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

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

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