Rajiv Gandhi University of Health Sciences



Rajiv Gandhi University of Health Sciences

Bangalore

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

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| | |SHEETAL BAPURAO PHULE, |

|1. |Name of the candidate and |GARDEN CITY COLLEGE OF PHYSIOTHERAPY, 16th KM, OLD MADRAS ROAD, |

| |Address |VIRGONAGAR POST, |

| | |BANGALORE-49. |

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|2. |Name of the Institution |GARDEN CITY COLLEGE OF PHYSIOTHERAPY. |

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|3. |Course of study and subject |MASTER OF PHYSIOTHERAPY |

| | |(MUSCULOSKELETAL AND SPORTS PHYSIOTHERAPY). |

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|4. |Date of admission to course |27-05-2010 |

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|5. |TITLE OF THE TOPIC: |

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| |A COMPARATIVE STUDY ON THE EFFECTS OF MUSCLE ENERGY TECHNIQUE AND ECCENTRIC EXERCISES IN LATERAL EPICONDYLITIS. |

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|6. |BRIEF RESUME OF THE INTENDED WORK: |

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| |6.1 NEED FOR THE STUDY |

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| |Lateral epicondylitis (tennis elbow) defined as a pathologic condition of extensor muscles at their origin on lateral humeral |

| |epicondyle. Tennis elbow is an inflammation of the tendons that join the forearm muscles on the outside of the elbow. The forearm |

| |muscles and tendons become damaged from overuse repeating the same motions again and again. This leads to pain and tenderness on the |

| |outside of the elbow. It is generally work related or sport related pain disorder usually caused by excessive, quick, monotonous, |

| |repetitive motions of the wrist. The dominant arm is commonly affected.1 Tennis elbow is a common disorder of the elbow. A recent |

| |demographic study described the epidemiology of this condition and investigated its risk factors in a sample of 4783 people aged |

| |30–64 years. The prevalence in this group was 1.3% and did not differ between men and women. The condition was most prevalent in the |

| |age group of 45–54 years. People with a history of current or prior tobacco use were found to have an increased risk of developing |

| |tennis elbow. Repetitive movements and forceful activities were also positively correlated with lateral epicondylitis.2 |

| | |

| |Although pain around the lateral epicondyle is commonly referred to as “tennis elbow”, tennis players make up only 10% of the patient|

| |population2,3. Half of tennis players develop pain around the elbow, of which 75% represent true tennis elbow.4 |

| |The natural course of the condition seems to be favorable, with spontaneous recovery within 1–2 years in 80–90% of the patients; |

| |however there is very little scientific data available on the natural history of the disease.5 |

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| |The patient usually first seen because of gradual onset of aching pain in the region of the lateral epicondyle and in the proximal |

| |muscles of the forearm. The pain is often related to the flexion and extension of the wrist and to pronation and supination |

| |activities.6 Physical examination will confirm tenderness over the common extensor tendon origin often localized to the extensor |

| |carpi radialis brevis.7 |

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| |One of the major misconceptions about all upper limb joints concerns whether they are weight-bearing or not. The more correct term |

| |that should be applied to upper limb joints is that they are load-bearing and the level of the load depends on the position of the |

| |limb and the activity being undertaken. Certainly, the upper limb joints bear less load than the hip or knee but to say they are not |

| |load-bearing is incorrect. An and Morrey have estimated that, at 90°of flexion, a force three times body weight can be transmitted |

| |through the elbow. The stability of the elbow depends on the bony architecture, The collateral ligaments (medial and lateral), and |

| |dynamic forces from the extensive musculature that crosses the joint. The contribute on made by each component depends on the |

| |position of the joint. Further, it must be remembered that the radiohumeral joint and the ulnohumeral joints both play a significant |

| |role in stress distribution.8 |

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| |Traditional treatment program for people with lateral epicondylitis have focused primarily on the pain control by |

| |ultrasound,anti-inflammatory medication , iontophoresis or phonophoresis followed by rehabilitation program which ranges from |

| |flexibility to strengthening and endurance training. Numerous treatments have been tried for lateral epicondylitis including drug |

| |therapies, corticosteroid injection9, electrical stimulation10, laser11, acupuncture12, counterforce bracing,ergonomics, ,splintage |

| |,etc. However no one treatment has been found to be efficacious. |

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| |This study involves comparing two treatment protocols, muscle energy technique (MET) and Eccentric strengthening exercises. MET |

| |appears to increase range of motion of joints and extensibility of muscle by means of an as yet unidentified mechanism, expressed as |

| |‘increased tolerance to stretch’. Previously assumed mechanisms, including Post Isometric Relaxation and Reciprocal Inhibition do not|

| |appear to be major contributors to the benefits deriving from use of MET. MET leads to marked analgesic effects. A number of pain |

| |related biomarkers have been identified that may explain the analgesic influence of MET, including the increased tolerance to |

| |stretch.13 |

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| |Slow progressive eccentric exercises for tennis elbow should be performed with the elbow in extension, forearm in pronation, and |

| |wrist in extended position (as high as possible). However, it is unclear how the injured tendon, which is loaded eccentrically, |

| |returns to the starting position without experiencing concentric loading and how the “slowness” of eccentric exercises should be |

| |defined. The progressive strengthening is usually undertaken utilising an 'eccentric contraction' and is referred to as an eccentric |

| |program. An eccentric contraction is defined as a contraction where the muscle is lengthening, as opposed to a concentric |

| |contraction where the muscle is shortening, or an isometric contraction where there is no change in the muscle length.14 |

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| |The ice may decrease the extravasation of blood and protein from new capillaries found in tendinopathy as well as decreasing the |

| |metabolic rate of tendon. Both mechanisms promote healing of lateral epicondylitis tendinopathy.ice can be used for relief of pain.15|

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| |Although the signs and symptoms of tennis elbow are clear and its diagnosis is easy, to date no ideal treatment has emerged. Many |

| |clinicians advocate a conservative approach as the treatment of choice for tennis elbow. Physiotherapy is a conservative treatment |

| |that is usually recommended for tennis elbow patients. A wide array of physiotherapy treatments have been recommended for the |

| |management of tennis elbow.16 |

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| |So the study intends to compare the muscle energy technique vs. eccentric strengthening exercises in a way to find out the optimum |

| |treatment for lateral epicondylitis. |

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| |6.2 REVIEW OF LITERATURE |

| |1.Grindstaff TL, et al.(2009)- Muscle energy technique (MET) is a form of manual therapy frequently used to correct lumbopelvic pain |

| |(LPP), here in the patient voluntarily contracts specific muscles against the resistance of the clinician. Studies on MET regarding |

| |magnitude and duration of effectiveness are limited. This study was a randomized controlled trial in which 20 subjects with |

| |self-reported LPP were randomized into two groups (MET or control) after magnitude of pain was determined. Tests for current and |

| |worst pain, and pain with provocation were administered at baseline, immediately following intervention and 24 hours after |

| |intervention. Subjects receiving MET demonstrated a decrease in VAS worst pain over the past 24 hours, thereby suggesting that MET |

| |may be useful to decrease LPP over 24 hours17. |

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| |2. Greg w. Johnson, MD, et al (2007) suggested multiple treatment for tennis elbow Topical nonsteroidal anti-inflammatory drugs, |

| |corticosteroid injections, ultrasonography, and iontophoresis with nonsteroidal anti-inflammatory drugs appear to provide short-term |

| |benefits. Use of an inelastic, nonarticular, proximal forearm strap (tennis elbow brace) may improve function during daily |

| |activities.18 |

| |3.Jean Lowis, Croisier,Margarite (2007) conducted study and compared the outcome of patients performing an isokinetic eccentric |

| |training with that age, gender, activity-matched patients receiving a non satrenthning exercises. Results highlight the relevance of|

| |implementing isokinetic adapted eccentric in the management of chronic lateral epicondyler tendinopathy.19 |

| |4.Brett L Woodly.et al (2006) This review demonstrates the dearth of high quality reaserch in support of the clinical effectiveness |

| |of eccentric exercises over other treatments in management of tendinopathies.20 |

| |5. Alison M et al (2000) did a study on the changes in the chronic pain severity over time: the von korff chronic pain grade is a |

| |valid measure. They found that von korff chronic pain grade scale is a valid measure for measuring pain intensity.21 |

| |6. Isam Atrishi, et al(2000) conducted study on reliability and validity of the disability of the arm, shoulder and hand |

| |(DASH)outcome questionnaire. They found that DASH questionnaire is a self administered region specific outcome instrument developed |

| |to measure upper extremity disability and symptoms.22 |

| |7. Simon P Frostick, et al (1999) conducted study on sport injuries of the elbow and gives an overview of some of the factors that |

| |must be considered in the etiology of injuries in the sporting elbow and provides details of some of the conditions that are |

| |encountered. It is likely that our approach to both diagnosis and treatment will change dramatically over the next few years as we |

| |gain a better understanding of the physiology of elbow function and the consequences of changes in the physiology in response to |

| |sport.23 |

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| |6.3 OBJECTIVE OF THE STUDY |

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| |The main objective of study includes: |

| |To find out the efficacy of muscle energy technique on lateral epicondylitis. |

| |To find out the efficacy of eccentric strengthening exercises on lateral epicondylitis. |

| |To compare the effectiveness of Muscle Energy techniques and Eccentric strengthening exercises in lateral epicondylitis. |

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| |6.4 HYPOTHESIS |

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| |NULL HYOTHESIS |

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| |There is no significant difference between Muscle Energy technique and eccentric strengthening exercises in patients with lateral |

| |epicondylitis. |

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| |ALTERNATE HYPOTHESIS |

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| |There is significant difference between Muscle energy Technique and eccentric strengthening exercises in patients with the lateral |

| |epicondylitis. |

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| |MATERIALS AND METHODS: |

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| |SOURCE OF DATA |

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| |Patients referred to the physiotherapy department of Garden City College of physiotherapy, Bangalore. |

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| |2. Patients referred to the physiotherapy department of ITI Hospital, Bangalore. |

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| |7.2 METHOD OF COLLECTION OF DATA |

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| |30 subjects will be randomly selected into two groups of 15 each by using non- random sampling method. |

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| |The study population would be 30 subjects. In case of any drop out during the conduct of study the next subject with the same |

| |criteria will be selected. |

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| |STUDY DESIGN |

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| |Experimental Study design (purposive sampling). |

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| |SAMPLE SIZE |

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| |Thirty subjects. |

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| |SAMPLING TECHNIQUE |

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| |Non random sampling method. |

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| |INCLUSION CRITERIA |

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| |1. Subject with diagnosis of chronic lateral epicondylitis. |

| |2. Age group between 30-60 years. |

| |3. Males and females subjects. |

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| |EXCLUSION CRITERIA |

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| |1. Fractured around elbow joint. |

| |2. Radio humeral bursitis. |

| |3. Cervical spondylosis with radiating pain on the lateral elbow. |

| |4. Arthritis. |

| |5. Lateral epicondyler avulsion. |

| |6. Ossification or calcification of the elbow joint. |

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|7. | |

| |7.3 ASSESSMENT TO BE DONE |

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| |METHODOLOGY: |

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| |The sample size of the study will be consisting of 30 subjects which would be divided into Two Groups of 15 in each group. |

| |Group-A-(n=15) Muscle energy Technique (MET) and Group-B (n=15) - Eccentric Strengthening exercises. Both are the experimental group.|

| |Both the group will undergo cryotherapy as common protocol. |

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| |Prior to the intervention treatment both group will be measured with von korff and DASH scales for pain and disability as pre-test |

| |measure. |

| |Subjects in Group-A will be given muscle energy technique. |

| |Group A will assign to 10 sessions of MET follows. Using passive range of motion of the wrist extensor muscle will stretch to the |

| |natural barrier following a slight release from the stretch. The subject will be asked to take a deep breath and hold it in, |

| |providing minimal resistance the subject will ask to contract the extensors against the resistance for 10 sec. The subject will ask |

| |to take another breath and the extensors will stretch to its natural barrier again. This procedure will repeat 10 times. |

| |Group B- eccentric strengthening exercises. |

| |Eccentric exercises will performed with forearm in pronation by moving slowly from full passive wrist extension to full wrist |

| |flexion. The eccentric exercise will performed by first putting the pronated wrist into full extension by lengthening the band with |

| |the opposite hand so that it will lax and, thus resisted concentric will not occur during wrist extension. Next the band will slowly |

| |lower from full wrist extension to full wrist flexion. For each repetition the band will lengthen by opposite hand to position the |

| |wrist in extension without resistance on the band. |

| |The questionnaire of Von Korff for grading the severity of pain and the disabilities of the arm, shoulder and hand (DASH) will be |

| |calculated for post test measure after three weeks. |

| |DURATION |

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| |The duration of the study will be approximately 6 months. |

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| |STATISTICAL TOOL |

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| |Data will be analyzed using‘t’ test. |

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| |7.4 ETHICAL CLEARENCE |

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| |Ethical clearance for the study has been obtained from the ethical committee of our |

| |Institution. |

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| |LIST OF REFRENCES: |

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| |1) D Stasinopoulos, K Stasinopoulou, M I Johnson An exercise programme for the management of lateral elbow tendinopathy, Br J|

| |Sports Med 2005; 39:944–947. |

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| |2) Shiri R, Viikari‐Juntura E, Varonen H. et al Prevalence and determinants of lateral and medial epicondylitis: a population |

| |study. Am J Epidemiol 2006; 164:165. |

| | |

| |3) Assendelft W J, Hay E M, Adshead R. et al Corticosteroid injections for lateral epicondylitis: a systematic review. Br J Gen |

| |Prac 1996; 46:209–216. |

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| |4) Haker E, Lunberg T. Pulsed ultrasound treatment in lateral epicondylalgia. Scand J Rehabil. Med1991; 23:115–118.  |

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| |5) Gruchow H W, Pelletier D. An epidemiologic study of tennis elbow. Incidence, recurrence, and effectiveness of prevention |

| |strategies. Am J Sports Med 1979; 7:234–238. |

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| |6)  Labelle H, Guibert R, Joncas J. et al Lack of scientific evidence for the treatment of lateral epicondylitis of the elbow. An |

| |attempted meta‐analysis. J Bone Joint Surg. 1992; 74:646–651. |

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| |7) Conway JE, Jobe FW, Glousman RE, et al. Medial instability of the elbow in throwing athletes: treatment by repair or |

| |reconstruction of the UCL. J Bone Joint Surg [Am] |

| |1992; 74:67–83. |

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| |8) An KN, Morrey BF. Biomechanics of the elbow. In: Morrey BF,ed. The Elbow, |

| |Philadelphia: WB Saunders, 1993; 53–72. |

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| |9) Boyer, Hastings, lateral tennis elbo .Is there any science out there? J shoulder elbow surgical.1999; 8:481-91. |

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| |10) Wright A, Vicenzino B. Lateral epicondylgia, Therapeutic management. Phys. Ther. 1997; 2; 39-48. |

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| |11) Basford JR.Laser therapy. A randomized controlled trial of the effect of low intensity Nd-YAG, laser iradication on lateral |

| |epicondylitis. Arch Phys. Med Rehabilitation. 2000; 81:1504-70. |

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| |12) Brattberg G Acupuncture therapy for tennis elbow. Pain 1983; 16:283-288. |

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| |13) Wilson E Payton O Donegan-Shoaf L et al. 2003 Muscle energy Technique in patients with acute low back pain: a pilot clinical |

| |trial. Journal of Orthopedic & Sports Physical Therapy, 2000; 33:502–512. |

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| |14) Julio A Martinez-Silvestrini, MD. Chronic lateral epicondylitis: comparative effectiveness of a home exercise program including |

| |stretching alone versus stretching supplemented with eccentric or concentric strengthening.2005; ( 18):411-419. |

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| |15) P Manias Stasinopoulos. a controlled clinical pilot trial to study the effectiveness of ice as a supplement to the exercise |

| |programme for the management of lateral elbow tendinopathy.B J sports med 2006 ; 40:81-85. |

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| |16) Hong QN, Durand MJ and Loisel P. Treatment of lateral epicondylitis: where is the evidence? Joint Bone Spine2004; 71(5):369–373. |

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| |17) J Man Manip Ther. Short-Term Effect of Muscle Energy Technique on Pain in Individuals with Non-Specific Lumbopelvic Pain: A Pilot|

| |Study. Journal of Manual & Manipulative Therapy 2009; 17(1): 14–18. |

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| |19) Jean-Lousis Crosier ,marguerite Foidart-Dessalle,Francem Tinant,an isokinetik eccentric programme for the management of chronic |

| |lateral epicondyler tendinopathy.Br.Sport Med.2007; 41:269-275. |

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| |20) Brett L Woodly, Richard J Newsham-West, G David Baxter. Chronic tendinopathy-effectiveness of eccentric exercise. Br. Sport |

| |med.2006; 10:1136. |

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| |21) Alison M Elliott, Blair H Smith,W Ciarons Smith,W Alastair Chambers. Changes at chronic pain severity over time; the chronic pain|

| |grade is a valid measure. Pain. 2000; 88(3):303-308. |

|8. | |

| |22) Islam Atroshi, Christina Gummeesson, Bodil Anderson, Elsa Dahlgren and Anita Johansson. The disabilities of the arm, shoulder and|

| |hand (DASH) outcome questionnaire. Acta Orthop Scand.2000; 71(6):613-618. |

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| |23) Simon P Frostick, Mohammad mohmmad,david A Ritchie, sport injuries of the elbow.BJSM 1999; 33:301-311 |

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