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Effectiveness of myofascial release to biceps brachii, latissimus dorsi & pectoralis major in structural diagnosis and management protocol for patients with tennis elbow

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  • Bangladesh Health Professions Institute (BHPI), The academic institute of Centre for the Rehabilittaion of the Paralysed (CRP)

Abstract and Figures

Background: Tennis Elbow (TE) is a common disorder affecting the tendinous origin of the wrist extensors and evidences suggest association of trigger points in Biceps brachii, Pectoralis major and Latissmus dorsi with TE. Structural diagnosis and management (SDM) is a comprehensive biomechanical assessment process to treat musculoskeletal dysfunctions conceptualized by Dr, M Shahadat Hossain over 15 years of clinical practice. Objective: The objective of the study was to find out the effectiveness of myofascial release technique of Biceps brachii, Pectoralis major and Latissmus dorsi in SDM approach on pain and associated impairments in TE subjects. Study design: This study was a pilot randomized controlled trial (RCT). The study was conducted in the Outdoor musculoskeletal physiotherapy department of Centre for the Rehabilitation of the Paralyzed (CRP) and Popular Medical College Hospital. 20 subjects with the LE were introduced in two groups equally. The MFR in SDM treatment protocol was provided for four weeks with 10 sessions. As Outcome measures Pain was measured by numerical pain rated scale (NPRS), ROM measured by using universal Goniometer, muscle powered measured by OXFORD grade scale and functional disability measured by patient rated tennis elbow disability questionnaires (PTEDQ). The outcome was assessed at baseline and after 4 weeks by independent assessor. Result: The result shown a significant decrease in pain and improvement in functional performance (p<0.05) in SDM group compared to control groups. MFR in SDM protocol found to have a greater effect on all outcome measures in TE subjects. However no significant change has been noted in ROM in any group. Conclusion: The result of this pilot study indicates that 4 weeks with 10 session of MFR in SDM Protocol was effective in improving pain and associated impairments in tennis elbow patients.
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ISSN Print: 2394-7500
ISSN Online: 2394-5869
Impact Factor: 5.2
IJAR 2019; 5(12): 41-45
www.allresearchjournal.com
Received: 25-10-2019
Accepted: 27-11-2019
KM Amran Hossain
Lecturer of Physiotherapy,
Bangladesh Health Professions
Institute, Dhaka-1343,
Bangladesh
Mohammad Shahadat Hossain
Doctoral Fellow,
Jahangirnagar University,
Savar, Dhaka-1342,
Bangladesh
Sapia Akter
Consultant Physiotherapist,
ASPC Manipulation Therapy
Centre, Dhaka-1207,
Bangladesh
Dr. Nasirul Islam
Visiting Faculty, Bangladesh
Health Professions Institute,
Apt 1412, 10-Teesdale Place,
Scarborough, Toronto, ON,
Canada
Md. Shahoriar Ahmed
Project Coordinator, BPA-
Towards Global Health (HI),
Dhaka-1207., Bangladesh
Zahid Hossain
Lecturer of Physiotherapy,
Bangladesh Health Professions
Institute, Dhaka-1343,
Bangladesh
Correspondence Author:
KM Amran Hossain
Lecturer of Physiotherapy,
Bangladesh Health Professions
Institute, Dhaka-1343,
Bangladesh
Effectiveness of myofascial release to biceps brachii,
latissimus dorsi & pectoralis major in structural
diagnosis and management protocol for patients with
tennis elbow
KM Amran Hossain, Mohammad Shahadat Hossain, Sapia Akter,
Dr. Nasirul Islam, Md. Shahoriar Ahmed and Zahid Hossain
Abstract
Background: Tennis Elbow (TE) is a common disorder affecting the tendinous origin of the wrist
extensors and evidences suggest association of trigger points in Biceps brachii, Pectoralis major and
Latissmus dorsi with TE. Structural diagnosis and management (SDM) is a comprehensive
biomechanical assessment process to treat musculoskeletal dysfunctions conceptualized by Dr, M
Shahadat Hossain over 15 years of clinical practice.
Objective: The objective of the study was to find out the effectiveness of myofascial release technique
of Biceps brachii, Pectoralis major and Latissmus dorsi in SDM approach on pain and associated
impairments in TE subjects.
Study design: This study was a pilot randomized controlled trial (RCT). The study was conducted in
the Outdoor musculoskeletal physiotherapy department of Centre for the Rehabilitation of the
Paralyzed (CRP) and Popular Medical College Hospital. 20 subjects with the LE were introduced in
two groups equally. The MFR in SDM treatment protocol was provided for four weeks with 10
sessions. As Outcome measures Pain was measured by numerical pain rated scale (NPRS), ROM
measured by using universal Goniometer, muscle powered measured by OXFORD grade scale and
functional disability measured by patient rated tennis elbow disability questionnaires (PTEDQ). The
outcome was assessed at baseline and after 4 weeks by independent assessor.
Result: The result shown a significant decrease in pain and improvement in functional performance
(p<0.05) in SDM group compared to control groups. MFR in SDM protocol found to have a greater
effect on all outcome measures in TE subjects. However no significant change has been noted in ROM
in any group.
Conclusion: The result of this pilot study indicates that 4 weeks with 10 session of MFR in SDM
Protocol was effective in improving pain and associated impairments in tennis elbow patients.
Keywords: Tennis elbow, MFR, structural diagnosis & management
Introduction
Lateral Epicondylitis (LE) or Tennis elbow (TE) as it is well known musculoskeletal
condition of elbow, first introduced 100 years ago by Runge in 1873 [2, 14]. TE is one of the
most common condition generally affect to the extensor carpi radialis brevis (ECRB), and the
extensor digitorum communis muscles to the lateral epicondyle and most often affected in
the dominant arm rather than non-dominant arm [3, 10]. This is a debilitating disorder
occurring most often between the third to sixth decades of life [4] with a prevalence of 1 to
3% of general population and high risk of hand task industries 15% [3-8, 17]. Evidence found
the etiology of TE as local trauma, repeated overuse of hypovascular zone [9], contusion, or
sprain, soft-tissue calcification, bursitis, monotonous, repetitive eccentric contractions and
gripping activities of the wrist [7] radiohumeral synovitis [2], tear of the extensor carpi radialis
brevis muscle [4], avulsion of the tendon origin [8], displacement of the orbicular ligament on
the radial head [7] or idiopathic spontaneous occurrences [2]. The impairments of the condition
have a major impact on social participation and professional life [9].
Every year, near about four among one thousand adults come to medical practitioner with
elbow pain where initial diagnosis of TE can be interpreted therefore less of them has
International Journal of Appl ied Research 2019; 5(12): 4 1-45
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perfect diagnosis [14, 9]. TE patients visits Physiotherapists
and a wide range of physiotherapy regimen as electrical
stimulation, laser, ultrasound, manual therapy techniques,
acupuncture, NSAID’s along with corticosteroid injections
have been introduced; Manual Therapy techniques include
stretching, strengthening, transverse friction, manipulation,
strain and counter strain technique [13].
TE manifests several sign and symptoms related to specific
muscles of wrist extensor; but there are more associations
relating arm, shoulder, neck and back [20]. Gun & Milbrant
[21] conducted a baseline study on the cases that were not
responded to conventional management of TE on the
affected site. The study found that there is strong association
of motor points of pectoralis major, shoulder rotator cuff,
neck and trunk muscles on the basis of frequency of
tenderness. In the study, the tender points located in Biceps
brachii and latissmus dorsi and causing remarkable postural
abnormality of upper quarter in affected side of TE patients.
The idea to release these muscles was from the
biomechanical analysis derieved from Structural diagnosis
and Management (SDM) concept. SDM concept of
musculoskeletal medicine focuses on a comprehensive
approach to assess both the contractile and non-contractile
structures to generate a hypothesis to solve the specific
sources hindering normal activities. This has been
developed from 15 years’ experience of Dr. M Shahadat
Hossain treating diverse cases of musculoskeletal medicine.
The SDM assessment directs conservative management
procedure in a way of taking history, examination of
arthokinemetic and osteokinemtic motions, stretching the
series of muscles with biomechanical rationale, strength the
relative stabilizer, examination to the biomechanical
contributor, myotomes and isolated release to neural
sensitive structures to treat patients (Figure 1).
Gerwin stated [22] Myofascial release (MFR) of trigger points
may improve impairments and functional state of upper
extremities in different musculoskeletal conditions. MFR is
being used as good efficacy for the patients with TE and
usually have two types; Stanborough explains one as direct
technique MFR and second as indirect technique [11].
Evidence suggests that, MFR is used in restricted fascial
layers either directly or indirectly as slow with sustain
pressure ranging 120 seconds to 300seconds. During direct
technique MFR, pressure is being applied by the
practitioners hand in knuckles shape of hand, elbow or other
tools to apply tension or stretch slowly into the fascia [12].
The pilot study has been conducted to enlist the associated
trigger points in TE patients at physiotherapy department of
2 rehabilitation centre at Dhaka, Bangladesh. The trigger
points were diagnosed according to the recommended
guideline of Johnson and Dommerholt [19]. The study states
Trigger point can be diagnosed by palpable taut band in
accessible muscle, extreme spot tenderness of a nodule in a
taut band or by an indicative point of pain located by
patient. The pilot study recognized biceps brachii, latissimus
dorsi & pectoralis major as the tender points and active
nodules in most cases. Hence, the study has been conducted
to find out the effectiveness of Myofascial Release
Technique (MFR) in SDM concept to the biceps brachii,
latissimus dorsi & pectoralis major to elicit changes in pain,
ROM, Muscle power and functional disability in tennis
elbow patients.
Materials and Methodology
Total 25 participants screened with tennis elbow from
musculoskeletal department of CRP and Popular Medical
College Hospital (PMCH) has been screened for eligibility.
Then 20 subjects with the TE were introduced in this study
according to inclusion criteria. Inclusion criteria were
diagnosed case of TE by graduate physiotherapist or
physician with an age 14-60 years of both sexes. The
diagnosis has been done through several special tests as
cozen test, Mills test, middle finger extension test [23]
resisted wrist extension test [24], resisted radial deviation test,
palpation test [25]. Exclusion criteria were infective
conditions of upper limb, dermatitis, malignancy or
hazardous to myofascial release.
Interventions
The subjects were divided into two different groups
randomly by concealed allocation; one group received MFR
in SDM concept (n=10) and another group received
Conventional physiotherapy (n=10). The predefined
treatment protocol was provided for four weeks with 10
sessions. The pain, ROM, Muscle power, and functional
disability were assessed at baseline assessment and after last
treatment session.
Myofascial Release Technique in SDM
Myofascial release has been applied to fascia’s excessive
pressure on the pain sensitive structure and restores proper
alignment [26] prior to diagnosis through SDM. The
procedure is low load long duration stretched over the fascia
complex which intended to restore optimal length and
decrease pain and improves function [15-17].
The steps of the technique were as follows (Figure 1)
1. Place the patient in supine lying position; place the
affected shoulder free from any restriction (Picture A)
2. To release Biceps place the shoulder in 30 to 40 degree
abduction with less than half range of external rotation
(Picture B) Press over humeral head outward and
inward (Picture C) and perform arm distraction.
Concern about the pain and progress according to the
tolerance of patient.
3. To release pectoralis major and latissmus dorsi place
the shoulder 90 degree abducted, more than half of
external rotation and elbow in 90 degree (Picture D).
Press over humeral head, upper shaft of humerus and
muscle belly of pectoralis major from this position
onwards up to full external rotation (Picture E, F).
The interventions have been applied for 10 sessions in 4
weeks. A session of MFR consisted 3- 5 minutes in a trigger
point with total release time exceeding not more than 7-10
minutes.
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A B C
D E F
Fig 1: MFR in SDM protocol for Biceps, Pectoralis & Latissmus dorsi in TE Patients
Conventional Physiotherapy: Conventional physiotherapy
included the variety of physiotherapy regimen that is
generally applied as the treatment of TE [16, 17]. Treatment
includes electrical modalities as cryotherapy, LESER,
Transcutaneous electrical nerve stimulation (TENS),
Infrared Radiation (IRR), and ultrasound. In addition
stretching exercise, strengthening exercise has been
prescribed. Elbow has been supported by elbow band, or
splint. To maintain the efficacy self- stretching, awareness
and education has been provided to patients. As
electrotherapy, Pulse ultrasound provided only those
patients who are recommended [15, 16]; Frequency was 1
MHz, Intensity was 0.8 W/cm2, provided in pulse mode
with 1:4 ratios, for 5 minutes for 4 weeks. The stretching
exercise has been performed both in laying and sitting
position where shoulder flexed in 90 degrees and elbow
extended where therapist hand pulling wrist into flexion [15-
17]. The Strengthening exercise has been performed both
sitting and lying position where therapist give the manual
resistance over dorsum aspects of the hand and patients
instructed to perform full extension of the wrist [15-17].
Ethical Issue
Research proposal was submitted for approval to the
administrative bodies of Institutional review board of
Bangladesh Health Professions Institute. The intervention
provider and data collector followed the Helsinki guideline
and CRP ethical committee guidelines. Researcher strictly
maintained the confidentiality and Informed consent was
taken individually from the participants. Every participant
had to right to proceed or withdrawal from the study
anytime. Data has been collected by separate data collector,
auditor and blinded assessor.
Outcome Measures
Numeric pain rating scale (NPRS) a valid 0 (no pain) to 10
(worst pain) point scale to measure the pain status of LE
subjects [18] Patient rated tennis elbow disability
questionnaire (PRTEDQ) were used to measure the
functional disability of TE subjects [27] OXFORD grade
scale used to measure the muscle power of TE subjects. The
outcome measure during baseline assessment and
effectiveness compare after 4 weeks (10 sessions) treatment.
Statistical Analysis:
The analysis is being done by a statistician using SPSS 20
version and Microsoft excel 2007. The significance level
was set at 95% CI where (p=0.05). Descriptive analysis is
being used for measure the mean and SD. For inter group
comparison using “t” test and Mann Whitney “U” test and
for intra group comparison paired t and Wilcoxon sign rank
test is being used.
Result
Table 1: Demographic variable of SDM (n:10) and control group (n:10)
SDM
Control
P value
Mean (SD)
Mean (SD)
Age
42 (±18.87)
37.6 (±10.34)
0.001*
Occupation
5 (25%) Service holder, 4 (20%) Housewife, 1 (5%)
Student
5 (25%) Service holder, 5 (25%) Housewife
Gender
5 male (25%), 5 Female (25%)
4 male (20%), 6 Female (30%)
Side elbow pain
4 (20%) Front, 1 (5%) Medial, 4 (20%) Lateral, 1 (5%)
Back
9 Front (45%), Lateral (5%)
Forceful Activity
10 (50%) Yes
8 (40%) Yes, 2 (10%) No
Pain state
3 (15%) Improving, 5 (25%) Worsening, 2 (10%) Staying
same.
7 (35%) Worsening, 3 (15%) Staying same.
Current problem
6 (30%) Every time, 4 (20%) Sometime
8 (40%) Every time, 2(10%) Sometime
* Significant (<.05)
Both SDM and control groups age between 3rd and 4th
decade of life, most of the subject of experimental and
control were respectively service holder and housewife
(Table 1). In SDM group both gender were equal and in
control group shows prominence of female 6 (30%). SDM
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International Journal of Applied Research http://www.allresearchjournal.com
has less pain worsening (25%) subjects than control group
(35%).
The statistical analysis of individual groups shows a
significant decrease in pain and improvement in functional
performance (p<0.05) in SDM group compared to control
group (table 2). The between group comparison shows
relative improvements in both groups in pain and associated
impairments, but SDM has marked change than control
(table 3).
Table 2: Pre and Post treatment within group comparison (n: 20)
Scale
SDM Group
Control Group
Min
Max
Mean (SD)
Min
Max
Mean (SD)
NPRS
5
9
6 (1.58)
7
10
4.7 (.66)
PRTEQ
0
5
5.73 (2.03)
4
9
6.88 (1.512)
OXFORD
Grade
Flexion
3
4
3.90 (.31)
3
5
3.80 (.63)
Extension
3
5
4 (.47)
3
4
3.60 (.51)
Scale
SDM Group
Control Group
Min
Max
Mean (SD)
Min
Max
Mean (SD)
NPRS
0
4
1.16 (.937)
0
4
1.81 (.544)
PRTEQ
0
3
.76 (.74)
0
5
2.86 (1.067)
OXFORD
Flexion
5
5
5 (0)
4
5
4.90 (.31)
Extension
5
5
5 (0)
4
5
4.60 (.51)
Table 3: Intra group comparison between control group and SDM group
Scale
SDM group
Control Group
Min
Max
Mean (SD)
P Value
Min
Max
Mean (SD)
P Value
NPRS
Pre
5
9
6 (1.58)
.001*
7
10
4.7 (.66)
.005*
Post
0
4
1.16 (.937)
0
4
1.81 (.544)
PRTEQ
Pre
0
5
5.73(2.03)
.04*
4
9
6.88 (1.512)
.06
Post
0
3
.76 (.74)
0
5
2.86 (1.067)
Oxford Grade
Pre-test
Flexion
3
4
3.90 (.31)
.02*
3
5
3.80 (.63)
.05
Extension
3
5
4 (.47)
.04*
3
4
3.60 (.51)
.02*
Post-test
Flexion
5
5
5 (0)
.02*
4
5
4.90 (.31)
.05
Extension
5
5
5 (0)
.04*
5
5
4.60 (.51)
.02*
* Significant (<.05)
Discussion
The purpose of this study was to evaluate the effectiveness
of myofascial release in SDM concept at Biceps brachii,
latissmus dorsi and pecoralis major compare to only
conventional physiotherapy for tennis elbow. This is the
unique component of the study; there are available resources
on managing the affected site but making considerations to
arm, chest and back components in TE is something beyond
imagination and this study is creating new concepts to
consider. Ajimsha and colleagues [30] conducted a single
blind RCT to investigate the effect of myofascial release vs.
sham ultrasound on pain and function in 65 computer
professionals suffering from chronic lateral epicondylitis or
TE. Both groups were similar in baseline characteristics
such as gender, age, body mass index, seniority and duration
of symptoms. The treatment intervention was three days per
weeks for four weeks. They use patient rated tennis elbow
evaluation for measurement of pain. They concluded that
MFR technique is more effective than control group. In this
study, control group had little more pain in baseline from
SDM group but both group had improvement in pain,
muscle strength and patient rated disability with a
significant level <.05 but SDM group had more significant
improvements than control. An experimental study [28] on 30
participants with chronic lateral epicondylitis, myofascial
release technique has been applied and in outcome measures
found that the myofascial release technique significantly
improved pain, grip strength and functional activity.
In the study, 10 sessions on MFR has been applied and
similar [29] study on 36 patients with TE investigated the
comparison of active releasing technique and myofascial
release technique on pain, grip strength and functional
performance. They concluded that 12 sessions of treatment
both active release technique and myofascial release
technique were effective in the treatment of chronic lateral
epicondylitis but myofascial release technique was found
superior than active release technique.
We found very little research evidence in the regards of TE
treatment protocol in biceps brachii, pectoralis major and
latissmus dorsi muscles; this was a primary limitation. None
of the studies suggest any specific evidence based treatment
protocol. This study of 4 weeks MFR technique in SDM
concept found to be effective for TE subjects and found
significant change to decrease pain in NPRS and functional
improvement in PRTEQ and improve in muscle power and
disability. Other limitations were smaller sample size,
blinding process and duration of the study.
Conclusion
This investigation of MFR technique in SDM concept
explores the new era for the evidence based treatment of TE
subjects. Study explored MFR in SDM concept to Biceps
brachii, Pectoralis Major and Latissmus dorsi can improve
pain, muscle strength and disability state induced by TE.
Further studies with larger samples in multi-centre setting
along with follow up can evident more to enhance a new
dimension in evidence based practice of TE for
physiotherapy professionals.
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International Journal of Applied Research http://www.allresearchjournal.com
Acknowledgements: Author acknowledges the clinicians of
outdoor physiotherapy department of CRP and Popular
Medical College Hospital for their cooperation.
Funding: The study is a self-funded study.
Copyright: Structural Diagnosis and Management (SDM) is
a copyright concept of Institute of Advanced Mechanical
Correction Therapy, Dhaka-1207.
Conflict of interest: Author declares no conflict of interest.
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Article
Full-text available
Aim The aim of this study is to find the effectiveness of ultrasound and stretching exercise as a comprehensive with ultrasound and strengthening exercise in relieving pain and improving functional activities for lateral epicondylitis. Methodology 30 patients will be chosen based on inclusion and exclusion criteria from Outpatient department of ACS medical college and hospital. Both male and female patients between 25 to 50 years will be taken. Group A-Consist of 15 subjects with lateral epicondylitis who will be given ultrasound therapy and stretching exercise. Group B-Consist of 15 subjects with lateral epicondylitis who will be given ultrasound therapy and strengthening exercise. Group A and Group B subjects will be compared to know which treatment is more effective. Both groups will receive therapeutic exercise for 4 weeks (5 days in a week) which consist of ultrasound therapy, stretching and strengthening exercise for lateral epicondylitis. Results Thus it can be assumed from this study that (group B) ultrasound therapy and strengthening exercise is an effective approach in reducing pain and improving functional activities in lateral epicondylitis. Conclusions There is significant difference between Group A (ultrasound and stretching) and Group B (ultrasound and strengthening exercise).
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