Dissertation Research Proposal Submitted to The

A STUDY ON “EFFECTIVENESS OF MUSCLE ENERGY TECHNIQUE, MYOFASCIAL RELEASE TECHNIQUE AND POSITIONAL RELEASE THERAPY AMONG PATIENTS WITH TRAPEZIUS FIBROSITIS"

FERNANDES TRACY VANESSA

Dissertation research proposal submitted to the

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA

In partial fulfillment of the requirements for the Degree of

MASTER OF PHYSIOTHERAPY (M.P.T) IN MUSCULOSKELETAL DISORDERS & SPORTS PHYSIOTHERAPY

Under the guidance of

Mr. Mrutyunjay Kumar

1 RAJIV GANDHU UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. Name of the Candidate FERNANDES TRACY VANESSA and Address Hosmat girls hostel, 33, 80 ft road, opposite laggere ring road bridge, bangalore 560058

2. Name of the Institution HOSMAT COLLEGE OF PHYSIOTHERAPY

3. Course of study and subject Master of Physiotherapy (MPT) Musculoskeletal Disorders and Sports Physiotherapy

4. Date of admission to Course 17-06-2013

5. Title of the Topic

A STUDY ON “EFFECTIVENESS OF MUSCLE ENERGY TECHNIQUE, MYOFASCIAL RELEASE TECHNIQUE AND POSITIONAL RELEASE THERAPY AMONG PATIENTS WITH TRAPEZIUS FIBROSITIS"

6. Brief Resume of the Intended Work : 6.1) Need for the study :

Neck pain is a common disorder with a reported 6 months, prevalence rate of 54%. Non Specific neck pain can be defined as the Shape 676 pathoanatomical source of an individuals pain that cannot be identified. Women are more affected than men, women of working age are more affected than older ones. A trigger point has received a little scientific emphasis in a non specific neck pain. Trigger points have been found to frequently occur in individuals with mechanical neck pain as compared to their age matched controls.

Myofascial Release Techniquemay be used inclusively to mean any form of soft tissue release work. A more 0teric definition uses terms of "energy fields" and combines the two concepts. A mechanic interpretation of Myofascial Release highlights an "indirect" operator induced procedure designed to move away from restrictive barriers. As a technique, the term Myofascial Release has been used to describe both indirect and direct release procedures designed to directly stress firmly apparent movement barriers that typically occur in three-dimensionally related patterns.

Myofascial release technique decrease pain, strengthens the immune, improves nerve functions and increases blood circulation. Myofascial release techniques are used to improve movement potentials, reduce restriction, release spasm, and ease pain. A potential treatment option, muscle energy technique (MET), is a form of active stretch commonly used in manual therapy to increase range of motion. There are evidences proving that Muscle Energy Technique over upper trapezius muscle is effective in relieving myofascial pain and improving Range Of Motion of neck in patients with myofascial pain syndrome over upper trapezius muscle and there are evidences proving that Myofascial release technique is also effective.This study may prove that MuscleEnergyTechnique is more effective or Myofacial release technique is more effective in relieving pain and improving functional ability of neck in patients with myofascial pain syndrome over upper trapezius muscle. Several authors have suggested different conclusions. Some says Muscle Energy Technique is effective in relieving of neck pain and some says Myofascial release technique is effective. Therefore the purpose of this study is intended to know whether MuscleEnergyTechnique or Myofascial release technique is effective on upper trapezius patients with non specific neck pain.

3 HYPOTHESIS Experimental Hypothesis:

There will be a significant reduction in pain and disability when treated with Muscle energy technique in patients with trapezius fibrositis

There will be a significant reduction in pain and disability when treated with Myofascial release technique in patients with trapezius fibrositis

There will be a significant reduction in pain and disability when treated with Positional release technique in patients with trapezius fibrositis

There will be significant difference between Muscle Energy Technique, Myofacial Release and positional release in reducing pain and improving the functional range of neck among trapezius fibrositis patients

Null Hypothesis:

There will be no significant reduction in pain and disability when treated with Muscle energy technique in patients with trapezius fibrositis

There will be no significant reduction in pain and disability when treated with Myofascial release technique in patients with trapezius fibrositis

There will be no significant reduction in pain and disability when treated with Positional release technique in patients with trapezius fibrositis

There will be no significant difference between Muscle Energy Technique, Myofacial Release and positional release in reducing pain and improving the functional range of neck among trapezius fibrositis patients

4 6.2) Review of Literature

Viswas Rajdurai (2011): Conducted a study to assess the effectiveness of muscle energy technique on temporomandibular joint dysfunction. The study included 40 patients between 20-30 years diagnosed with temporomandibular dysfunction of less than 3 months duration. Participants were treated with MET, which included post isometric relaxation and reciprocal inhibition given on alternate days for 5 weeks. The subjects were evaluated for pain and maximal mouth opening. The study concluded that MET is effective in reducing pain and improving maximal mouth opening in patients with temporomandibular joint dysfunction

Amit V Nagrale et al(2010): Conducted a study on the efficacy of an integrated neuromuscular inhibition technique on upper trapezius trigger points in subjects with non- specific neck pain. In the study they compared the effects of two manual treatment regimens on individuals having myofascial pain syndrome over upper trapezius. The study included 60 patients who were divided into 2 groups. One group received muscle energy technique while the 2nd group received integrated neuromuscular inhibition technique consisting of MET, ischemic compression and strain-counter strain. The study concluded that the integrated neuromuscular inhibition technique had better effect than muscle energy technique

Anne z. Hoch, et al., (2010).The visual analogscale (VAS) is a reliable and valid tool in assessing clinical changes in patellofemoral pain syndrome patients.

Cassisi G et. al. [2008] stated that etiology of fibromyalgia is not completely understood and the symptom is influenced by factors such as stress , medical illness and variety of pain condition.

Thompson E [2008] stated that, Myofascial Release is a very effective hands-on technique that provides sustained pressure into myofascial knots to eliminate pain and restore motion.[20]

5 Dr. MOHANTY et. al (2006): They conducted a randomized trial to find out the effectiveness of spinal mobilization. The study was conducted on 42 patients around the age group 25 to 40 who were suffering from myofascial pain syndrome over periscapular muscles such as trapezius, levator scapulae and rhomboideus. Group A- control group received ischaemic compressions with stretching by hold- relax technique and group B with standard therapy and spinal mobilization. Visual analogue scale had been used to quantify the pain before and after treatment. The results of the study concluded that there is a significant reduction in pain pressure point threshold in group B than group A.

Di Giovanna, et. al. [2005] stated that, Myofascial release is a form of soft tissue therapy used to treat dysfunction and accompanying pain and restriction of motion. This is accomplished by relaxing contracted muscles, increasing circulation, increasing venous and lymphatic drainage, and stimulating the stretch reflex of muscles and overlying fascia

Fiona Macmillan, et al., (2004).The visual analogue scale has been reported as being capable of detecting statistically significant changes in small small samples of patients with patellofemoral pain syndrome. A 10-cm horizontal line has been shown to produce a more uniform distribution than a vertical line, with anchor words of "no pain" and "worst pain".

Kari Anne Holte, Rolf H. Westgaard et al (2004) They studied Daytime trapezius muscle activity and shoulder-neck pain of service workers with work stress and low biomechanical exposure. And the result was Stress-induced shoulder and neck pain is not necessarily associated with elevated trapezius muscle activity, but pain-free workers may benefit from better muscle relaxation in leisure

Schmerz et al (Dec 2003) had confirmed about diagnosis and therapy of myofacial trigger points for the upper trapezius spasm.it gives more support for the new diagnosis.

HERALD BRODIN, et. al (2003): Conducted an experimental study on 41 subjects with myofascial pain syndrome. The purpose of the study was to find out the effectiveness of muscle energy technique in patients with myofascial pain syndrome over periscapular muscles. The treatment duration was 3 weeks. The result of the study shows that there was a significant reduction in pain and improvement of range of motion of cervical spine

6 Rebecca marshall et al (2002) Evaluating the effectiveness of myofascial release to reduce pain in people with myofascial pain syndrome and the conclusion was myofascial release may help reduce the severity and intensity of muscle pain in people with myofascial pain syndrome. Hanten W P et al (2002) Ischemic pressure and sustained stretching was shown to be effective in reducing trigger point sensitivity and pain intensity in individuals with myofascial trigger points. . Lewit. K, et.al (1999): Conducted an experimental study on 70 patients with myofascial pain syndrome. The purpose of the study was to find out the effectiveness of muscle energy technique on myofascial pain syndrome. The result of the study shows that there is significant reduction of pain in myofascial pain syndrome following the application of muscle energy technique

Veeliming et al (1999) studied the effectiveness of MFR and US for upper trapezius trigger point for 35 subjects, 20 subjects with 4 stretch of 90 second and 15 subject with 1.5 watt/cm2 intensity and pulsed mode. He found MFR was more effective than modality

7 6.3) Objectives of the study: The objectives of the study are:  To determine the effect of muscle energy technique in reducing pain and improving functional range of motion among patients with trapezius fibrositis.  To determine the effect of myofascial release technique in reducing pain and improving functional range of motion among the patients with trapezius fibrositis  To determine the effect of Positional release technique in reducing pain and improving functional range of motion among patients with trapezius fibrositis  To compare the effectiviness of muscle energy technique, myofascial release technique and positional release technique in reducing the pain and improving 7 functional range of neck among patients with trapezius fibrositis

7.1 Source of data :

Samples for the study will be selected from HOSMAT Hospital Bangalore Methods of collection of data Primary data will be collected from the subjects and 45 subjects with Trapezius fibrositis will be included for the study based on selection criteria. Study design: This study is an experimental study design involving the pre and post test analysis of data. Sampling method: Forty Five subjects for the study will be selected on the basis of convenient sampling(Non-Probability) method. Materials Used:  Stool  Treatment Couch  Pillow  Towel  Goniometer  Stationaries

8 Measurement of Range of Motion: The cervical spine (neck) flexion ROM can be measured in sitting position with the thoracic and lumbar spine well supported by the back of a chair. The cervical spine is positioned in neutral position. The shoulder girdle is stabilized to prevent flexion of thoracic and lumbar spine. Center the fulcrum of goniometry over the external auditory meatus. Align the proximal arm either perpendicular or parallel to the ground then align the distal arm with the base of the neck and ask the patient to forward bend his/her neck. For extension, position, stabilization and alignment are same as flexion and ask the patient to bend his/her neck backward. For rotation, center the fulcrum over the center of the cranial aspect of head. Align the proximal arm parallel to an imaginary line between the two acromial processes. Then align the distal arm with of the nose and ask the patent to rotate his/her head.[15] Statistical Analysis: The effectiveness of treatment given within the groups will be analyzed statistically using Dependent 't' test and the significant difference between the groups will be analyzed using Independent 't'test. Ethical Clearance: Ethical clearance has been obtained from the ethical committee of the institution where the subjects belong to. ------

9 8 List of References: Walter.R.Frontera, Julie k.Silver, Thomas D.Rizzo; Essentials of Physical Medicine and Rehabilitation-musculoskeletal disorders, pain and rehabilition.2nd edition, Saunders Elsevier 2008; 37. Amit V.Nagrale, Paul Glynn, Aakanksha joshi, Gopichand Ramteke; The Efficacy of an integrated neuromuscular inhibition technique on upper trapezius trigger points in subjects with non-specific neck pain: a randomized controlled trial. Journal of Manual and Manipulative therapy 2010 Vol. 18 NO.1. Douglass AB, Bope ET. Evaluation and treatment of posterior neck pain in family practice.J Am Board Fam Pract 2004;17:S13-22. 4. Michel Guez et al; The prevalence of neck pain 2002,Vol.73,No.4, Pages 455- 459(doi: 10.1080/00016470216329). 5. Acta Orthopaedica-Informa Health care. Nachemson A, Waddell G, Norlund AI. Epidemiology of neck and low back pain. Nachemson AL, Johnsson E, editors. , (eds.) Neck and back pain, the scientific evidence of causes, diagnosis, and treatment. Philadelphia, PA Simons,D.G.,J.G.Travell,and L.S.simons.1999. Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol I.2nd ed: L.Mense S, Simons DG, Russell IJ. Muscle pain: understanding its nature, diagnosis and treatment. Philadelphia, PA: Lippincott Williams & Wilkins; 2000. Travell J, Simons DG. Myofascial pain and dysfunction. The trigger point manual. The lower extremities. 1st ed. Vol. II Baltimore, MD: Lippincott Williams & Wilkins; 1999. Harden RN, Bruehl SP, Gass S, Niemiec C, Barbick B. Signs and symptoms of the myofascial pain syndrome: a national survey of pain management providers. Clin J Pain 2000;16: 64-72. [PubMed] Fernandez-de-las Penas C, Sohrbeck Campo M, Fernandez Carnero J, Miangolarra Page JC. Manual therapies in myofascial trigger point treatment: a systematic review. J Bodyw Mov Ther 2005;9: 27-34. Choiniere M, Amsel R.: A visual analogue thermometer for measuring pain intensity. J Pain Symptom Manage. May 1996; 11(5):299-311

10 Jenson, M. P., P. karoly, and S. Braver: the measure of clinical pain intensity: a comparison of six methods. Pain 1956; 27:117-126. Paul S. Myles, Sally Troedel, Michael Boquest: The Pain Visual Analogue Scale: Is it Linear or Non Linear? Anesth Analg 1999;89:1517-20. McCormack HM, Horne DJ, Sheather S. Clinical application of visual analogue scales: a critical review. Psychol Med 1988;18:1007-19. Rickards LD. The effectiveness of non-invasive treatments for active myofascial trigger point pain: a systematic review of the literature. Int J Osteopath Med 2006;9: 120-36.

Manheim, Carol. 2001. The Myofascial Release Manual. 3rd Edition. Slack Inc DiGiovanna, Eileen; Stanley Schiowitz, Dennis J. Dowling (2005) [1991]. "Myofascial (Soft Tissue) Techniques (Chapter 12)". An Osteopathic Approach to Diagnosis and Treatment (Third ed.). Philadelphia, PA: Lippincott Williams & Wilkins; 80-82. Manheim, Carol. 2001. The Myofascial Release Manual. 3rd Edition. Slack Inc Benefits of a Myofascial Release .Available from http://www.myofascialrelease.com Leon Chaitow, Judith walker Delany, Clinical application of Neuromuscular Techniques.Vol-2.Churchill Livingstone, 2002; 209. Goodridge JP. Muscle Energy Procedures. In: Ward RC. (Ed) Foundations of Osteopathic Medicine. Philadelphia: Lippincott Williams & Wilkins; 1997. p. Cynthia C. Norkin, D. Joyce White: Measurement of Joint Motion, A guide to Goniometry Edition 2. Jaypee brothers Medical Publishers (p) Ltd 1998; 16. Kari Anne Holte, Rolf H. Westgaard. Department of Industrial Economics and Technology Management, The Norwegian University of Science and Technology, Trondheim, Norway PP.Mohanty et.al. "Muscle energy technique in myofascial trigger point treatment; A randomized trial". The Journal of the Indian association of Physiotherapists. Volume 2, Issue: 1 April 2006. Lewit. K, Simons.D.G. "Myofascial pain: relief muscle energy technique", Archives of physical medicine rehabilitation, volume 65, 1999, Pp: 452-456. Viswas Rajadurai; "The effect of muscle energy technique on temporomandibular

11 joint dysfunction: a randomized clinical trail". Asian journal of scientific research, 2011, vol 4, pg: 71-77 Herald Brodin: "Myofascial pain syndromes; Part2 syndromes of the head, neck and shoulder girdle", Henry ford hospital Medical Bulletin 4:22-28, 1956 Walter.R.Frontera, Julie k.Silver, Thomas D.Rizzo; Essentials of Physical Medicine and Rehabilitation-musculoskeletal disorders, pain and rehabilition.2nd edition, Saunders Elsevier 2008; 37. Walter.R.Frontera, Julie k.Silver, Thomas D.Rizzo; Essentials of Physical Medicine and Rehabilitation-musculoskeletal disorders, pain and rehabilition.2nd edition, Saunders Elsevier 2008; 37. Choiniere M, Amsel R.: A visual analogue thermometer for measuring pain intensity. J Pain Symptom Manage. May 1996; 11(5):299-311. Jenson, M. P., P. karoly, and S. Braver: the measure of clinical pain intensity: a comparison of six methods. Pain 1956; 27:117-126. Paul S. Myles, Sally Troedel, Michael Boquest: The Pain Visual Analogue Scale: Is it Linear or Non Linear? Anesth Analg 1999;89:1517-20.

12 9. Signature of the candidate :

10. Remarks of the Guide: Details of the study has been discussed and found to be satisfactory

11. Name and Designation of

Guide :Dr. Mrutyunjay Kumar

Signature :

Co-Guide :Dr. Dipika Verma

Signature :

Head of the Department : Dr. Vikranth. G.R

Signature :

12. 12.1 Remarks of the Principal :Recommended for registration

12.2 Signature :

13 APPENDIX- I HOSMAT HOSPITAL AND EDUCATIONAL INSTITUTE COLLEGE OF PHYSIOTHERAPY

No.33, 80 Ft Road, Opposite Laggere Ring Road, Bangalore-560058

Review Board on Ethics for Research

Review Category: Exemption from Review Expedited Review Full Review We hereby declare that the project titled, A STUDY ON “EFFECTIVENESS OF MUSCLE ENERGY TECHNIQUE, MYOFASCIAL RELEASE TECHNIQUE AND POSITIONAL RELEASE THERAPY AMONG PATIENTS WITH TRAPEZIUS FIBROSITIS" carried out by FERNANDES TRACY VANESSA, of 1st year M.P.T has been brought forward for scrutiny to the board members. Involvement of Special groups: Yes No If Yes Pregnant / Nursing Women: Children: Economically Disadvantaged: Socially Disadvantaged: Mentally Challenged: Type of Study: Cross sectional survey Case Control Cohort RCT AV Needs: Yes No After analyzing the objectives, subjects involved and the methodology of the study, the following conclusion was drawn. The study does not cause any mental or physical harm to the subjects involved and there are no risks involved in the subjects. The performance of the study procedure will not cause any injury to the subjects. The board has evaluated and confirmed that the experimenter is trained and qualified in measuring outcome. The informed consent form ensures that the experimenter explain the procedure of the study to the subjects, their voluntary participation is confirmed and the identification of maintained confidential. More over the finding of the study will benefit similar subjects, the profession and the society. Hence the review board has no objections on the conduct of the study.

Project guide Chairman of the review board

14 APPENDIX – II HOSMAT College of Physiotherapy Rajiv Gandhi University Consent Form

I ______agree to take part in the research study conducted by FERNANDES TRACY VANESSA, Postgraduate student (M.P.T Musculoskeletal Disorders and Sports Physiotherapy), HOSMAT College of Physiotherapy, Rajiv Gandhi University, entitled A STUDY ON “EFFECTIVENESS OF MUSCLE ENERGY TECHNIQUE, MYOFASCIAL RELEASE TECHNIQUE AND POSITIONAL RELEASE THERAPY AMONG PATIENTS WITH TRAPEZIUS FIBROSITIS" I acknowledge that the research study has been explained to me and I understand that agreeing to participate in the research means that I am willing to • Provide information about my/his/ her health status to the researcher • Allow the researcher to have access to my/his/her medical records, pertaining to purpose of the study • Participate in evaluator program • Make myself available for further follow up I have been informed about the purpose; procedures, measurements and risks involved in the research and my queries towards the research have been clarified. I provide consent to the researcher to use the information, video or audio recordings, for research and educational purpose only. I understand that my subject’s participation is voluntary and can withdraw at any stage of the research project. I understand that no monetary benefit will be given for participation in this research study.

Name of the applicant – Date-

Signature-

Signature of the researcher-