Effect of Muscle Energy Technique with Deep Friction Massage on Pain, Disability and Internal Rotation Range of Motion of Hip J

148 Indian Journal of Physiotherapy and Occupational Therapy. January-March 2020,DOI Vol.Number: 14, No. 10.5958/0973-5674.2020.00027.1 1 Effect of Muscle Energy Technique with Deep Friction Massage on Pain, Disability and Internal Rotation Range of Motion of Hip Joint in Individuals with Piriformis Syndrome

Nithya Narayanan Kutty1, Saad Siddeeque2, Heiskrujam Tamphaibema3, Azharuddin3, Nishanth Othayoth4, Bineesh C P5 1Assistant Professor (Dept. of Physiotherapy), Cooperative Institute of Health Sciences, Thalassery, Kannur, Kerala-India, 2Orthopedic Physiotherapist, Burjeel Hospital for Advanced Surgeries, Dubai, 3Physiotherapist, Burjeel Hospital for Advanced Surgeries, Dubai, 4Registered Physiotherapist, Hamilton Physio and Rehab, 5Assistant Professor (Dept. of Medical Biochemistry) Cooperative Institute of Health Sciences, Thalassery, Kannur, Kerala-India

Abstract Background: Piriformis Syndrome (pseudo sciatica) is caused by pressure of an injured or irritated piriformis muscle which leads to neuritis of branches of the sciatic nerve; mimics the signs and symptoms of low back pain. Due to high incidence of low back pain in our society, P.S frequently goes unrecognized or misdiagnosed in clinical settings.

Method: Patients with piriformis syndrome were screened for inclusion and exclusion criteria after detailed assessment. 30 patients who meet the inclusion criteria were grouped into 2groups (15 patients in each group). Control group received UST and piriformis muscle stretching and experimental group received MET with DFM. Treatment period was about 30-40min each session in regular period of 6 days for a week for both groups.

Outcome Measures: Oswestry Disability Index, Visual Analogue Scale, Standard Goniometer

Results: Statistical analysis of intergroup significance by Mann Whitney U-test for IR ROM (sig.0.000 < p = 0.05) and independent sample t-test for VAS (t = 2.895 > table value, t = 2.048) and ODI (t = 4.842 > table value, t = 2.048) reveals that experimental group shows significant difference between pre test and post test values of IR ROM, VAS and ODI than that in the control group.

Conclusion: experimental group who received MET along with DFM shows greater improvement on pain, disability and IR ROM in individuals with piriformis syndrome than those in the control group who received U.S.T and piriformis muscle stretching.

Key words: Piriformis Syndrome, MET, DFM

Introduction Corresponding Author: 1 Nithya Narayanan Kutty Piriformis syndrome also referred as pseudo sciatica 2 Assistant Professor (Dept. of Physiotherapy) or pseudo disc is defined as a neuritis of branches of the Cooperative Institute of Health Sciences, sciatic nerve caused by pressure of an injured or irritated 3 Kannur-670105, Kerala-India Piriformis muscle .The term “sciatica” was coined in th PH: 09747356186 Florence in the 15 century for the leg pain thought to 4 [email protected] originate at the ischium .When the term is used, most Indian Journal of Physiotherapy and Occupational Therapy, January-March 2020, Vol. 14, No. 1 149 people think of intervertebral disc pathology as a source of the Piriformis muscle, which are most useful in ruling of the problem, radiating down the lower extremity out disc and vertebral pathologic conditions5. posteriorly. Several studies reported physical therapy modalities Piriformis syndrome (PS) is a painful musculoskeletal such as heat therapy, cold therapy, and ultrasound condition, characterized by a constellation of symptoms therapy along with stretching of the Piriformis muscle that include buttock or hip pain. There are two types have a beneficial effect on treatment. Also manual of P.S: Primary P.S is caused by an anatomic variation therapy approach may combine muscle stretches, muscle like split Piriformis muscle, split sciatic nerve etc.The energy techniques, soft tissue and myofascial techniques Secondary P.S, caused by precipitating factors such to address all somatic dysfunctions in the patients with as macrotrauma,local ischemia, microtrauma due to Piriformis syndrome. overuse or direct compression (e.g.: wallet neuritis)etc5. In 50% of cases, piriformis syndrome is caused by a STUDY PROCEDURE 6 macro trauma to the buttocks . Subjects (40-60yrs, both males and females) with Piriformis syndrome occurs most frequently during low back pain are taken into consideration, in which the 4thand 5thdecades of life and affects individuals of all piriformis syndrome subjects are selected by the proper occupations and activity levels. Reported incidence screening and fulfilling the inclusive and exclusive rate for P.S among patients with LBA vary widely, criteria. Informed consent was taken from each subject from5-36%7,8.It is more common in women than prior to participation. Instructions were given to the men(6:1),possibly because of biomechanics associated subjects about techniques performed. A total of 30 with the wider ‘Q’ angle in the oscoxae of women5.A subjects was divided equally into two groups [Group Morton foot can predispose the patient to develop A (n=15) and Group B (n=15)]. Group A was received piriformis syndrome. A fraction of population is at high ultrasound therapy(UST) and piriformis muscle risk, particularly skiers, truck drivers, tennis players and stretching and Group B was received Muscle Energy long distance bikers9. Technique(MET) with Deep Friction Massage(DFM), for treatment duration of about 30- 40min in each It was first described by Yeoman in 192810. session for regular period of 6days for a week. Both Contemporary use of piriformis syndrome begin with groups received hot pack application for 10min prior to Robinson4 1947,who delineated five salient features;(1) muscle stretching in order to induce muscle relaxation. History of local trauma,(2)Pain localized to SI joint, Home care programs were taught in both groups. greater sciatic notch and piriformis muscle which extends along the course of the sciatic nerve and Control group: presents difficulty in walking,(3)Acute pain brought on Patient was positioned in side lying FAIR position. by stooping or lifting,(4)Palpable spindle or sausage Ultrasound therapy, with intensity 2.0w/cm2 using 1MHz shaped mass at the anatomic location of the piriformis frequency pulsed ultrasound apparatus administered in 7 muscle,(5)Positive Lasegue sign. Pace and Nagle have broad strokes longitudinally along the piriformis muscle reported dyspareunia as a symptom of P.S. Steiner et from the tendon to the lateral edge of the greater sciatic 11 al found the most trigger area to be located 3cm caudal foramen for 10min. After that, positioned the patient in and lateral to the midpoint of the lateral border of the prone lying for application of hot pack on the myofascial sacrum. Another positive sign of the P.S is a persistent trigger point area for 10min. Then passive stretching of external rotation of the ipsilateral foot(splay foot), which the piriformis muscle5times each session with stretch 5, 6 is easily detectable when lying in supine . Thus ROM period 15secs each was given by positioning the patient evaluation may reveal decreased internal rotation of the in supine. ipsilateral hip in such cases. Experimental group: The FAIR test12, the FREIBERG’s test, LASEGUE’s test, the PACE and BEATTY maneuver13etc shows a The patient was positioned in prone lying, close positive sign to diagnose piriformis syndrome. EMG can to the edge of the table then applied hot pack over the be beneficial in differentiating P.S from inter-vertebral myofascial trigger point area for 10min, then in the disc herniation. MRI and CT scanning reveal enlargement same position knee flexed at 900 grasping the ankle and 150 Indian Journal of Physiotherapy and Occupational Therapy. January-March 2020, Vol. 14, No. 1 brought the hip joint to internal rotation. A degree of subjects are selected by the proper screening and compression was applied via the elbow for 5-7secs while fulfilling the inclusive and exclusive criteria. The control the muscle is kept at a reasonable but not excessive group received U.S.T and piriformis muscle stretching degree of stretch. Maintain contact on the point but and experimental group received MET along with eases the pressure and asks the patient to introduce D.F.M, for treatment duration of about 30-40min each an isometric contraction for 5-7secs to piriformis by session in a regular period of 6days for a week. Both bringing the lower leg towards external rotation against group received hot packs application for about 10min resistance. After the contraction ceases and the patient prior to muscle stretching in order to induce relaxation. relaxes, the lower limb was taken to its new resistance barrier and elbow pressure was reapplied. The procedure The outcome measures used were Oswestry was done 10times in each session. disability index to measure pain and disability, Visual Analogue Scale to measure pain intensity and standard goniometer to detect IR ROM deficit. Each measurement was done on the first day of treatment (pre test) and on the last day of the treatment (post test). Then datas were analyzed statistically.

Statistical data reveals that MET along with DFM shows significant effect over standard physical therapy treatment on pain, disability and IR ROM of hip joint in individuals with P.S.

According to Fred Mitchell, MET can be defined as, technique where the patient voluntarily moves body as specifically directed by the physician from a precisely controlled position, in a specific direction and against a distinctly execute counter force.

Clinical uses of MET are:

• Lengthen tight muscle fibers and fascia GRAPH: MEAN VALUES OF IR ROM, VAS AND ODI • Mobilize joints in which movement is restricted. Result • Strengthen muscle fibers that become weak and Statistical analysis was done by using SPSS.16. hypotonic. When comparing the post test values of IR ROM, VAS & ODI of both control and experimental group • Regain overall muscle balance. through analysis of inter group significance; IR ROM shows sig.value 0.000 in Mann Whitney U-test Main physiological effects proposed by the (p<0.05),VAS shows calculated t-value=2.895(>table application of MET are: value=2.048,df-28 at p=0.05) and ODI shows calculated • It has been shown to improve joint ROM. t-value=4.842(>table value=2.048,df-28 at p=0.05) in independent sample t-test. This shows that experimental • It has been shown to improve muscle group shows significant difference from control group extensibility more effectively than passive stretching – in all outcome measures. Hence, “there is significant both the short term and long term effect. effect by MET along with deep friction massage on pain, disability and IR ROM of hip joint in individuals • Myofascial trigger point deactivation has been with piriformis syndrome”. shown to be enhanced by the use of MET. The reason behind this physiological effect is due Discussion to the neurological mechanism that may follow use of In this study, Subjects with low back pain are taken MET. into consideration in which the piriformis syndrome Indian Journal of Physiotherapy and Occupational Therapy, January-March 2020, Vol. 14, No. 1 151 • The effect may result from the inhibitory Golgi Pre test evaluation of control and experimental group tendon reflex activated during the isometric contraction shows that there is no significant difference between the that leads to reflex relaxation of the muscle as a result groups before treatment. When analysis of intragroup of Post Isometric Relaxation (PIR), (Mitchel et al 1979 significance were done within the groups in both control &Lewit 1986)14. and experimental, there shows significant difference between the pre test and post test values of IR ROM, • An alternative reflex effect has been suggested VAS & ODI in both groups. But when the analysis of in which an isometric contraction of the antagonists inter group significance was done between the post of affected muscle induce relaxation via Reciprocal test values of IR ROM, VAS & ODI of control group 14 Inhibition (RI),(Liebenson 1996 & Levin 1954) . and experimental group; it is evident that experimental According to Cyriax16, DFM technique temporarily group shows significant improvement in pain, disability reduces pain by activating the gate mechanism and and IR ROM of hip joint in individuals with P.S increases the destruction of Lewis substance P thought to be the principal chemo mediator of pain impulses from Conclusion the periphery to the CNS. Movement imparted through In this study, 2groups with P.S were treated with friction results in stimulation of the mechano receptors 2 different treatment approaches. Control group were that transmit impulses along large fiber afferent pathways treated with standard physical therapy approach i.e. U.S.T to the spinal cord. They serve to decrease nociceptor and piriformis muscle stretching and the experimental transmission to higher pain centers. It appears that as group with manual therapy approach i.e. MET with deep the patient responds to friction massage on subsequent friction massage. The group treated with manual therapy treatment the time for anesthesia to occur lessens. The approach had significant improvement in IR ROM of hip temporary relief at the end of the treatment session of joint, pain and disability due to piriformis syndrome than friction massage permits other treatment. those treated with standard physical therapy treatment.

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