive methods, trigger point injections prove to be an effective
treatment for acute MTP. Non-invasive method includes electrical treatment and
exercise treatment. Electrical treatments include extracorporeal shockwave therapy,
transcutaneous electrical nerve stimulation, ultrasonic treatment, laser tic field
treatment and diathermy. Exercise treatments include hold relax (HR), ischemic
compression(IC), spray and stretching, massages, taping, stabilization exercises, post-
isometric relaxation, and positional release therapy.8-11
Hold Relax (HR) technique is the proprioceptive neuromuscular facilitation
stretching technique frequently used in clinics which works on four theoretical
physiological mechanisms: autogenic inhibition, reciprocal inhibition, stress
relaxation, and the gate control theory. These mechanisms are reflexes that occur
when the Golgi tendon organs (GTOs) detect harmful stimuli either in the tendons of
the target muscle or in the antagonist muscle to the target muscle.12 It uses the means
of facilitation to correct muscle imbalances and restore the patient’s ability to
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perform effective co-ordinated movement, increasing flexibility and improving
pain.13,14
Ischemic compression (IC) technique refers to trigger point pressure release which is
the application of slowly increasing, non-painful pressure over a MTP until a barrier
of tissue resistance is encountered. Contact is then maintained until the tissue barrier
releases, and pressure is increased to reach a new barrier to eliminate the trigger point
tension and tenderness.15 IC is firm sustained compression at a MTP. The hypothesis
suggests compression lengthens the shortened sarcomere, the subsequent release of
pressure corresponds to reactive hyperaemia which flushes away noxious substances
and by-products of cellular metabolism that enhance muscle contraction.16
Research examining the treatment methods independently is widely available, yet no
research has directly examined the effects between HR and IC for improving pain,
pressure pain threshold and flexibility of patients with MTP of the upper trapezius
muscle, thereby presenting precise and efficient treatment methods. There is a need
for further research to compare the effects between these two treatment methods so
clinicians have an objective basis for selecting a particular method in the treating
MTP. Hence the purpose of this study is to compare the effects of hold relax
technique versus ischemic compression technique on subjective pain, pressure pain
threshold and trapezius flexibility for subjects with upper trapezius muscle MTP.
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Research Question
Whether there is any differences in effect of hold relax technique versus ischemic
compression technique on pain, pressure pain threshold and flexibility of upper
trapezius myofascial trigger points?
Hypothesis:
Null hypothesis
There will be significant difference in effect of hold relax technique versus ischemic
compression technique on pain, pressure pain threshold and flexibility of upper
trapezius myofascial trigger points.
Research hypothesis
There will be significant differences in effect of hold relax technique versus ischemic
compression technique on pain, pressure pain threshold and flexibility of upper
trapezius myofascial trigger points.
6.2 Review of Literature:
Review on Myofascial Trigger Points :
Marco Barbero et al. (2013) carried out research on Myofascial trigger points and
innervations zone locations in upper trapezius muscles where they classified
myofascial trigger point under the non-articular category of musculoskeletal disorder.
They found that MTP in upper trapezius are proximally located to the IZ but not
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overlapped. 1
Cesar Fernandez de las Penas et al. (2005) reviewed on the manual therapies in
myofascial trigger point treatment where they defined myofascial trigger point as
discrete, focal, hyperirritable spots causing pain, tenderness, motor dysfunction and
autonomic phenomena.2
Review on Hold Relax :
Jung-Ho Lee et al. (2013) examined the effects of treatment using PNF extension
techniques on the pain, pressure pain, and neck and shoulder functions of the upper
trapezius muscles of myofascial pain syndrome (MPS) patients. In their study they
found exercise programs that apply hold relax techniques is said to be effective at
improving the pain and range of motion in MPS patients.10
Kayla B. Hindle et al. (2012) reviewed possible mechanisms, proposed theories and
physiological changes that occur due to proprioceptive neuromuscular facilitation
techniques. Four theoretical mechanisms that occur in hold relax were identified:
autogenic inhibition, reciprocal inhibition, stress relaxation, and the gate control
theory which are the reasoning behind the increase in range of motion and function.12
Review on Ischemic Compression:
Marie Alricsson(2012) published musculoskeletal disorder where it was concluded
that ischemic compression is effective technique as compression lengthens the
shortened sarcomere, the subsequent release of pressure corresponds to reactive
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hyperaemia which flushes away noxious substances and byproducts of cellular
metabolism that foster muscle contraction.16
William P Hanten, et al. (2000) conducted a study on effectiveness of a home
program of ischemic pressure followed by Sustained Stretch for treatment of
myofascial trigger points and the results suggested that clinicians can treat myofascial
trigger point through monitoring of home program.11
Review on Outcome measurement
Leighann Litcher-kelly, et al (2007) in their systemic review on measures used to
assess chronic musculoskeletal pain in clinical and randomized controlled clinical
trials by using many type of pain assessments available to researcher conducting
clinical trials ranging from simple, single item visual analogue scale (VAS) question
through extensive, multidimensional inventories. They stated that VAS were
responsive than the other complex measures as it is easy to assess pain.17
Ann L. Persson et al. (2004) conducted study on tender or not tender: test-retest
repeatability of pressure pain thresholds in the trapezius and deltoid muscles of
healthy women. They considered the device valid as the device itself was also highly
correlated with readings from a force plate.5
Polly E. Bijur, et al. (2001) measured the reliability of the visual analogue scale for
measurement of acute pain and found that reliability of the VAS for acute pain
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measurement as assessed by the ICC appears to be high.18
Richard L Gajdosik, et al. (1987) studied the emphasizing reliability and validity of
the goniometer for measuring range of motion. Study suggests that measurement of
range of motion by goniometer also represent flexibility. However they
recommended for future study on outcome measures.19
Review on inclusion and exclusion criteria:
Athanasios Trampas, et al. (2010) conducted study on clinical massage and
modified Proprioceptive Neuromuscular Facilitation stretching in males with latent
myofascial trigger points where they mentioned the following as exclusion criteria:
neck or shoulder surgery within the past year, neurological or rheumatic disorders,
whiplash in the previous 6 months, pregnancy, concomitant painful disorders, psycho
emotional distress, overweight,etc.20
Luke D. Rickards (2006) carried out study on the effectiveness of non-invasive
treatments for active myofascial trigger point pain where it has been mentioned that
myofascial trigger point includes the physical signs which are presence of a palpable
taut band in a skeletal muscle, the presence of a hypersensitive tender spot in the taut
band and palpable or visible local twitch response on snapping palpation. These
physical signs are used to categorise the patient for inclusion and exclusion.6
6.3 Objectives of the study:
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7.
Primary Objective
1. To determine the comparative effect between hold relax technique versus
ischemic compression technique by analyzing pain, pressure pain threshold
and flexibility in subjects with trapezius myofascial trigger point.
Secondary Objective
2. To evaluate the effect of hold relax technique by analyzing pain, pressure
pain threshold and flexibility before and after intervention in subjects with
trapezius myofascial trigger point.
3. To evaluate the effect of ischemic compression technique by analyzing pain,
pressure pain threshold and flexibility before and after intervention in
subjects with trapezius myofascial trigger point
Materials and Method
7.1 Study Design
Pre to post test comparative experimental study design with two groups-
Hold relax group (HR group)
Ischemic compression group (IC group)
7.2 Methodology
Study Population
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Subjects with unilateral upper trapezius myofascial trigger point.
Sample size
The study will be carried on total of 40(n=40) subjects.
20 subjects in HR group.
20 subjects in IC group.
Study Setting and Source of data
Study will be carried out at KTG Hospital, Bangalore.
Sampling Method
Simple Random Sampling.
Study Duration
Three sessions per week for two weeks.
Sample Selection
Inclusion Criteria
Age group between 18 and 50
Both male and female subjects
Pain of VAS scores more or equal to 3.
Pain on stretching of trapezius muscle.
Travell and Simon’s minimal criteria
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1. presence of a palpable taut band in the upper trapezius muscle,
2. presence of a tender spot in the taut band,
3. local twitch response elicited by the snapping palpation of the taut band,
4. reproduction of subject’s pain only upon palpation without patient
recognition of the symptom as familiar.6
Exclusion Criteria
Neck or shoulder surgery within the past year,
Neurological or rheumatic disorders,
Clinical evidence of radiculopathy, myelopathy or joint disorders,
Whiplash in the previous 6 months,
Concomitant painful disorders and psycho emotional distress to avoid adverse
effects and confounding factors during the MTP palpation procedure.
Overweight patients as excessive subcutaneous fat layer thickness can limit
the MTP palpation.20
Materials used:
Treatment couch
Visual Analogue Scale
Pressure algometer
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Universal Goniometer
Variables
Independent Variable
Hold Relax, Ischemic compression.
Dependent Variable
Pain, pressure pain threshold and flexibility.
7.3 Methods of data collection :
Ethical Clearance
As the study includes human subjects ethical clearance is obtained from ethical
committee of K.T.G. college of physiotherapy. All subjects fulfilling the inclusion
criteria will be informed about the study and a written consent will be taken.
Randomization into group
All the subjects who fulfill the inclusion criteria will be assigned to two groups based
on simple random sampling. The subjects were randomly allocated into two groups
of 20 each. Forty pieces of paper were used; in twenty papers written with the letter
“HR” to identify the subjects to take into hold relax group and the other twenty with
the letter “IC” to identify the subjects to take into ischemic compression group. All
the forty pieces of paper were tightly folded and placed in a box. 20 subjects with the
letter “HR” will be enlisted under hold relax group and the other 20 subjects twenty
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with the letter “IC” under Ischemic compression group. Complete explanations were
given to both the groups separately but the subjects were unaware to which group
they belonged. Once the subject agrees to participate in the study, an informed
written consent (Annexure-1) was taken from the subjects.
Subjects were blinded on either type of intervention and to which group they were
belonged. Throughout the treatment sessions, subjects from both the groups were not
allowed to have any interaction to each other and the subjects were not aware of what
kind of treatment they received and its effects.
No other conventional method of treating myofascial trigger point will be given as
the patients with the minimal pain intensity will be included in the both HR and IC
group.
Pre- Intervention Outcome measurement
All the patients will be assessed for the following:
1. Upper trapezius pain is measured by Visual Analogue Scale (Annexure-II) .
Pain intensity will be assessed using a visual analogue scale (VAS). Patients
placed a vertical mark on a continuous 10 cm line to indicate pain intensity,
ranging from no pain or discomfort to the worst pain they could possibly feel.
The VAS measurement will be used to assess local pain evoked by pressure
applied with the algometer on the MTP. The reliability and validity of this
instrument has been established previously.19
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2. Pressure pain threshold (PPT) is measured by pressure algometer .
The subject will be seated in a chair comfortably with a low support for the
back and with a pillow on their lap for arm support. The PPT will be measured
over the relaxed trapezius muscles. Three test trials, on a single point over
rhomboid muscle will be performed to familiarize the subject with the
procedure. Then pressure will be applied perpendicularly against the skin over
the marked points in a fixed order over the trapezius muscle. Thereafter, the
same sequence will be repeated on the affected trapezius muscle. The patient is
asked to say “yes” when they feel any discomfort or pain. Immediately the
pressure is stopped if the patient feels pain and the pain pressure threshold will
be noted. Time gap of 5 to 10 minutes will be given during the trails. The
average score of all three trails will used to determine the effect. To measure
PPT on the same after 2 weeks of intervention, the procedure is standardized by
marking a permanent marker (skin marker) and marking will be periodically
examined and marked to avoid erasing. Measuring PPT in this way has been
reported as a reliable method for assessing the severity of MTP.5
3. Flexibility is measured in degree by Goniometer
Universal goniometer will be used to measure cervical lateral flexion. Patient
will be asked to sit with thoracic and lumbar spine well supported by the back
of the chair. Cervical spine in 00 of flexion, extension, and rotation. Tongue
depressor can be held between teeth for reference. Shoulder girdle is stabilized
to prevent lateral flexion of thoracic and lumbar spine. The axis of goniometer
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placed over spinous process of C7. Stable arm placed over spinous processes of
thoracic vertebrae so that arm is perpendicular to ground and movable arm is
placed dorsal to midline of head where reference can be taken as occipital
protuberance. Patient will be asked to perform lateral flexion opposite to the
involved side and reading will be taken. This method of measuring range of
motion has previously been found to be reliable.19
Procedure of Intervention for HR Group
The patient in the sitting position and the therapist will be back of the patient.
Therapist stretch the upper trapezius until the stretching discomfort level reached the
“4 out of 10” intensity by pulling the head in direction opposite to the affected side
and rotating the patient’s face toward the affected side. Stretch perception is the
amount of force exerted in order to elicit the “4 out of 10” on the verbal NRS by the
patient. The patient will be asked to perform isometric contraction for 10 seconds
followed by relaxation of 10 seconds. Then new position is held for further 10
second. This procedure will be repeated for a total of five times for six sessions per
weeks for two weeks.
Procedure of Intervention for IC Group
Patients will be placed supine with head fully on the couch to reduce tension in the
upper trapezius muscle. Arm positioned in slight shoulder abduction with the elbow
bent and hands resting on stomach. Therapist stands at the head side of the couch. 15
First, trigger point will be located by palpating the muscle to feel for a taut band or a
twitch response in the trapezius muscle. Then ischemic compression will be
performed till the pain tolerance by gradually applying pressure to the trigger point
with thumb. The patient may feel referred pain. Patient will be asked frequently to
ensure that he/she is staying within the limits of his/her pain tolerance. It will be held
till the patient tells that pain has diminished or until muscles fibers begins to relax
under pressure. Then pressure gradually released with few effleurage strokes to flush
out the area. This will be repeated for three to five times for six sessions per week for
two weeks.
Post intervention outcome measurement
All the patients will be assessed again after the treatment for the following outcome
measures:
1. Neck pain is measured by Visual Analogue Scale (Annexure-II).
2. Pressure pain threshold will be measured by Pressure algometer.
3. Flexibility of neck measured by Goniometer.
Statistical Tests
Statistical analysis will be performed by using SPSS software for window
(version16) and p value will be set as 0.05 (1-tailed hypothesis).
Descriptive statistics and Chi square test will be used to analyze baseline data for
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8.
demographic data.
Unpaired t test and Wilcoxon signed ranked test will be used to find the significance
of parameters pre to post test.
Independent t test and Mann Whitney U test will be used to find the significance of
parameters between the groups.
7.4 Ethical Clearance
As this study involve human subjects, the ethical clearance has been obtained from
research and ethical committee of K.T.G college of physiotherapy, Bangalore as per
the ethical guidelines for Bio-Medical research on human subjects, 2000 ICMR, New
Delhi.
List of References:
1) Marco Barbero, Corrado Cescon, Andrea Tettamanti, Vittorio Leggero, et al.
Myofascial trigger points and innervation zone locations in upper trapezius
muscles. Biomed central Musculoskeletal Disorders 2013; 14:179.
2) Cesar Fernandes de las, Monica Sohrbeck Campo, Josue Fernandez Carnero, et
al. Manual therapies in myofascial trigger point treatment: a systematic review.
Journal of Bodywork and Movement Therapies 2005; 9: 27–34.
3) Lucy Whyte Ferguson et al. Myofascial Pain: A Manual Medicine Approach to
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Diagnosis and Treatment. The Pain Practitioner 2012 summer; 22(2): 34-39.
4) David J Alvarez, Pamela G Rockwell. Trigger points: Diagnosis and
management. American Family Physician 15th February 2002; 65(4):653-660.
5) Ann L. Persson, Christina Brogardh and Bengt H. Sjolund. Tender or not tender:
test-retest repeatability of pressure pain thresholds in the trapezius and deltoid
muscles of healthy women. Journal of rehabilitation medicine 2004; 36: 17-27.
6) Luke D. Rickards. The effectiveness of non-invasive treatments for active
myofascial triggers point pain: A systematic review of the literature. International
Journal of Osteopathic Medicine 2006; 9:120-136.
7) Simons DG, Travell JG, Simons IS. Travell and Simon’s myofascial pain and
dysfunction: the trigger point manual: Vol 1, Upper half of body, 2nd ed.
Baltimore, Maryland: Williams and Wilkins; 1999.vol 2 p.287.
8) Kim GU, Choe SC, Song HJ, et al. Trigger point injection for the treatment of
cervical strain in the emergency department. Kor Soc Traumatol 2002; 15:33–38.
9) Edwards J, Knowles N. Superficial dry needling and active stretching in the
treatment of myofascial pain. Acupuncture Medicine 2003; 21: 80–86.
10) Jung-Ho Lee, Soo-Jin Park, Sang-Su Na. The Effect of Proprioceptive
Neuromuscular Facilitation Therapy on Pain and Function. Journal of Physical
Therapy Science 2013; 25:713–716.
11) William P Hanten, Sharon L Olson, Nicole L Butts, Aimee L Nowicki.
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Effectiveness of a Home Program of Ischemic Pressure Followed by Sustained
Stretch for Treatment of Myofascial Trigger Points. Physical therapy 2000;
80:997-1003.
12) Kayla B. Hindle, Tyler J. Whitcomb, Wyatt O. Briggs, Junggi Hong.
Proprioceptive Neuromuscular Facilitation (PNF): Its Mechanisms and Effects on
Range of Motion and Muscular Function. Journal of Human Kinetics March
2012; 31:105–113.
13) Chow TP, Ng GY. Active, passive and proprioceptive neuromuscular facilitation
stretching are comparable in improving the knee flexion range in people with
total knee replacement: a randomized controlled trial. Clinical Rehabilitation
2010; 24: 911–918.
14) Lim CH. Effects of static, dynamic, PNF stretching on the isokinetic peak torque.
Journal of Korean Society Physical Therapy 2011; 23: 37–42.
15) Simons DG, Travell JG. Chronic myofascial pain syndromes. Mysteries of the
history, chapter 6. In: friction JR, Awad EA, editors. Myofascial Pain and
Fibromyalgia, Advances in Pain Research and Therapy. Vol. 17 New York:
Raven press; 1990.p. 129-37.
16) Bang Nguyen. Myofascial Trigger Point: Symptoms, Diagnosis, Intervention. In:
Marie Alricsson,editor. Musculoskeletal Disorder. Croatia: Janeza Trdine 9;
2012.
17) Leighann Litcher Kelly, et al. A systemic review of measures used to assess
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chronic musculoskeletal pain in clinical trials. Pub Med Central 2007.
18) Polly E. Bijur, Wendy Silver, E. John Gallagher. Reliability of the Visual
Analogue Scale for Measurement of Acute Pain. Academic Emergency Medicine
December 2001; 8(12):1153-1157.
19) Richard l. Gajdosik and Richard w. Bohannon. Clinical Measurement of Range of
Motion- Review of Goniometry Emphasizing Reliability and Validity. Physical
Therapy 1987; 67:1867-1872.
20) Athanasios Trampas, Athanasios Kitsios, Evagelos Sykaras, Stamatios
Symeonidis, Lazaros Lazarou. Clinical massage and modified Proprioceptive
Neuromuscular Facilitation stretching in males with latent myofascial trigger
points. Physical Therapy in Sport 2010; 11:91-98.
9. Signature of Candidate
10. Remarks of the Guide
11. Name and Designation of
11.1 Guide :
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11.2 Signature
11.3 Co-Guide :
11.4 Signature
11.5Head of Department :
11.6 Signature
12. 12.1Remarks of the Chairman and Principal
12.2Signature
ANNEXURE –I
CONSENT FORM
I Subodh Kumar Mahato have explained to............................................the purpose
of the research, the procedures required, and the possible risks and benefits to the
best of my ability.
...............................................
...............................................
Investigator Signature Date
College:21
Place:
CONSENT TO PARTICIPATE IN THE STUDY
Purpose of Research
I .........................have been informed that this study is for neck pain like mine. All
test measures are acceptable Physiotherapy interventions for this problem. This
study will help physiotherapy better understand the comparative effect between
hold relax technique and ischemic compression technique on upper trapezius
myofascial trigger points
Procedure
I understand that I will be performing both hold relax technique and ischemic
compression. I will be expected to perform treatment in the Physiotherapy
department or an outside setting in a day.
I am aware that in addition to ordinary care received, I will be examined by a
research Physiotherapist. The Physiotherapist examination will consist of
measuring pain, pressure pain threshold and flexibility. I have been informed that
these treatments will be conducted at the beginning of the study, and after the
study.
Risk and Discomforts
I understand that I may experience some pain or discomfort during the
examination or during my treatment. This is mainly the result of my condition, as
the procedure of this study is not expected to exaggerate these feelings which are
associated with the usual course of assessment.
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Benefits
I understand that my participation in the study will have no direct benefit to me
other than the major potential benefit that is to find out which technique is more
effective.
Confidentiality
I understand that the information produced by this study will became part of my
research record and will be subject to the confidentiality and privacy regulation,
but will be stored in the investigator’s research file.
If the data is used for publication in the literature or for the teaching purpose, no
names will be used, and other identifiers, such as photographs and audio or
videotapes, will be used without my special written permission.
Refusal or Withdrawal of Participation
I understand that my participation is voluntary and that I may refuse to participate
or may withdraw consent and discontinue participation in the study at any time
without prejudice to my present or future care at the Hospital. I also understand
that Subodh Kumar Mahato may terminate my participation in this study at any
time after he explains the reasons for doing so.
I confirm that Subodh Kumar Mahato has explained to me the purpose of this
research, the study procedures that I will undergo, and the possible risks and
discomforts as well as benefits that I may experience. Alternatives to my
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participation in the study have also been discussed. I have read and I understand
this consent form. Therefore, I agree to give my consent to participate as a subject
in this research project.
..........................................
..........................................
Participant Signature Date
..........................................
..........................................
Witness to Signature Date
ANNEXURE –II
Visual Analogue Scale(VAS)
VAS is presented as 10cm line.
No pain at one end and worst imaginable pain at other end.
Patient is asked to mark a 100mm line to indicate pain intensity.
I----------------------------------------------------------------------------------------I
No pain Worst Pain
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If used as a graphic rating scale, 10 cm baseline is recommended for VAS scale.
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