Rajiv Gandhi University of Health Sciences, Karnataka

Bangalore

Annexure II

1. Name of the candidate and ad-

dress (in block letters)

IDRIS SAJJAD HUSSAIN EZZY

Dr. M. V. SHETTY COLLEGE OF

PHYSIOTHERAPY,VIDYA NAGAR, KULOOR,

MANGALORE-575013

2. Name of the Institution Dr. M. V. SHETTY COLLEGE OF

PHYSIOTHERAPY

3. Course of study and subject MASTER OF PHYSIOTHERAPY

MUSCULOSKELETAL DISORDERS AND

SPORTS PHYSIOTHERAPY

4. Date of admission to the course 31st-OCT-2011

5. Title of the Topic COMPARATIVE STUDY BETWEEN IMMEDIATE

EFFECTS OF LOW LEVEL LASER WITH

STRETCHING AND ULTRASOUND WITH

STRETCHING IN THE TREATMENT OF UPPER

TRAPEZIUS TRIGGER POINTS

6.Brief Resume of the Intended Work

6.1) Introduction and Need of the Study:

Pain is described as an unpleasant sensation. Out of different varieties of

pain, one of most common variety of pain is myofascial pain. Myofascial pain is a clinical syn-

drome of soft tissue arising from skeletal muscle1 and are very frequent in general popula-

tion.2,3,4

In chronic muscle pain syndrome or myofascial pain syndrome (MPS), myofascial trigger point

(MTrP) is the cause of muscle pain. The term “myofascial trigger point” or “myofascial trigger

area” was first mentioned by Travell in 1942.

Poor posture often results from muscles; weakened by lack of exercise, obesity, sedentary life-

style or from use of non ergonomically designed furniture or improperly designed tools or ma-

chinery, sustained awkward head postures that often lead to the development of trigger points

in head, neck, shoulders and masticatory musculature.5 Formation of MTrPs result from re-

peated and prolonged activities like telephoning, sitting without arm rest support, playing vio-

lin, sleeping prone with head fully rotated to one side.6A degree of nerve compression can also

lead to increase of trigger point in the muscle supplied by that nerve.7 However trapezius mus-

cle appears to be the most frequently cited in clinical settings.8 Trigger points in the trapezius

muscle refer head pain to the temple, the neck, the orbital and periorbital regions9and also may

include jaw.10 Activity of trigger points may cause intolerance to weight of heavy clothing, such

as misfitting heavy overcoat which presses on the trapezius at the angle and back of the neck,

instead of o the acromial process.6

A MTrPs is a sensitive spot in taunt band of a skeletal muscle that is painful on compression

and/or stretch and that can give rise to a typical referred pain pattern. simmons et al

An active MTrP produces spontaneous referred pain, and always evokes clinical symptoms la-

tent MTrP is usually asymptomatic and may cause referred pain is response to compression.

Due to stretch or overload of the affected tissues(simmons et al. , 1999,pp.23-24) La tent

MTrPs may become active (painful) in relation to an acute injury or chronic repetitive trauma

to soft tissues, lesions involving various structures, or emotional stress.11,12,13

The word laser is an acronym for “Light Amplification by Stimulated Emission of Radiation”.

The Low Level Laser Therapy principle is based on the principle of stimulated emission. The

biological effects of Low Level Laser Therapy includes 1) Growth by cellular biostimulation 2)

The anti-inflammatory effects 3) The analgesic effects. LILT increases oxygen supply to hy-

poxic cells in trigger point areas by regulating microcirculation.14It has been suggested that the

LASER is a form of needleless(or painless) acupuncture. The electromagnetic energy from a

laser may penetrate and stimulate the MTrP in a manner similar to dry needling.15

John Z Serbely and James P Dickey did a randomized controlled trial o ultrasound treatment of

MTrps and found that ultrasound may be useful clinical tool for the treatment and management

of trigger points and myofascial pain syndromes.16 Ultrasound treatment involves the use of

high frequency acoustic energy that is generated using the reverse piezoelectric effect to

produce the thermal and non thermal effects in tissues.17 Pain relief is theorized to be related to

washout of pain mediators by increased blood flow, changes in nerve conduction or alterations

in cell membrane permeability that increase inflammation.18

Jj

Need of the study:

Myofascial pain syndrome is a common source of discomfort and disability for many pa-

tients, however, it is generally ignored or misdiagnosed leading to chronic painful conditions .19

Besides these so called specific methods, various physical modalities such as ice, heat, ultra-

sound, transcutaneous electrical nerve stimulation (TENS), ischaemic compression and mas-

sage have been used to treat trigger points. Despite the widely use of therapeutic modalities,

Hanten et al. claimed the quality of the studies on the efficacy of these modalities were low and

the supporting results reported only temporary relief for many of the modalities.

Low level laser therapy has often been applied in various musculoskeletal and soft tissue pain

syndromes.20 Many studies have been done to prove the efficacy and effectiveness of Laser on

myofascial trigger points.25-27

Studies have proved the effectiveness of ultrasound and stretching on myofascial trigger

points.22,23

Hence both the modalities have been proved to be effective in treating myofascial trigger

points. But no comparative studies have been done to compare the effects of Laser and ultra-

sound. Hence the need arises to measure the effects of Laser with stretching and ultrasound

with stretching in upper trapezius trigger points.

Research Question:

Is there significance difference between effects of low level laser with stretching and

Ultrasound with stretching in decreasing pain, elevating pain threshold and improving ROM of

neck rotation and lateral flexion?

Hypothesis:

Null hypothesis:

There will be no significant immediate difference in pain reduction, pain threshold elevation

and ROM of cervical lateral flexion and rotation following low level laser with stretching when

compared to ultrasound with stretching in the patients with upper trapezius trigger points.

Research Hypothesis:

There may be a significant immediate difference in pain reduction, pain threshold elevation and

ROM of cervical lateral flexion and rotation following low level laser with stretching when

compared to ultrasound with stretching in the patients with upper trapezius trigger points.

6.2) REVIEW OF LITERATURE :

Srbely JZ et al (2008) did a randomized controlled study to investigate the antinociceptive effects after

stimulation of myofascial trigger points with ultrasound. The result of the study established that low-

dose ultrasound evokes short-term segmental antinociceptive effects on trigger points which may have

applications in the management of musculoskeletal pain.21

Tayfun Aldemir et al (2007) conducted a randomized control study. The treatment interventions were

botox-A trigger point injection, lidocaine, conventional ultrasound, high power pain threshold ultra-

sound and stretching exercise. The result of the study shows that trigger point injections were more ef-

fective; conventional ultrasound and high power pain threshold ultrasound were equally effective in re-

ducing pain intensity in patient with chronic myofascial pain syndrome.22

James P Dickey and John Z Srbely (2006) conducted a single blinded randomized control trial to in-

vestigate whether therapeutic ultrasound modulates the pain sensitivity of MTrPs. The result of the

study shows that therapeutic exposure to ultrasound reduce the trigger point sensitivity.16

Esenyl, Caglar et al (2000) did a study to investigate the effectiveness of ultrasound and trigger point

injections in combination with neck stretching exercise on 102 patients who had a myofascial trigger

point in upper trapezius muscle. The result of the study shows that ultrasound is useful in reducing trig -

ger point sensitivity.23

Jason C Lee (1996) did a study to investigate the effectiveness of combining ultrasound therapy and

modified electrotherapy for the treatment of MTrPs of upper trapezius muscle. The combination of ul -

trasound therapy and electrotherapy offers a greater immediate increase in the range of motion of the

muscle than placebo therapy ultrasound therapy alone or electrotherapy alone.24

Ali Gur et al (2004) A prospective, doubleblind, randomized, and controlled trial was conducted in pa-

tients with chronic myofascial pain syndrome (MPS) in the neck to evaluate the effects of infrared low

level 904 nm Gallium-Arsenide (Ga-As) laser therapy (LLLT) on clinical and quality of life (QoL). This

study revealed that short-period application of LLLT is effective in pain relief and in the improvement

of functional ability and QoL in patients with MPS.25

Ebru Ilbuldu, Aysegul Cakmak et al (2004) did a study of Comparison of Laser, Dry Needling, and

Placebo Laser Treatments in Myofascial Pain Syndrome. observed a significant decrease in pain at rest,

at activity, and increase in pain threshold in the laser group compared to other groups and conclude that

Laser therapy could be useful as a treatment modality in myofascial pain syndrome because of its nonin-

vasiveness, ease, and short-term application.26

M. ZEKI KIRALP , HUSEYIN ARI et al (2006) did study on Comparison of low intensity laser therapy

and trigger point injection in the management of myofascial pain syndrome and found out that low in-

tensity laser therapy and trigger point injection are equally effective. Although the results obtained from

the laser therapy were better.27

Aral Hakguder et al (2003) did a study to clarify the effect of low level laser therapy in MPS by using

algometry and thermography. The result of the study concludes that low level laser therapy seemed to be

beneficial for pain in MPS by using algometry and thermography.19

Synder-Mackler L et al (1986) did a randomized double blinded study to ascertain the effect of a he-

lium-neon (He-Ne) Laser on the resistance of areas of skin overlying musculoskeletal trigger points. The

results of a two-way analysis of covariance with one repeated measure showed a statiscally significant

increase in skin resistance.28

Olavi A et al (1989) did a study to investigate the effects of the infrared laser therapy at treated and

non-treated increased the pain threshold. Trigger points. The result of the study suggests that infrared

laser had an effect at the trigger points and that the treatment significantly.29

Reeves JL et al (1986) reviewed studies demonstrated the reliability of the pressure algometer

as an index of myofascial trigger point sensitivity. Among those studies, showed high reliability

between and within experimenters when measuring marked trigger point locations30.

James W Youdas et al (1991) result of study demonstrated the reliability of universal goniome-

ter and cervical range of motion instrument when used by same physical therapist.31

6.3) OBJECTIVES OF STUDY:

1. To find out whether the application of laser and stretching can reduce the pain, elevate

pain threshold and improve ROM of neck lateral flexion and rotation immediately after

treatment in patient with upper trapezius trigger points.

2. To find out whether the application of ultrasound and stretching can reduce the pain, ele-

vate pain threshold and improve ROM of neck lateral flexion and rotation immediately

after treatment in patients with upper trapezius trigger points.

3. To compare the efficacy of laser therapy with stretching and ultrasound with stretching to

reduce pain, elevate pain threshold and improve ROM of neck lateral flexion and rotation

immediately after treatment in patients with upper trapezius trigger points.

7. MATERIALS AND METHODS:

7.1) Study design:

Experimental.

7.2) Sources of Data:

Patients from Govt. Wenlock Hospital and Dr. M.V. Shetty Physiotherapy Clinic,

Mangalore will be recruited for the study.

7.3) Definition of Study Subjects:

A sample size of 60 patients in the age group of 18-60 years with 30 in each group of the

two groups will be there for the study.

7.2 II) Inclusion and Exclusion Criteria:

Inclusion criteria:

Age between 18 and 60

Male and Female

Presence of palpable taunt band in a upper back muscles

Presence of a hypersensitive tender spot in a taunt band

Local twitch response provoked by the snapping palpation of the taunt band

Reproduction of the typical referred pain pattern of the MTrPs in response to compression

Trigger-points in the neck region and having a duration more than 3 months

Exclusion criteria:

Pregnancy.

Any type of previous neck or shoulder surgery within the past year.

Signs of cervical discus prolapsed, systemic disorder or migraine.

Changes in medication or other treatments 3 weeks prior to entrance.

Systemic and Psychological disorders.

Patients with radiographic pathology.

Malignancy.

Taking MTrPs injections

Severe orthopedic abnormalities and presence of nerve root irritation findings.

7.2 III) Study Sampling Design, Method and Size:

Sample design :

Purposive sampling technique.

Sample size:

Around 60 patients fulfilling the inclusion and exclusion criteria will be selected.

7.2 (IV) Follow up:

One time study

7.2 (V) Parameters used for comparison and statistical analysis used:

Collected data will be analyzed by mean, standard deviation, paired and unpaired ‘t’ tests.

7.2 (VI) Duration of the Study:

Duration of the study will be around 10-12 months.

7.2 VII) Methodology:

60 subjects those satisfying the inclusion criteria will be recruited for the study. Following

screening for inclusion, all eligible patients will be allocated into two groups of Group A and

Group B, 30 in each group. Pre test will be recorded for all groups for pain by VAS , pain

threshold using pressure algometer and cervical lateral flexion and rotation using goniometer.

Patients in Group A will receive a combination of low level laser and stretching whereas

patients in Group B will be administered a combination of ultrasound and stretching. lastly,

after treatment algometer , cervical lateral flexion and rotation and visual analogue scale

readings were taken again.

Treatment:

Group A :

Low level laser and stretching

LOW LEVEL LASER:

It will be used with parameter such as Ga-As-Al (780nm), maximum

power 10 mW, intensity 5 J/cm2.19Scanning method will be used with appropriate Amplitude,

Frequency and Position hand held LASER probe.

TECHNIQUE OF APPLICATION:

The parameter will be taken same as above with patients treated for 3

minutes 16 sec per trigger point.19 The patients will be explained about laser technique and need

for improvement in pain. The patient will be positioned in comfortable sitting position, so that

the patient is relaxed and comfortable and also the affected part well exposed. The therapist will

be standing by side of the patient.

Duration of a single session will be 3 minutes 16 sec per trigger point.19

STRETCHING

PROCEDURE: The patient is supine. Ask him to rotate his head to opposite side then tuck his

chin as far as possible. Ask him to pull his same side shoulder down away from his head.

Therapist places his one hand at the patient’s occiput, fingers pointing toward the ceiling.

Places his other hand crossing over his first hand on patients shoulder. The therapist pushes his

occiput and shoulder away from each other and maintained the stretch for 10-15 secs and

repeats for 2-3 times.32

.

Group B :

Ultrasound and stretching

ULTRASOUND

1 w/cm2, continues wave , 1 MHz for 5 mins each trigger point.22

TECHNIQUE OF APPLICATION:

The parameter will be taken same as above with patients treated for 5 minutes per trigger

point. The patients will be explained about ultrasound technique and need for improvement in

pain. The patient will be positioned in comfortable sitting position, so that the patient is relaxed

and comfortable and also the affected part well exposed. The therapist will be standing by side

of the patient. The skin surface to be treated will be inspected for open wounds. The coupling

medium will be applied to the skin in order to transmit ultrasound waves to treatment part.

Duration of a single session will be 5 minutes per trigger point.22

STRETCHING

PROCEDURE: Same as given in group A

7.3) Does the study require any investigations to be conducted on patients or other hu-

man or animal if so please describe briefly?

Yes.

Pain- VAS (Visual Analogue Scale)

Pain Pressure Threshold (Algometer)

Cervical lateral flexion and rotation (Goniometer)

7.4) Has ethical clearance been obtained from your institution incase of 7.3?

Yes.

8.

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