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AN ADDITIVE EFFECT OF DEEP TRANSVERSE FRICTION

MASSAGE TECHNIQUE IN LATERAL EPICONDYLITIS


1
GOPAL NAMBI SUBASH CHANDRA BOSE, 2SHANMUGANANTH, 3DIPIKA INBASEKARAN
1
Dept of Physical Therapy, College of Applied Medical Sciences, Prince Sattam Bin Abdul Aziz University, Al-Kharj, Saudi
Arabia
2
Dept of Physiotherapy, Saveetha College of Physiotherapy, Chennai, Tamil Nadu, India
3
Dept of Periodontics, Saveetha University, Chennai, India
E-mail: physio_gopal@rediffmail.com

Abstract -
Objective: A study to determine the additive effect of deep transverse friction massage in patients with lateral epicondylitis.
Design: Experimental study. Methods: In a 3-week intervention study, 30 patients with lateral epicondylitis were studied.
Patients were divided in two Groups: Group A (n = 15) received ultrasound & exercises programme; Group B (n= 15)
received deep transverse friction massage along with ultrasound & exercises. Both groups were submitted to 3 consecutive
weeks of treatment consisting of five times weekly, sessions performed once in a day. A Visual analog scale (VAS), PRTEE
score & grip strength values collected were administered at pretest and posttest. Dependent‘t’ test was used for the
comparison between the pre and posttest values within the Group A and Group B. independent ‘t’ test was used for
comparison between the pretest&posttest values of the two groups. Results: The results showed a significant decline in the
pain intensity (p<0.05), a significant improvement in function (p<0.05), and a significant improvement in the hand grip
strength (p<0.05) in the post treatment stage in comparison to the pre treatment stage in both the groups. Conclusion: The
inclusion of deep transverse friction massage along with ultrasound and exercises produced a statistically significant decline
in the pain intensity and improvement in function, grip strength when compared to ultrasound and exercises alone, in patients
with lateral epicondylitis of the elbow.

Keywords - Lateral Epicondylitis, Ultrasound, Deep Transverse Friction Massage, Exercises, VAS, Grip Strength

I. INTRODUCTION single treatment has been found to be universally


efficacious.
Lateral Epicondylitis is a common complaint among Therapeutic ultrasound is one of the more established
sports people and manual workers often experienced and most widely used of theelectro physical agents
by but not exclusive to tennis players during back [6].The goal of any rehabilitation protocol is to return
hand stroke[1]. It is usually defined as the tendinitis the patient to full function with no pain [7].Therapists
of the extensor carpi radialis (ECR) [2]. Less claim that static stretching, an extremely effective and
frequently, the extensor carpi radials longus is simple stretching procedure, is the most widely used
affected at its attachment to the supracondylar ridge stretching technique [8], [9].
[3] or sometimes the anterior portion of the extensor Deep transverse friction massage (DTFM) is one of
digitorum communis. It is primarily a mechanical several physiotherapy interventions suggested for the
type of overuse injury featuring pain associated with management of pain due to lateral epicondylitis [10-
and aggravated by movement particularly of the wrist 11].DTFM is a technique popularized by Dr. James
and decreasing in grip strength [1].It is indicated that Cyriax for pain and inflammation relief in
microscopic fracture may be seen as well as round musculoskeletal conditions. It may be part of
cell infiltration, scattered foci of fine calcification and a physiotherapy program offered in the treatment of
scar tissue with marginated areas of cystic and fibroid various musculoskeletal conditions. DTFM is a
degeneration [4]. technique that attempts to reduce abnormal fibrous
The syndrome is most prevalent (35-64% of all cases) adhesions and makes scar tissue more mobile in sub-
in jobs requiring repetitive manual tasks [5].The peak acute and chronic inflammatory conditions by
prevalence of lateral epicondylitis is in the fourth realigning the normal soft tissue fibres[12-13]. Pain
decade of life when it is four times more common relief during and after DTF may be due to modulation
than any other decade & the peak incidence of this of the nociceptiveimpulses at the level of the spinal
condition occurs between the ages of 30 and 60 and cord, the “Gate control theory” The centripetal
usually affects the dominant arm & with a prevalence projection into the dorsal horn of the spinal cord from
of 1-3% in the general population. the nociceptive receptor system is inhibited by the
Traditional treatment program for people with lateral concurrent activity of the mechanoreceptors located
epicondylitis have focused primarily on the pain in the same tissues [14-15].
control by ultrasound, anti-inflammatory medication, Hence the effort was to determine whether the
iontophoresis or Phonophoresis followed by inclusion of Deep transverse Friction massage along
rehabilitation program which ranges from flexibility with the existing traditional treatment is effective in
to strengthening and endurance training. However no

Proceedings of Academics World 87th International Conference, Kuala Lumpur, Malaysia, 1st -2nd July 2018
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An Additive Effect of Deep Transverse Friction Massage Technique in Lateral Epicondylitis

the treatment of lateral epicondylitis & thereby yield  The exercises were continued even if the
best results & greater benefits for the population. patients experienced mild pain & were
instructed to stop the exercise if the pain
II. METHODS became disabling. When patients were able
to perform the eccentric exercises without
The study was performed an experimental study and experiencing any minor pain or discomfort,
the samples were recruited in convenient sampling the load was increased. The load of eccentric
method. We had taken patients who are having tennis exercises was increased according to the
elbow from orthopedic physiotherapy department of patient’s symptoms, to prevent the
C. U. SHAH Physiotherapy College, Surendranagar. possibility of re-injury.
Gujarat, India. 30 patients were selected and divided
them into two groups, Group A & B. 15 subjects in Group – B additionally will receive deep transverse
group A & 15 in group B. Duration of the study was friction massage.
one year. Duration of the treatment of patient was 4  Deep Transverse Friction Massage
weeks (3 days in a week). The anterolateral aspect of the lateral epicondyle was
located and the area of tenderness was identified.
Inclusion criteria: Subjects who were in the age Deep transverse friction massage was applied over
group of 30-60 years, 3 months (Subacute), male and the site of lesion & tenderness. The patients were
female subjects, Patients with lateral epicondylitis of positioned comfortably in sitting & holding their
the dominant hand were included. forearm 45 degrees short of full extension & in nearly
Exclusion criteria: Neuromuscular disorder, full pronation at the elbow joint, when the lesion was
ankylosed joint, concurrent Medication, post-surgical at, or included, the tendon body of the extensor carpi
neoplasic, vascular or infectious diseases affecting radialis brevis tendon. Facing the patient, holding
joint were excluded. his/her hand by one hand at the patients wrist, and
All patients diagnosed to have lateral epicondylitis with the fingers & thumb of the other hand, the
were identified by convenience sampling technique. patients forearm was grasped. The antero-medial
The procedure was clearly explained to all the edges of the muscles were identified & the affected
patients and their consent was obtained. area located and the forearm was fully supinated.
Outcome measures Facing the patient, holding his/her hand by one hand
at the patients wrist, and with the fingers & thumb of
Visual Analog scale (VAS):Using the visual analog the other hand, the patients forearm was grasped. The
scale (VAS) ranging from 0 to 10cm, each patient antero-medial edges of the muscles were identified &
was evaluated prior to the first session, and after the the affected are located. It was given 6 sessions - 15
last session of the following. minutes/session, twice a week for 3 weeks.
Data collection procedure:
Functional Disability: Using the patient rated Tennis Consent would be taken from all the subjects
elbow evaluation (PRTEE), where the total PRTEE fulfilling the selection criteria and willing to
scores rates pain and disability equally, and higher participate in the study. The sample population would
scores indicates more pain and functional disability. then be randomly divided into two groups: A and B.
Hand Grip strength: The grip strength was The outcome measurement of was performed at each
evaluated using a calibrated baseline hydraulic hand treatment session and after 4 weeks.
dynamometer.
Treatment protocol: III. RESULTS
Both the groups (A&B) would receive
conventional therapy in form of: The present study compared effectiveness of Deep
 Pulsed ultrasonic therapy at 20% duty cycle, transverse friction massage technique along with
frequency 1MHz and an intensity of 1.2 ultrasound and conventional therapy and
W/cm2 for 5 min. x 5 consecutive days. conventional therapy & ultrasound only on VAS,
PRTEE and Hand grip in subjects with lateral
 Active Range of Motion (AROM) exercises
epicondylitis. The study comprised of total 30
10 repetitions of AROM exercises of wrist
subjects with 15 subjects in each group. Data was
and elbow flexion, extension were
analyzed using statistical software SPSS 20. Before
performed by the patients prior to the
applying statistical tests, data was screened for
stretching and strengthening exercises.
normal distribution. All the outcome measures were
 Static Stretching: stretch for the ECR tendon analyzed at baseline and after 4 weeks of treatment
was given slowly with the elbow in using appropriate statistical test. Level of significance
extension, forearm in pronation, and wrist in was kept at 95%. Changes in outcome measures were
flexion and with ulnar deviation, according analyzed within group as well as between groups.
to the patient’s tolerance.19 The stretch was Following Table:1 shows baseline characteristics of
held for 30 seconds and then released. subjects in each group:

Proceedings of Academics World 87th International Conference, Kuala Lumpur, Malaysia, 1st -2nd July 2018
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An Additive Effect of Deep Transverse Friction Massage Technique in Lateral Epicondylitis
Table:1 Baseline characteristics of subjects in Group-A & B. Hand Grip: To analyse the difference in the Hand
Variables GROUP A GROUP B P grip score after 4 weeks of intervention in both the
Mean SD Mean SD groups, z- test was used. For both the groups A and
VAS 6.53 1.24 5.60 1.29 0.792 B, p values were <0.001, showing extremely
PRTEE 44.87 4.37 45.53 4.13 0.055 significant difference in hand grip score as compared
Hand 20.8 3.42 19.67 6.95 0.079 to baseline. (Table:4 and Figure:3)
Grip
Table: 4Pre and Post scores of TMDI in Group-A & B.
VAS:To analyse the difference in the VAS score after Pre Post
GROUP Z P
4 weeks of intervention in both the groups, z -test was Mean SD Mean SD
GROUP
used. For both the groups A and B, p values were 20.80 3.42 22.33 3.35 11.50 0.000
A
<0.001, showing statistically signifacant difference in
GROUP
VAS score as compared to baseline. (Table:2 and 19.67 6.95 22.22 7.28 10.71 0.000
B
Figure:1)

Table:2Pre and Post scores of VAS in Group-A & B.


Pre Post 23
GROUP z P 22
Mean SD Mean SD 21
GROUP 20
6.53 1.24 3.47 1.12 14.86 0.000 19 Pre
A 18
GROUP
5.60 1.29 2.20 0.41 12.47 0.000 Post
B

10
Figure:3 Pre and Post scores of MMO in Group-A & B.
5
0 Pre
DISCUSSION
Post
The results found in this study disclosed that after a 3
week treatment program, both the groups attained a
significant reduction in pain intensity, an
Figure:1 Pre and Post scores of VAS in Group-A & B. improvement in grip strength and performance of
functional activities. This findings in accordance with
PRTEE: To analyse the difference in the PRTEE the ones foundby A Binder e t al, 2002 [16] who
after 4 weeks of intervention in both the groups z-test allocated patients with lateral epicondylitis to receive
was used. For both the groups A and B, p values were ultrasound and concluded that an improvement in
<0.001 respectively, showing extremely significant pain score, grip strength, weight lifting occur in
difference in PRTEE as compared to baseline. patients who receive ultrasound treatment, and the
(Table:3 and Figure:2) studies by D Stasinopoulos et al, 2004 [17] to
determine the effects of deep transverse friction
Table: 3Pre and Post scores of PRTEE in Group-A & B. massage who concluded that deep transverse friction
Pre Post massage was effective in the reduction of pain,
GROUP z P
Mean SD Mean SD improvement in function and pain free grip strength
GROUP
44.87 4.37 28.27 2.52 19.80 0.000 in patients with lateral epicondylitis.
A
Johnson MI et al, 2005 [18] in their study “An
GROUP
45.53 4.13 23.80 2.18 27.11 0.000 exercise program for the management of lateral
B
epicondylitis” described the uses and effects of
strengthening and stretching programs in the
50 treatment of lateral epicondylitis. These studies and
40 results suggest that the effects of ultrasound and
30 supervised exercise program including stretching and
20 Pre eccentric strengthening exercises are excellent in the
10 management of lateral epicondylitis patients.
0 Post Nagrale AV et al, 2009 [19] in their study on 60
patients, comparing the effectiveness of deep
transverse friction massage verses ultrasound,
phonophorosis with supervised exercises in managing
lateral epicondylalgia, concluded that both groups
Figure:2 Pre and Post scores of PRTEE in Group-A & B. improved significantly from initiation of treatment

Proceedings of Academics World 87th International Conference, Kuala Lumpur, Malaysia, 1st -2nd July 2018
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An Additive Effect of Deep Transverse Friction Massage Technique in Lateral Epicondylitis

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Proceedings of Academics World 87th International Conference, Kuala Lumpur, Malaysia, 1st -2nd July 2018
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