Rajiv Gandhi University of Health Sciences



A Comparative Study to Analyze the Effect of Low Level Laser Therapy and Ultrasound Therapy in Patients with Lateral Epicondylitis

SUBMISSION OF SYNOPSIS FOR THE REGISTRATION OF THE DISSERTATION FOR MASTER OF PHYSIOTHERAPY

SUBMITTED TO

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

SUBMITTED BY

VIJAY KUMAR C. PURANIK

NAVODAYA COLLEGE OF PHYSIOTHERAPY

P.B NO. 26 MANTRALAYAM ROAD, RAICHUR

KARNATAKA

APRIL 2009

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

ANNEXURE –II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

| | | VIJAY |

|1 |NAME OF THE CANDIDATE |KUMAR C. PURANIK |

| |AND ADDRESS |NAVODAYA COLLEGE OF PHYSIOTHERAPY, MANTRALAYAM ROAD, RAICHUR, |

| | |KARNATAKA |

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|2 |NAME OF THE INSTITUTION |NAVODAYA COLLEGE OF PHYSIOTHERAPY, |

| | |MANTRALAYAM ROAD, RAICHUR, |

| | |KARNATAKA |

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|3 |COURSE OF STUDY AND SUBJECT |MASTER OF PHYSIOTHERAPY (MPT) |

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| |: |PHYSIOTHERAPY IN MUSCULO-SKELETAL |

| | |DISORDERS AND SPORTS |

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|4 |DATE OF ADMISSION TO THE COURSE |APRIL 2009 |

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|5 |TITLE OF THE TOPIC: |

| |“A Comparative Study To Analyze the Effect of Low Level Laser Therapy and Ultrasound Therapy in Patients with Lateral Epicondylitis” |

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6. RESEARCH QUESTION:

Will there be any significant difference in outcome measures by Treating with Low Level Laser Therapy (LLLT) and Ultrasound Therapy in patients with Lateral Epicondylitis

6.1 BRIEF RESUME OF THE INTENEDED WORK:

Tennis elbow is a blanket term used to describe lateral epicondylitis, extensor tendinosus or extensor tendonitis, all of which cause pain around the lateral elbow region. While each of these conditions differ in their specific pathologies, the most common description of the primary pathological process refers to a degeneration (tendinosis) of Extensor Carpi Radialis Brevis Tendon (ECRD) usually the degeneration is within 1-2 cm of its attachment to the lateral epicondyle of the humerus, which results in lateral epicondylitis or tennis elbow16,20,15.

Tears of the tendon of the ECRB muscle and/or inflammatory changes as a result of aging, repeated overuse or trauma, contribute to degeneration of the tendon6. Poor blood supply to the area (which is a normal anatomical feature) prolongs healing, as does repeated use and failure to rest.

Inflammatory signs and symptoms as pain and stiffness bellowing rest relief with mild activity (a warming up effect) may indicate more of a tendonitis (inflammation of the tendon) rather than a degeneration process.

Causes and contributing factors are varied, but in general they are related injure of one or more, poor sports techniques (such as a tennis backhand stroke) occupational tasks involving repetitive movements of the wrist or secondary to injury16,11, which is either primary or secondary to degeneration20.

Many proposed etiologies for this condition have involved inflammatory processes of the radial humeral bursa, synovium, periosteum and the annular ligament. In 1979 Nirschi and Patron attributed the cause to microscopic tearing with formation of reparative tissue (i.e. angiofibroblastic hyperplasia) in the origin of the Extensor Carpi Radialis Brevis (ECRB) muscle. The micro tearing and repair response can lead to microscopic tearing and structural failure of the origin of the ECRB muscle.

Some of the signs and symptoms, which may be related to humeral epicondylitis, include tenderness over the lateral and medial aspect of the forearm, extensor and flexor tendons and the muscle bellies, which may radiate into the forearm.

➢ Decreased grip strength and pain on gripping.

➢ Decreased strength and pain on active flexion and wrist extension.

➢ Pain on resisted radial deviation and extension of the middle finger in lateral.

➢ May disturb the sleep when it is severe

➢ Chronic states – usually a loss of range of elbow extension or adduction with extension

➢ The condition may be irritable

➢ Onset may be gradual or related to a specific incident (insidious)

Frequency of epicondylitis has been demonstrated to occur in up to 50% tennis and golf players .However, this condition is not limited to players and has reported to be the result of overuse from many such activities. Epicondylitis is extremely common in today’s active society.

Upper limb play an important role in everyone’s daily life. From the functional view point the hand is the effectors organ of the upper limb which supports it mechanically and allows it to adopt the optional position for any given action9.

Power grip is generally a forceful act resulting in flexion at all finger joints. When the thumb is used, it act as a stabilizer to the object held between the finger and most commonly, the palm14.

Ultrasound has been used most commonly in the management of soft tissues injuries, there is little evidence for benefit in treatment of soft tissue injuries Ultrasound has a frequency range of 0.75 – 3MHZ with most machines set at a frequency of 1 to 3 MHZ.

Continuous or pulsed mode upon tissue increases blood flow and reduce muscle spasm, increases extensibility of collagen fibers and decreases inflammatory response in order to relieve pain5 with pulsed mode (1MHZ) with an intensity of 1.0W/cm2 for 6 min.

The Helium-Neon (He-Ne)Low Level laser Therapy at a wavelength of 632.8 nm has proved very successful in promoting wound healing particularly in indolsent ulcer resistant to conventional methods of therapy.

However, it’s limited depth of penetration and low power output have rendered it less effective when treating more deep seated causes of pain. The laser more frequently used for pain therapy is the Gallium Aluminium Arsenide (GaAlAs) diode emitting coherent light in the near infrared waveband, usually 820-830nm and with a continuous wave power output of some 60mW. The optoelectronic rational for choosing these parameters has been discussed by Moore and Calderhead13.

Thus the purpose of this study is to analyse the effect of Low Level Laser Therapy and Ultrasound Therapy in patients with Lateral Epicondylitis .

6.2 HYPOTHESIS

NULL HYPOTHESIS (H0)

There will be no significant difference in Pain level and Grip strength between Low Level Laser Therapy (LLLT) and Ultrasound Therapy among the patients with Lateral Epicondylitis.

ALTERNATIVE HYPOTHESIS (H1)

There will be a significant difference in Pain level and Grip strength between Low Level Laser Therapy (LLLT) and Ultrasound Therapy among the patients with Lateral Epicondylitis.

3. REVIEW OF LITERATURE

1. A Binder, G Hodge et al (1985) conducted a study to find whether there is any effectiveness of therapeutic ultrasound in treating soft tissue lesions. 76 subjects with lateral epicondylitis were taken in which 38 were randomly allocated to receive ultrasound treatment and 38 placebo. The treatment was given for 6 weeks. The condition of 24 patients (63%) treated with ultrasound and 11 (29%) given placebo improved, the difference being significant at the 1% level. The results shows that there is an improvement in clinical variables (pain score, weight lifting, grip strength) and also shown an advantage for the patient given ultrasound treatment. Thus the study concluded that ultrasound enhances recovery in most patients with soft tissues lesions1.

2. Haker E et al (1991) carried out a pilot study on 45 patients to explore the pain alleviating effects of pulsed ultrasound in lateral epicondylitis and concluded that results do support the use of the chosen parameters in lateral epicondylitis8.

3. Zlatko simonivic (1991) studied low level laser therapy with trigger point technique as a clinical study on 243 patients. He found the effect of LLLT and the results obtained after clinical treatment including humeral epicondylitis and other pain conditions. The result were measured with Verbal Rating Scale (VRS), VAS and Pressure Threshold Meter (PTM) scales. Acute pain diminished more than 70%, chronic pain decreased by 60%.They did not observe any negative effects on the human body and the use of analgesics drugs can be reduced are completely excluded. He suggested that the laser beam can be used as monotherapy or as a supplementary treatment to other therapeutic treatment for pain treatment19.

4. Tuomo T Pienimaki, Tuula K Tarvbainen et al (1995) carried a study on progressive strengthening and stretching exercises and ultrasound for chronic lateral epicondylitis. The subjects were 39 which were collected randomized in two treatment groups. Group A (n = 20) was treated with progressive slow, repetitive wrist and forearm stretching, muscle conditioning and occupational exercises. Group B (n = 19) were treated with pulsed ultrasound. A pre-post test design paired sample ‘t’ test was used to compare the pre and post pain (VAS) in the exercises group works has strengthen as compare to ultrasound group (p = 0.004). Maximum isometric grip strength increase group and 12% in the exercises group and remain unchanged in the ultrasound group (p = 0.05)18.

5. Bolsaubert et al (2004) conducted a 46 randomized controlled trials on non surgical treatment of tennis elbow and concluded that pulsed ultrasound, deep friction massage and exercises program was the best option for treating tennis elbow but further trials are still required4.

6. A.P.D Vaz, A.J.K. Ostor et al (2005) conducted a study to find the effectiveness of low intensity ultra sound (LIUS) on tennis elbow. 55 subjects were taken and randomized into active group and placebo group. The treatment was given for 12 weeks with an intensity of 30mW/cm2 , 1.5MHz for 20 mins duration. Results shows that .there is 50% improvement in the active group as compared to the placebo group .Thus the study concluded that LIUS was no more effective for a large treatment effect than placebo for lateral epicondylitis2.

7. Apostolos Stergioulas (2007) conducted a study to find the effects of low level laser and plyometric exercises in the treatment of lateral epicondylitis. Fifty patients were taken and randomised into 2 groups (25 in each groups). Group a has treated with 904 Ga-As laser CW, frequency 50 Hz, intensity 40 Mw and energy density 2.4 J/cm2, plus plyometric exercises and group B that received placebo laser plus the same plyometric exercises. The treatment was given for 8 weeks. The result should that relative to the group B. The group A has a significant decrease of pain at rest at the end of 8 weeks treatment (p ................
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