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The Effects of Ischaemic Compression versus Therapeutic Massage with a Percussive Device in Treating Hamstring

Myofascial Pain Dysfunction

A research dissertation presented to the Faculty of Health Sciences, University of

Johannesburg, as a partial fulfilment for the Master’s Degree in Technology,

Chiropractic by

Charlizé Jonker

Student Number: 201300673

Supervisor: ______________________ Date: __________________

Dr C. Yelverton

ii

DECLARATION

I, Charlizé Jonker, do hereby declare that this dissertation is my own unaided work,

except where otherwise indicated in text. This dissertation is being submitted in

partial fulfilment for the degree of Master of Technology, in the programme of

Chiropractic, at the University of Johannesburg. It has not been submitted before for

any degree or examination in any other tertiary institute.

_________________

Charlizé Jonker

On this _______ day of _______________ 2019

iv

DEDICATION

I wish to dedicate this dissertation to everyone that believed in me, supported me

and loved me during the course of this degree.

To my parents: thank you for giving me the opportunity to follow my dream and for

your endless love and support. If not for you, I would have been a lesser version of

myself. Thank you for always striving to give me the best, even when you weren’t

able to. You have been the motivation I have needed to succeed. I am truly blessed

to have you as my parents. Brian Tracy once said: “If you raise your children to feel

that they can accomplish any goal or task they decide upon, you will have succeeded

as a parent and you will have given your children the greatest of all blessing.”

To my grandfather, who has been my biggest fan since the day I was born: thank

you for always being in my corner, whether it was on the side of the sports field or

supporting me during this degree. I am truly blessed and grateful to have you in my

life and to share this great achievement with you.

To my brother: thank you for always listening to my never-ending stories about my

studies and for being there in difficult times. Best of luck with your journey ahead.

To my friend Colette: thank you for the amazing journey together. I am truly blessed

to have met a lifelong friend during this course, who shares the same hopes and

dreams. It has been a long journey with lots of memories that I will treasure for life.

Thank you for the early mornings, the numerous cups of coffee and the endless

chats when we were supposed to be studying. I will forever be grateful.

v

ACKNOWLEDGEMENTS

I would like to thank my supervisor, Dr Chris Yelverton, for your advice and

knowledge in helping me complete this study. I will always be grateful for all your

hard work, guidance and patience.

I would also like to thank Dr Glen Paton for being my mentor over the last two years

and reigniting my passion for the profession. Thank you for all the exciting

conversations and for sharing your knowledge and expertise.

vi

ABSTRACT

Purpose:

Soft tissue mechanotherapy can have an effect and be of benefit to muscle tissue,

because of the mechanosensitivity of the muscle, by shortening the recovering time

after exercise, improving muscle strength after the application of device-assisted soft

tissue manipulation, offsetting the effects of aging and facilitating the healing

process. The effect of device-assisted soft tissue manipulation on myofascial trigger

points and its effects on clinical outcomes needs to be further investigated, which

this study aims to do.

Design:

Thirty participants between the ages of 18 and 50 years old presenting with active

hamstring myofascial trigger points were included in this study. The participants were

randomly divided into two groups of 15 participants each (group A and group B).

Group A received ischemic compression and group B received therapeutic massage

with a percussive device on the active trigger point in the hamstring muscle. Each

participant was treated six times over a period of three weeks.

Measurements:

All measurements were collected at the first and fourth consultations prior to

treatment and on the seven consultation, where no treatment was performed. The

subjective measurements included the Numerical Pain Rating Scale. Objective

measurements included pressure algometric readings of pressure pain threshold of

the hamstring muscle trigger points, and hamstring extensibility was recorded using

a baseline goniometer.

vii

Results and Conclusion:

The outcome of this study suggests that patients with hamstring trigger point pain

can be treated effectively with each approach, as active trigger points respond well

to both ischemic compression and therapeutic massage with a percussive device.

Both groups showed a reduction in self-reported pain, an increase in pain pressure

threshold and an increase in hamstring extensibility over active hamstring trigger

points.

viii

DECLARATION ii

AFFIDAVIT iii

DEDICATION iv

ACKNOWLEDGMENTS v

ABSTRACT vi

CHAPTER ONE: INTRODUCTION

1.1 Problem Statement 1

1.2 Aim of the Study 2

1.3 Possible Outcomes of the Study 3

CHAPTER TWO: LITERATURE REVIEW

2.1 Introduction 4

2.2 Skeletal Muscle 4

2.2.1 Structure 4

2.2.2 Functional unit 5

2.2.3 Physiology of muscle contraction 6

2.3 Mechanoreceptors Specialised to Receive Tactile Information 8

2.3.1 Meissner’s corpuscles 8

2.3.2 Pacinian corpuscles 8

2.3.3 Markel’s disks and Ruffini’s corpuscles 9

2.4 The Hamstring Muscle Group 10

2.4.1 The anatomy of the hamstring muscle group 10

2.4.2 Innervation of the hamstring muscle group 10

2.4.3 Function of the hamstring muscle group 11

2.5 Myofascial Trigger Points 12

2.5.1 Introduction 12

ix

2.5.2 Myofascial trigger point criteria 12

2.5.3 Myofascial trigger point classifications 13

2.5.4 Pathophysiology of a myofascial trigger point 13

2.5.5 Hamstring trigger point location 15

2.5.6 Predisposing factors of hamstring trigger point development 16

2.5.7 Management of myofascial trigger points 17

CHAPTER THREE: METHODOLOGY

3.1 Introduction 21

3.2 Study Design 21

3.2.1 Participant recruitment 21

3.2.2 Sample selection and size 21

3.2.3 Inclusion criteria 22

3.2.4 Exclusion criteria 22

3.2.5 Random group allocation 23

3.3 Treatment Approach 23

3.3.1 First visit 23

3.3.2 Follow-up visits 24

3.4 Hamstring Trigger Point Examination 25

3.5 Intervention 26

3.5.1 Ischaemic compression 27

3.5.2 Percussive massage device 27

3.6 Subjective Measurements 28

3.6.1 Numerical Pain Rating Scale 28

3.7 Objective Measurements 28

3.7.1 Pressure algometer 28

3.7.2 Baseline goniometer 30

3.8 Data Analysis 31

3.9 Ethical Considerations 32

x

CHAPTER FOUR: RESULTS

4.1 Introduction 34

4.1.1 Normality testing 35

4.1.2 Descriptive and clinical analysis 35

4.1.3 Intragroup analysis 35

4.1.4 Intergroup analysis 35

4.2 Demographic Data Analysis 36

4.3 Subjective Data Analysis 36

4.3.1 Intragroup analysis of the Numerical Pain Rating Scale 36

4.3.2 Intergroup analysis of the Numerical Pain Rating Scale 40

4.4 Objective Data Analysis 41

4.4.1 Intragroup analysis of pressure algometer 41

4.4.2 Intergroup analysis of the pressure algometer 45

4.4.3 Intragroup analysis of the baseline goniometer 46

4.4.4 Intergroup analysis of the baseline goniometer 50

CHAPTER FIVE: DISCUSSION

5.1 Introduction 52

5.2 Demographic Data 52

5.2.1 Age and gender distribution 52

5.3 Subjective Data 52

5.3.1 Intragroup analysis of the Numerical Pain Rating Scale 52

5.3.2 Intergroup analysis of the Numerical Pain Rating Scale 54

5.3.3 Subjective data discussion 54

5.4 Objective Data 56

5.4.1 Intragroup analysis of the pressure algometer 56

5.4.2 Intergroup analysis of the pressure algometer 57

5.4.3 Discussion of pressure algometer results 57

xi

5.4.4 Intragroup analysis of the baseline goniometer 58

5.4.5 Intergroup analysis of the baseline goniometer 59

5.4.6 Discussion of the baseline goniometer results 60

CHAPTER SIX: CONCLUSION AND RECOMMENDATIONS

6.1 Conclusion 62

6.2 Recommendations 63

REFERNCES 64

xii

APPENDIX A: ADVERTISEMENT 75

APPENDIX B: INFORMATION FORM 76

APPENDIX C: CONSENT FORM 80

APPENDIX D: CASE HISTORY 81

APPENDIX E: PHYSICAL EXAMINATION 85

APPENDIX F: LUMBAR SPINE REGIONAL 90

APENDIX G: NUMRICAL PAIN RATING SCALE 93

APPENDIX H: HAMSTRING TRIGGER POINT EXAMINATION 94

APPENDIX I: ALGOMETER AND GONIOMETER READINGS 95

APPENDIX J: LETTER OF REQUEST 96

APPENDIX K: ETHICS CLERANCE LETTER 97

APPENDIX L: HIGHER DEGREES LETTER 98

APPENDIX M: SIMILARITY LETTER 99

APPENDIX N: EDITOR’S LETTER 100

xiii

LIST OF FIGURES

Figure 2.1 Organisation of Skeletal Muscle 5

Figure 2.2 Functional Unit of a Muscle 6

Figure 2.3 Hamstring Muscle Anatomy and Innervation 11

Figure 2.4 Hamstring Muscle Trigger Point Location 16

Figure 3.1 Patient Position for Semimembranosus and Semitendinosus 26

Figure 3.2 Thumper Maxi Pro 27

Figure 3.3 Pressure Algometer 29

Figure 3.4 Baseline Goniometer 31

Figure 4.1 Bar Graph Representing the NPRS Values of Each Visit for

Both Groups 40

Figure 4.2 Changes in the Mean Pain Threshold of the Pressure Algometer

for Group A and Group B 45

Figure 4.3 Changes in the Mean Readings of Baseline Goniometer 50

xiv

LIST OF TABLES

Table 4.1 Demographic Data within the Sample of 30 Participants 36

Table 4.2 Friedman Test Changes in NPRS Values of Group A 37

Table 4.3 Wilcoxon Signed-Rank Test for Group A 38

Table 4.4 Friedman Test Changes in NPRS Values of Group B 38

Table 4.5 Wilcoxon Signed-Rank Test for Group B 39

Table 4.6 Group A Column Statistics of the Pressure Algometer 41

Table 4.7 Group A Friedman Test for Changes in Pressure Algometer Mean

Values 42

Table 4.8 Group A Wilcoxon Signed-Rank Test for Changes over Time

(Pressure Algometer) 42

Table 4.9 Group B Column Statistics of the Pressure Algometer 43

Table 4.10 Group B Friedman Test for Changes in Pressure Algometer

Mean Values 43

Table 4.11 Group B Wilcoxon Signed-Rank Test for Changes over Time

(Pressure Algometer) 44

Table 4.12 Mann-Whitney U Test for Pressure Algometer Mean Values 45

Table 4.13 Group A Column Statistics of the Baseline Goniometer 46

Table 4.14 Group A Friedman Test for Changes in Baseline

Goniometer Mean Values 47

Table 4.15 Group A Wilcoxon Signed-Rank Test for Changes over Time

(Baseline Goniometer) 47

Table 4.16 Group B Column Statistics of the Baseline Goniometer 48

Table 4.17 Group B Friedman Test for Changes in Baseline


Table 4.18 Group B Wilcoxon Signed-Rank Test for Changes over Time

(Baseline Goniometer) 49

Table 4.19 Mann-Whitney U Test for Comparison of Baseline


1

CHAPTER ONE: INTRODUCTION

1.1 PROBLEM STATEMENT

Device-assisted soft tissue manipulation is regarded as a type of

mechanotherapy, which has a significant effect in the prevention of disease,

promotion of health and physical rehabilitation (Field, 2016). Device-assisted soft

tissue manipulation, e.g. therapeutic massage, is regarded as a manual therapy

used commonly by clinicians worldwide to treat musculoskeletal pain disorders

(Karels, Polling and Bierma-Zeinstra, 2006). Mechanotherapy applies a non-

invasive mechanical stimulus to the body surface, influencing molecules, cells

and tissue structures by means of mechanotransduction, which ultimately leads

to improved clinical outcomes and muscle function (Khan and Scott, 2009; Huang,

Holfeld, Schaden, Orgill and Ogawa, 2013).

Soft tissue mechanotherapy can have an effect and be of benefit to muscle tissue

because of the mechanosensitivity of the tissue, shortening the recovery time

after exercise, improving muscle strength after the application of device-assisted

soft tissue manipulation, offsetting the effects of aging and facilitating the healing

process (Brooks et al., 2005). Nevertheless, the effects of device-assisted soft

tissue manipulation on myofascial trigger points and its effects on clinical

outcomes need to be further investigated (Loghmani and Whitted, 2016).

Indeed, the human body consists of 50% skeletal muscle, one of the largest

organs in the human body, and any of these muscles can develop a dysfunction

or pain known as myofascial pain syndrome (Ching, 2007). According to Harden,

Bruehl, Gass, Niemiec and Barbick (2002), myofascial pain is one of the leading

diagnoses of pain sufferers by pain management physicians and general

practitioners.

Myofascial pain is defined as pain that derives from myofascial trigger points in

the skeletal muscle, which are small, very sensitive areas in the skeletal muscle.

2

These areas are hypersensitive, palpable, taut bands of muscle that produce pain

on touch. The patient’s symptoms and can cause localised or referred pain

(Travell and Simons, 1999; Bron and Dommerholt, 2012). Myofascial pain has a

high occurrence among individuals with regional pain complaints. It has been

found that the prevalence varied from 21% to 30% of general medical clinic

patients to as high as 85% to 93% of patients presenting to pain management

centers (Kaergaard and Andersen, 2002).

A latent myofascial trigger point is defined as a trigger point that is tender locally

on touch and may be associated with limited range of motion and muscle stiffness

but is not associated with spontaneous complaints of pain. An active myofascial

trigger point is thus associated with a clinical pain complaint. Muscles with

myofascial trigger points each have their own characteristic pain pattern, helping

the physician to identify which muscle may contain the responsible myofascial

trigger point (Borg-Stein and Simons, 2002).

There are a wide variety of therapies available for the treatment of myofascial

trigger points but there is little consensus as to the best treatment protocol

(Vernon and Schneider, 2008). Myofascial trigger points are routinely identified

and treated by clinicians in various health care disciplines by a non-invasive

method called ischemic compression. De Las Peñas, Alonso-Banco, Fernandez-

Carnero and Miangolarra-Page (2006) have proven ischemic compression to be

a safe and effective non-invasive procedure, known to successfully reduce the

tenderness caused by myofascial trigger points.

1.2 AIM OF THE STUDY

The aim of this study was to compare the efficacy of ischemic compression with

that of therapeutic massage with a percussive device in the treatment of active

hamstring myofascial trigger points in order to determine which of the two

treatment protocols is superior.

3

1.3 POSSIBLE OUTCOMES OF THIS STUDY

The possible outcome of the study would determine which of the two treatment

protocols, i.e. ischemic compression or device-assisted soft tissue massage, is

superior in the treatment of hamstring myofascial pain syndrome. The outcome

of the study could also provide additional understanding and knowledge of

myofascial pain dysfunction and the efficacy of treatment methods used by

chiropractors, physiotherapists and other health care practitioners.

4

CHAPTER TWO: LITERATURE REVIEW

2.1 INTRODUCTION

This chapter serves to give detail on relevant previously published literature and

research to provide background literature for this specific study. Emphasis is placed

on the relevant anatomic structures, such as skeletal muscle structure, specifically

of the hamstring muscles, the development of myofascial trigger points, and

ischemic compression and percussive massage devices used as treatment to this

condition.

2.2 SKELETAL MUSCLE

2.2.1 Structure

Skeletal muscle consists predominantly of muscle cells that are specialised for

contraction in order to produce skeletal movement, maintain body posture and

maintain body temperature (Martini, Nath and Bartholomew, 2018). As

demonstrated in figure 2.1, each muscle has three connective tissue layers: the

epimysium, perimysium and an endomysium. The epimysium covers the entire

muscle and consists of a dense layer of collagen fibers. The epimysium separates

the muscle from the surrounding structures. The perimysium divides the skeletal

muscle into different compartments. These compartments contain muscle fiber

bundles called fascicles. There are blood vessels and nerves within the perimysium

to supply the muscle fibers within the muscle fascicles (Martini et al., 2018).

A delicate connective tissue endomysium found within the fascicle surrounds each

individual skeletal muscle cell, called a muscle fiber. Every muscle fiber contains a

number of myofilaments that are composed of actin and myosin filaments, which

have the ability to shorten and allow for a contraction (Martini et al., 2018).

5

Figure 2.1 Organisation of Skeletal Muscle

(Martini et al., 2018)

2.2.2 Functional unit

Myofilaments are organised into repeating functional units called sarcomeres, as

illustrated in figure 2.2. Sarcomeres are the smallest functional unit of a muscle fiber.

The interaction between the thin and thick filaments of the sarcomere is responsible

for the contraction of the muscle. There are approximately 10 000 sarcomeres in a

myofibril. Each sarcomere comprises thick filaments, thin filaments, proteins

stabilising the thin and thick filaments and regulating proteins for the interaction

between the thin and thick filaments. Each sarcomere has dark bands called A bands

and light bands called I bands (Martini et al., 2018). Actin and myosin filaments are

arranged into repeating sarcomeres, with a Z-line marking the boundaries between

each of the sarcomeres. Actinin is a protein found in the Z-line that connects the

actin filaments to the adjacent sarcomere (Guyton and Hall, 2015).

6

Figure 2.2 Functional Unit of a Muscle (Martini et al., 2018)

2.2.3 Physiology of a Muscle Contraction

A contraction is initiated at the neuromuscular junction, where acetylcholine is

released from the synaptic terminal binding to the receptors on the sarcolemma

(Macintosh, Gardiner and McComas, 2006). Acetylcholine changes the

transmembrane potential of the muscle fiber, leading to an action potential spreading

across the entire surface of the muscle fiber. Stored calcium is then released from

the sarcoplasmic reticulum, increasing the calcium concentration of the sarcoplasm

in and around the sarcomeres. The calcium released from the sarcoplasmic

reticulum binds to the troponin, changing the troponin-tropomyosin complex

orientation that exposes the active sites on the thin actin filaments.

Cross-bridges form when the heads of the myosin bind to the active sites on the

actin (Guyton and Hall, 2015). The contraction is initiated when repeated cycles of

cross-bridge binding, pivoting and detachment occur, powered by the hydrolysis of

7

adenosine triphosphate (ATP). This event allow for the filaments to slide and for

shortening of the muscle fibers (Martini et al., 2018).

The muscle contraction cycle is reliant on energy in the form of ATP, which transfers

energy from one location to another. In muscle, this energy is used to shorten the

sarcomeres, sliding the myofilaments and restoring the calcium to the sarcoplasmic

reticulum after the muscle contraction is completed. Most of the cells in the body

generate ATP through aerobic metabolism in the mitochondria and glycolysis in the

cytoplasm (which is anaerobic) (Martini et al., 2018).

ATP demands are low in a resting skeletal muscle. Enough oxygen is available for

the mitochondria to meet the demand, and they produce extra ATP. During moderate

activity levels, the ATP demand of muscle cells increases. The demand is met by

the mitochondria as the rate of ATP production and oxygen consumption rises. The

muscle fibers require all the ATP and no extra ATP is produced. The skeletal muscle

depends primarily on aerobic metabolism to generate ATP (Martini et al., 2018).

The ATP and oxygen demands are enormous during strenuous exercise, where the

ATP production by the mitochondria is at its maximum. However, the rate of the

oxygen diffusion into the muscle fiber cannot reach the ATP demand; the

mitochondria can only produce about one third of the needed ATP. The remainder

is generated by glycolysis. This process occurs when glucose is broken down to

glycogen into pyruvate. The surplus pyruvate accumulates in the sarcoplasm and is

converted into lactic acid, changing the intercellular pH (Martini et al., 2018).

Skeletal muscle optimal function depends on four factors: substantial intracellular

energy reserves, good blood circulation, normal blood-oxygen and normal pH in the

muscle fibers (Martini et al., 2018). Disruption to these factors will impair skeletal

muscle bioenergetics, leading to muscle dysfunction (Preedy and Peters, 2002).

8

2.3 MECHANORECEPTORS SPECIALISED TO RECEIVE TACTILE INFORMATION

Mechanotherapy applies a non-invasive mechanical stimulus to the body surface,

influencing molecules, cells and tissue structures by means of

mechanotransduction, which ultimately leads to improved clinical outcomes and

muscle function (Khan and Scott, 2009; Huang et al., 2013). There are four major

types of mechanoreceptors: Meissner’s corpuscles, Pacinian corpuscles, Markel’s

disk and Ruffini’s corpuscles. These mechanoreceptors are specialised to provide

information to the central nervous system about touch, pressure, vibration and

cutaneous tension. They are referred to as low-threshold or high-sensitivity

mechanoreceptors. They can produce an action potential with a weak mechanical

stimulation to the skin. Large myelinated type Aβ axons innervate the low-threshold

mechanoreceptors, ensuring rapid central transmission of tactile information (Ebara,

Furuta and Kumamoto, 2017)

2.3.1 Meissner’s corpuscles

Meissner’s corpuscles are found between the dermal papillae just below the

epidermis of the fingers, palms and soles. The elongated receptors are formed by a

connective tissue capsule that comprises several lamellae of Schwann cells. The

capsule centre contains one or more afferent nerve fibers, which generate rapid

action potentials with minimal skin depression. Meissner’s corpuscles allow for

transduction of low-frequency vibration (30-50 HZ) (Ebara et al., 2017).

2.3.2 Pacinian corpuscles

Pacinian corpuscles are large encapsulated endings located in the subcutaneous

tissue. These mechanoreceptors differ from the Meissner’s corpuscles in their

morphology, distribution and response to threshold. The Pacinian corpuscle has an

9

onion-like capsule in which the inner core of the membrane lamellae is separated

from the outer lamella by a fluid-filled space. There are one or more rapidly adapting

afferent axons located in the centre of the structure. The capsule acts as a filter,

allowing only transient disturbances at high frequencies (250-350Hz) to activate the

nerve endings. The Pacinian corpuscles adapt more rapidly than Meissner’s

corpuscles and have a lower response threshold. This feature suggests that

Pacinian corpuscles are involved in the discrimination of fine surface textures or

other moving stimuli that produce high-frequency vibration of the skin. Pacinian

corpuscles provide information primarily about dynamic qualities of mechanical

stimuli (Ebara et al., 2017)

2.3.3 Merkel’s disks and Ruffini’s corpuscles

Merkel’s disks and Ruffini’s corpuscles are slow-adapting mechanoreceptors.

Merkel’s disks are located in the epidermis, where they are aligned with papillae that

lie beneath the dermal ridges. The slow-adapting nerve fiber associated with each

Merkel’s disk enlarges into a saucer-shaped ending that is closely applied to another

specialised cell containing vesicles that apparently release peptides that modulate

the nerve terminal. Merkel’s disks play a major role in the static discrimination of

shapes, edges and rough textures (Ebara et al., 2017).

Ruffini’s corpuscles are structurally similar to other mechanoreceptors, but are not

well understood. They have elongated, spindle-shaped capsules and are located

deep in the skin, as well as in ligaments and tendons. Ruffini’s corpuscles are

sensitive to cutaneous stretching produced by digital or limb movement. They

primarily respond to internally generated stimuli (Ebara et al., 2017).

10

2.4 THE HAMSTRING MUSCLE GROUP

2.4.1 The anatomy of the hamstring muscle group

The hamstring muscle group consists of the biceps femoris, semitendinosus and

semimembranosus. Some literature considers the adductor magnus muscle to be a

hamstring muscle as a result of its vertical line of pull (Koulouris and Connell, 2005).

The biceps femoris makes up the lateral component of the thigh and has two heads,

namely a long head originating from the medial facet of the ischial tuberosity and a

short head originating from the lateral linea aspera, lateral supracondylar line and

intermuscular septum. The short head of biceps femoris only crosses a single joint,

the knee. The distal tendon of biceps femoris muscle inserts onto the head of the

fibula (Moore, Dalley and Agur, 2017).

The medial component of the posterior thigh is made up of the semitendinosus

muscle (proximal part) and the semimembranosus muscle (distal part) (Koulouris

and Connell, 2005). The semitendinosus muscle overlies the semimembranosus

muscle. The semitendinosus and semimembranosus originate from the ischial

tuberosity. The semitendinosus inserts on the medial surface of the superior part of

the tibia as part of the pes anserinus. The semimembranosus inserts on the posterior

part of the medial tibial condyle (Moore et al., 2017).

2.4.2 Innervation of the hamstring muscle group

Figure 2.3 demonstrates the innervation of the hamstring muscle group. The long

head of biceps femoris muscle and the semitendinosus and semimembranosus

muscles are innervated by the tibial division of the sciatic nerve, which is derived

from nerve roots L5, S1 and S2. The short head of biceps femoris muscle is

innervated by the common fibular nerve of the sciatic nerve, derived from the L5, S1

and S2 nerve roots (Moore et al., 2017).

11

Figure 2.3 Hamstring Muscle Anatomy and Innervation

(Netter, 2018)

2.4.3 Function of the hamstring muscle group

The main action of the semitendinosus and semimembranosus muscles is extension

of the hip joint and flexion of the knee joint. The main action of biceps femoris muscle

is flexion of the knee joint and lateral rotation of the leg when the knee is flexed and

extension of the hip joint when initiating gait (Moore et al., 2017).

12

2.5 MYOFASCIAL TRIGGER POINTS

2.5.1 Introduction

The most commonly used description of trigger point is that by Travell and Simons

(1999). Travell and Simons (1999) define a trigger point as the presence of

tenderness at a nodule in a palpable taut band of muscle.

Trigger points can develop in skeletal muscle or its fascia, tendons, joint capsule,

ligaments and in the skin (Simmonds, Miller and Gemmell, 2010). Myofascial trigger

points cause pain on digital pressure and may give rise to distinguishing patterns of

referred pain, tenderness, restricted range of motion and autonomic nervous system

symptoms (Rickards, 2006). The muscle exhibits a muscle fasciculation, or the

whole body moves as a response to the digital compression. Trigger points may

cause muscle dysfunction, which may result in weakness, muscle imbalance and

impaired motor activation pattern (Lucas, Polus and Rich, 2003).

2.5.2 Myofascial trigger point criteria

The criteria for the presence of an active myofascial trigger point involve the

combined presence of the following (De Las Peñas, Campo, Carnero and

Miangolarra-Page, 2005):

A taut palpable band in skeletal muscle

A hypersensitive spot in the taut band

Patient recognition of the pain as ‘familiar’

Pain when stretching the tissue

Limited range of motion

Local twitch response

Referred pain

Muscle weakness without muscle atrophy

13

According to Tough, White, Richards and Campbell (2007), the four most commonly

applied diagnostic criteria of a myofascial trigger point are:

o Tender spot in a taught band of the skeletal muscle

o Patient pain recognition

o Predicted pain referral pattern

o Local twitch response

2.5.3 Myofascial trigger point classifications

A myofascial trigger point is classified as either latent or active. Active trigger points

usually cause symptoms that occur spontaneously at rest. Latent trigger points only

elicit pain when manually or actively stimulated, and are therefore considered

asymptomatic (Shah and Gilliams, 2008).

Raj and Paradise (2004) define three other classifications of a trigger point, i.e.

primary, secondary and satellite. A trigger point that develops independently of any

other trigger point is classified as a primary trigger point. It usually develops due to

overuse, either acute or chronic. Secondary trigger points usually develop in a

muscle as a result of compensational overload on a muscle that contains a primary

trigger point. Secondary trigger points may also develop after a primary trigger point

is removed. Satellite trigger points can develop because of their location within the

area of the primary trigger point referral area of pain (Raj and Paradise, 2004).

2.5.4 Pathophysiology of a myofascial trigger point

If a muscle is exposed to trauma, overuse, mechanical overload, postural faults or

psychological stress, it may lead to the development of myofascial trigger points

(Huguenin, 2004). The pathophysiology of a myofascial trigger point is still

debatable, although there is evidence that indicates a disruption of the

neuromuscular endplate (Fryer and Hodgson, 2005).

14

There are various hypotheses regarding trigger point development. The most

important, according to Mense and Simons (2000) and Kostopoulos and Rizopoulos

(2001), are as follows:

Muscle spindle hypothesis: states that the abnormal muscle spindle produces

an abnormal electrophysiological signal in the proximity of the trigger point.

Neuropathic hypothesis: states that the nerve supplying the specific muscle

involved in a neuropathic process results in trigger point hypersensitivity.

Fibrotic scar tissue hypothesis: states that damaged muscle tissue that heals

in the form of scar tissue forms a trigger point in that specific area.

Poor posture due to overwork and muscle fatigue: results in tension and

stiffness leading to the development of trigger points.

The energy crisis hypothesis is also a widely accepted hypothesis according to

Mense and Simons (2000) and Kostopoulos and Rizopoulos (2001). According to

this hypothesis, the sarcoplasmic reticulum functions to store and release calcium to

stimulate the activity of the contractile elements, shortening the sarcomere. Trauma,

overuse, mechanical overload, postural faults or psychological stress initiate(s) the

excessive release of acetylcholine, producing the local energy crisis, which accounts

for myofascial trigger point characteristics (Simons, 2004). The sarcomere contracts

continuously, causing ischemia and hypoxia with an increased energy demand.

The combination of loss of energy supply and increased demand in energy creates

the energy crisis. The result of the energy crisis is the release of sensitising, noxious

substances responsible for the pain associated with myofascial trigger points

(Kostopoulos and Rizopoulos, 2001; Mense and Simons 2000; Simons, 2004).

Kostopoulos and Rizopoulos (2001) further state that these processes lead to an

excess amount of calcium in the production of a normal amount of ATP, resulting in

the initiation of myofibrils and a sustained contraction. The sustained contraction

15

leads to a decrease of blood flow to the area, which is associated with

vasoconstriction due to the autonomic nervous system. Changes in the muscle may

cause muscle dysfunction, which results in weakness, muscle imbalance, an

impaired motor activation pattern and pain (Lucas et al., 2003).

2.5.5 Hamstring trigger point location

The semimembranosus and semitendinosus muscle trigger points are located on the

distal medial aspect of the posterior thigh. Pincer palpation can be used to grasp the

distal hamstring mass to pull the mass away from the femur to palpate the taut bands

within the muscle. The myofascial trigger points are clustered around the distal

medial posterior thigh, as demonstrated in figure 2.4. The myofascial trigger points

of biceps femoris are located on the posterior-lateral aspect of the posterior thigh

and are usually clustered in this area (Travell and Simons, 1999).

The referral pattern for semimembranosus and semitendinosus is pain generally

upwards to the lower gluteal region and inferiorly over the upper medial calf. The

biceps femoris pain referral pattern is upwards to the lower gluteal region and

inferiorly over the lower upper lateral popliteal fossa and calf. The hamstring muscle

group referral patterns are demonstrated in figure 2.4 (Hunter and Speed, 2007).

16

Figure 2.4 Hamstring Muscle Trigger Point Location (Travell and Simons, 1999)

2.5.6 Predisposing factors of hamstring trigger point development

Hamstring strain injuries are one of the most common injuries among the active

population, and have high rates of re-injury (DeWitt and Vidale, 2014). Opar and

Williams (2012) showed that lengthening and shortening of the hamstring muscle

leads to trigger point formation, which can contribute to weakness of the muscle. A

defect in hamstring muscle strength then leads to a hamstring muscle injury.

The hamstrings are predisposed to injury as they are working to decelerate knee

extension during activities such as sprinting and hill training. Predisposing factors to

general hamstring injury include increasing age, ethnicity, a muscle imbalance

between the ipsilateral hamstring and quadriceps muscles, inflexibility of the

hamstring muscle, fatigue and a previous history of hamstring muscle injury.

Additional factors are limited quadriceps flexibility, weak core muscles and pelvic

dysfunction (Kristin and White, 2011; Dewitt and Vidale, 2014).

17

2.5.7 Management of myofascial trigger points

Therapy for the treatment of myofascial trigger points can be classified as either

invasive or non-invasive treatment, both of which are focused on the relief of pain

(Huguenin, 2004). Invasive techniques include dry needling, corticosteroid use, local

anesthesia and botulism toxin A injections. Non-invasive techniques includes

vapocoolant spray, muscle stretch techniques, chiropractic manipulation therapy,

transcutaneous electrical stimulation (TENS), ultrasound, laser therapy, instrument-

assistant techniques and pressure-release therapies (Lavelle, Lavelle and Smith,

2007). The main goal of the treatment protocols is inactivation of myofascial trigger

points, restoring normal muscle length and eliminating and/or correcting the factors

that created the myofascial trigger points (Saxena, Chansoria, Tomar and Kumar

2015).

Ischemic compression

Ischemic compression is a non-invasive treatment. It is a sustained, firm, strong

digital pressure applied to the myofascial trigger point with the purpose of reducing

the tenderness of the trigger point (Travell and Simons, 1999).

Ischemic compression can be applied as a direct pressure to the trigger point or by

a pincer grip. This sustained digital pressure is delivered for a period of second to a

minute with the goal of reducing the tension in the taut band of the muscle (Arnau-

Masanet, Barrios-Pitarque, Bosch-Morell, Montanez-Aguilera, Pecos-Martin and

Valtuena-Gimeno, 2010). The sustain pressure applied to the muscle temporarily

occludes blood flow to the area, so release results in a reactive hyperemia. The rapid

increase in blood flow functions to flush out the inflammatory exudate metabolites

from the trigger point formed in the muscle (Fritz and Grosenbach, 2009).

A continuous pressure to the trigger point is applied until the tension in the muscle

is relieved, which implies inactivation of the myofascial trigger point (Raj and

Paradise, 2004). It is important to follow ischemic compression with stretching of the

18

muscle to re-establish an optimal length-tension relationship (Fritz and Grosenbach,

2009). Ischemic compression induces some trauma to the involved muscle tissue,

which might cause minor bruising. Bruising is reduced during treatment, however,

as pressure is applied for short periods at a time (Hains, 2002).

Ischemic compression was one of the earliest modalities recommended for the

treatment of pain related to myofascial trigger points, pioneered by Nimmon and

Travell in the early 1960s (Travell and Simons, 1999). Moderately strong evidence

supports ischemic compression as one of the most common techniques used among

chiropractors for pain relief related to myofascial trigger points (Vernon and

Schneider, 2008). Authors have also found ischemic compression to be effective for

pain relief and disabilities caused by myofascial trigger points in various types of

pathologies such as cervical spine (Cagnie, Dewitte, Coppieters, Van Oosterwijck,

Cools and Danneels, 2013) and shoulder pain (Hains, Descarreaux, and Hains,

2010).

De Las Peñas et al (2006) conducted a pilot study on the effects of ischemic

compression and that of cross friction on tenderness in subjects with active and

latent myofascial trigger points. They found a significant increase in pain threshold

of the participants that received ischemic compression as well as the participants

that received cross friction treatment, with no difference between the two treatment

protocols. Both these treatment protocols are considered to be effective in the

treatment of myofascial trigger points, with the authors encouraging further research

to study the effects of different manual therapies.

In another relevant study, Gemmell, Miller and Nordstrom (2008) examined 45

subjects with non-specific neck pain related to trapezius myofascial pain syndrome.

The aim of the study was to compare the effects of ischemic compression and sham

ultrasound on non-specific neck pain in these subjects. It was confirmed by the

results that ischemic compression is superior to sham ultrasound, and the subjects

that received ischemic compression were five times more likely to improve compared

to those who received sham ultrasound.

19

Finally, Menakam and Kalaichandran (2015) investigated the efficacy of ischemic

compression combined with stretching regimes. Ischemic compression followed by

passive stretching was found to be affective in the relief of pain and a significant

increase in the pain pressure threshold over the myofascial trigger points.

Percussive massage device

The application of electro-mechanical and device-assisted soft tissue mobilisation

has a unique action of steady, comfortable pulsed acupressure that delivers a

thorough and effective massage. The vibration frequency penetrates large parts of

the body without having to dig deep as one does with hand massage. The action of

these devices was originally designed to mimic the action of massage therapist’s

hands gliding over the tissue (Thumper Massager, 2019). These therapeutic devices

are used worldwide in sport medicine, physical therapy and rehabilitation owing to

the beneficial effects they have on neuromuscular systems (Karacan, Cidem,

Yilmaz, Sebik, Cakar and Türker, 2016).

Most of the devices used for soft tissue manipulation operate with an ordinary 120-

volt household current at a frequency of 50-60 Hz with a speed impact of 1200-2100

rate per minute (20-35 pulses) (Comeaux, 2011). Device-assisted soft tissue

manipulation requires little to no energy as the therapeutic friction is produced by the

motor and device applicator. The therapeutic effect is achieved in a much shorter

time than manual therapy because these devices achieve a much higher degree of

friction than that of the human hand, allowing the therapist to cover a greater surface

area (Comeaux, 2011).

Deep tissue work can be challenging for massage therapists, chiropractors,

physiotherapists and physical therapists, especially in high-volume clinical

environments where routinely they engage in using hands for repetitive soft tissue

manipulation techniques. In such cases, the use of the device-assisted soft tissue

manipulation tool can significantly reduce strain and load on the therapist’s body

20

(Green and Goggins, 2006). However, there is little research on the effect of these

devices on myofascial pain syndrome and the clinical outcomes (Best, Crawford,

Haas, Charles and Zhao, 2014).

So far, Comeaux (2011) has reviewed several of these devices, such as the

percussion vibrator, vibrational platform and deep tissue oscillation. He describes

the possible mechanisms of effect on the fascial and neuromuscular systems,

emphasising the physiological phenomenon of the tonic vibratory reflex.

Schillinger, Koenig, Haefele, Vogt and Heinrich (2006) then demonstrated that

participants that received soft tissue manipulation had a more rapid decrease in

muscle enzymes indicative of muscle damage after a strenuous exercise test

compared to a control group. The application of soft tissue manipulation was found

to reduce the recovery period after exercise and increase muscle strength

(Schillinger et al., 2006).

Furthermore, Bakhtiary, Fatemi, Khalili and Ghorbani (2011) investigated the

application of device-assisted soft tissue manipulation on hamstring extensibility and

reported a general increase in range of motion and flexibility of the hamstring muscle.

21

CHAPTER THREE: METHODOLOGY

3.1 INTRODUCTION

This chapter serves to explain how the study was conducted.

3.2 STUDY DESIGN

This study was a comparative, quasi-experimental study that made use of

convenience sampling and random group allocation.

3.2.1 Participant recruitment

Individuals of any gender between the ages of 18-50 years who suffered with

posterior thigh pain were considered. Participants were recruited by word of mouth

and by means of advertisements (Appendix A) placed in and around the University

of Johannesburg’s Doornfontein campus and the Chiropractic Day Clinic.

3.2.2 Sample selection and size

The study was explained to each of the participants, who were required to read the

information form (Appendix B) and sign the consent form (Appendix C) specific to

this study. Each participant underwent a screening process to determine whether

s/he was eligible for this study, taking into consideration the inclusion and exclusion

criteria. Participants had to present with active hamstring myofascial trigger points.

Participants were excluded and included from this study based on the following:

22

3.2.3 Inclusion criteria

To be included into the study, the participants needed to comply with the following

criteria:

Be either male or female

Be between the ages of 18-50 years old with active hamstring myofascial trigger

points of the hamstring muscle.

According to Tough et al., (2007) the four most commonly applied diagnostic criteria

of a myofascial trigger point are:

o Tender spot in a taught band of the skeletal muscle

o Patient pain recognition

o Predicted pain referral pattern

o Local twitch response

3.2.4 Exclusion criteria

Participants were excluded from the study if they:

Used non-steroidal anti-inflammatory drugs, analgesic drugs or muscle relaxants

for the duration of the study (Fleckenstein, Zaps, Rüger, Lehmeyer, Freiburg,

Lang and Irnich, 2010).

Showed any contra-indications to massage and ischemic compression, as listed

by Batavia (2004) and Perle, Schneider and Seaman (1999):

o Acute trauma: open wounds, muscle ruptures, tendon ruptures,

contusions, burns broken bone

o Periostitis and bursitis

o Rheumatoid arthritis and gout

o Myositis ossificans

o Infection: bacterial, viral and fungal

o Bleeding disorders, artificial blood vessels and thrombosis

23

o Tumors

o Application over neurovascular bundles

o Patients taking anti-coagulant medication or long-term steroids

3.2.5 Random group allocation

A sample group of 30 participants were divided into one of two groups that consisted

of 15 participants each. The allocation of the participants was determined by asking

the participants to draw a piece of paper on which was written either a letter “A” or

“B” out of a hat. The hat contained 15 pieces of paper labeled “A” and 15 pieces of

paper labeled “B”, which represented group A and group B respectively. As such,

the letter drawn by each participant from the hat represented the group to which s/he

was allocated.

Participants in group A received ischemic compression directly applied to the active

hamstring myofascial trigger point. Participants in group B received a percussive

massage with a device over the entirety of the hamstring muscle containing active

myofascial trigger points.

3.3 TREATMENT APPROACH

3.1.3 First visit

The initial visit for both groups involved the following:

The researcher conducted a case history (Appendix D), a full physical

examination (Appendix E), and a lumbar spine examination (Appendix F).

Thereafter, a Subjective Objective Assessment Plan (SOAP) form was

completed.

Each participant completed subjective measurements in the form of a Numerical

Pain Rating Scale (NPRS) (Appendix G) under the supervision of the researcher.

24

A hamstring trigger point examination (Appendix H) that consisted of digital

palpation was done by the researcher in order to locate an active hamstring

trigger point in either the left or right muscle.

Objective measurements were taken using a hand-held pressure algometer. The

tip of the pressure algometer was applied to determine the amount of pressure

that caused the participants’ first point of pain, known as pain threshold. The

readings were recorded for all participants on the first, fourth and seventh visits

(Appendix I). The hamstring flexibility of each participant was measured with a

baseline goniometer on the first, fourth and seventh visits.

Thereafter, participants received treatment:

o Group A: Ischemic compression was applied to the most active hamstring

myofascial trigger point found during examination for 60 seconds.

o Group B: therapeutic massage was applied by the researcher with a

percussive device over the entirety of the hamstring muscle containing the

most active myofascial trigger point for 60 seconds.

3.3.2 Follow-up visits

Subjective indications of pain (using the NPRS) were provided by each participant

at the first, fourth and seventh visits prior to treatment, under the supervision of the

researcher. A baseline goniometer was used to measure the popliteal angle, which

determined the hamstring flexibility at the first, fourth and seventh visits. Pressure

algometry of the same trigger point found during the first visit was again undertaken

at the fourth and seventh visits to determine the changes in pain threshold and the

pain tolerance of all participants.

At each visit, participants were reassessed and a SOAP note was completed to

update the current display of pain and symptoms of each participant.

Participants were treated over a three-week period, where they attended seven

visits. At the first six, they received treatment and measurements were taken, while

25

at the seventh visit, only measurements were taken. Group A and group B received

two treatments over a three-week period to ensure tissue recovery (Travell and

Simons, 1999; Puri, Flatow and Soslowsky, 2015)

Participants in group A received ischemic compression applied to the most

active hamstring myofascial trigger point found during examination for 60

seconds.

Participants in group B received therapeutic massage applied by the

researcher with a percussive device over the entirety of the hamstring muscle

containing the most active trigger point for 60 seconds.

3.4 HAMSTRING TRIGGER POINT EXAMINATION

Each participant had to undergo a hamstring trigger point examination (Appendix H)

on the initial visit. There were a number of trigger points located in the hamstring

muscle group.

The semimembranosus and the semitendinosus trigger points were approached

from the medial aspect of the thigh (Travell and Simons, 1999; Hunter and Speed,

2007). The participant was in a supine position as demonstrated in figure 3.1, with

the involved thigh abducted, the knee flexed to change the tension in the muscle and

the lower limb supported with a pillow.

For the pincer palpation, the researcher used the thumb and index fingers to grasp

the distal medial hamstring mass 8-12 cm superior to the posterior knee fold. The

pinched muscle mass was pulled away from the femur to ensure that all of the

semitendinosus and semimembranosus musculature was included for palpation.

The researcher then rolled the muscle mass between the digital contacts to examine

for a taut band and a tender spot (Travell and Simons, 1999; Hunter et al., 2007).

The biceps femoris trigger points were examined from the posterior aspect of the

thigh in a lateral recumbent position on the opposite side with the knee slightly bent.

The researcher used flat palpation to identify the trigger points in the biceps femoris

26

muscle on the lateral aspect of the thigh (Travell and Simons, 1999; Hunter et al.,

2007).

Figure 3.1. Patient Position for Semimembranosus and Semitendinosus: A, Pincer Grip Palpation; B, Flat Palpation (Travell and Simons, 1999)

3.5 INTERVENTION

3.5.1 Ischemic compression

The participants from group A each received six treatments of ischemic

compression. Ischemic compression was only applied to the most active hamstring

trigger point identified through the hamstring trigger point examination (Appendix H).

The participants were positioned in the same way as in the trigger point examination

as it has been proven that ischemic compression is more effective when the muscle

is in a lengthened position (Travell and Simons, 1999).

The most active trigger point was located by the researcher, who used thumb pad

contact to apply a manual pressure directly to the trigger point. The researcher

gradually increased the pressure until the symptomatic pain reduced and a tissue

resistance barrier could be clearly felt (Nagrale, Glynn, Joshi and Ramteke, 2010).

27

The digital pressure was sustained for 60 seconds only, with no stroking, rubbing or

stripping movements (De Las Peñas et al., 2006).

3.5.2 Percussive massage device

Participants from group B received six treatments of therapeutic massage with a

percussive device. Percussive massage with a device was applied over the entirety

of the hamstring muscle on the side containing the most active trigger point identified

through the hamstring trigger point examination (Appendix H).

The device-assisted soft tissue manipulation technique was performed by the

researcher with a percussive massaging device. In this research, the Thumper Maxi

Pro demonstrated in figure 3.2 was used. The Thumper Maxi Pro device operates

with ordinary 230-240-volt household current at a frequency of 50-60 Hz with a

speed impact of 1200-2100 rate per minute (20-35 pulses per second) (Thumper

Massager, 2019).

Figure 3.2 Thumper Maxi Pro (Thumper Massager, 2019)

Participants were asked to expose the hamstring muscle by putting on shorts, after

which they were shown the device and informed of the procedure. Participants were

positioned in a prone position with their hips and knees extended. The Thumper Maxi

28

Pro was wiped clean with a dampened cloth before every intervention and plugged

in. No oil or liniment were used as instructed by the Thumper Maxi Pro operator’s

manual. The percussive massaging device was switched on and applied over the

entirety of the hamstring muscle on the side containing the most active trigger points

for 60 seconds. The device was kept stationary during the treatment.

3.6 SUBJECTIVE MEASUREMENTS

3.6.1 Numerical Pain Rating Scale

The NPRS (Appendix G) is a horizontal line that is divided into equal parts of ten. A

vertical line marks each equal part and is assigned a number from 0 to 10. Zero

indicated ‘no pain’ and 10 indicated the ‘worst possible pain’, while 4-5 indicated

moderate pain. A study conducted by Young, Cleland, Michener and Brown (2010)

have proved the NPRS to be viable and reliable. It is one of the most frequently used

tool for the subjective measurement of pain (Ferreira-Valente, Pais-Ribeiro and

Jensen, 2011).

In this study, the NPRS (Appendix G) was used to monitor the pain intensity from

the hamstring myofascial trigger point as perceived by the participants throughout

the trial period. The NPRS was completed by all participants with regards to their

hamstring trigger point pain. Participants read and filled out a NPRS on the first,

fourth and seventh visits.

3.7 OBJECTIVE MEASUREMENTS

3.7.1 Pressure algometer

The pressure algometer seen in figure 3.3 is a device used to measure pain pressure

threshold. Algometer testing is based on the minimum amount of pressure that

initiates pain and is a good indication of an individual’s pain sensitivity. The hand-

29

held device consists of a spring operator force gauge that is attached to a rounded

1cm rubber tip. The pressure algometer is calibrated in kg/cm² and allows the

recording of measurements and for the device to be reset between measurements

(Harrison and Siskin, 2013). A study by Kinser, Sands, and Stone (2009)

demonstrated the reliability of the pressure algometer when the application force

was compared and correlated with that of the force plate.

Figure 3.3 Pressure Algometer (Fischer, 1986).

The measurements with the pressure algometer were done on the active hamstring

trigger point found during the hamstring trigger point examination on all participants.

Algometer measurements took place on the initial, fourth and seventh visits. The

hand-held device was placed perpendicular on the body surface over the trigger

point. A gradual increasing downwards pressure was applied onto the trigger point

and the researcher instructed the participant to inform when the first point of pain or

discomfort was felt. At that time, the researcher then stopped applying the pressure

and recorded the reading (Kinser et al., 2009).

30

3.7.2 Baseline goniometer

A goniometer is used to measure the total amount motion at a specific joint during

both active and passive range of motion. For this study, a universal goniometer was

used. This goniometer consisted of a stationary arm that was held on a fixed part of

the body and a moving arm that was moved with the moving joint to measure the

respective value. It has been found that manual goniometers can be used with

confidence for clinical assessments (Nussbaumer, Leunig, Glatthorn, Stauffacher

Gerber and Maffiuletti, 2010).

The baseline goniometer was used to record measurements of hamstring

extensibility during passive knee extension. Muscle extensibility is defined as ability

of a muscle to extend to a set endpoint, which is usually measured by the relevant

joint angle (Weppler and Magnusson, 2010). The passive knee extension test has

excellent inter rater as well as test-retest reliability (Gnat, Kuszewski, Koczar and

Dziewońska, 2010).

For the passive knee extension test, the participant was asked to lie in a supine

position. The researcher lifted the leg with the most active trigger points so that the

hip and knee were flexed to 90 degrees. The researcher ensured that the opposite

lower limb remained extended on the bed throughout the test. From this position, the

hip flexion was maintained at 90 degrees while the knee was passively extended

until firm resistance to motion was felt. During the procedure, a plastic standard 360-

degree goniometer with two arms demonstrated in figure 3.4 was used to measure

the popliteal angle to determine the hamstring extensibility (Bakhtiary et al., 2011).

31

Figure 3.4 Baseline Goniometer (Prohealthsys, 2019)

3.8 DATA ANALYSIS

Objective and subjective data were collected by the researcher and analysed by a

consultant from STATKON (located on the University of Johannesburg Kingsway

Campus). The analyst used normality tests, descriptive data and clinical statistics to

summarise, organise and interpret the data gathered from the entire sample of 30

participants. The Shapiro-Wilk test was used to check normality of the variables.

Intra-group analysis consisted of one-way repeated measures ANOVA and the

Friedman test when the data was distributed non-parametrically. This test

determined the possibility of any statistically significant changes pre and post

treatment over the three-week trial period and when (i.e. between which visits) those

changes occurred. Inter-group analysis was done by the use of the independent t-

test (for data distributed parametrically) and the Mann-Whitney U test (for data

distributed non-parametrically) in order to check statistically significant differences

between the two groups.

32

3.9 ETHICAL CONSIDERATIONS

All participants that took part in this study were requested to read the information

form (Appendix B) and sign the consent form (Appendix C) specific to this study. The

information form outlined the details of the researcher, purpose of the study and

benefits of participating in the study, as well as participant assessment and treatment

procedure.

Any risks, benefits and discomforts related to the treatment involved were explained

and the participants’ safety were ensured at all times (prevention of harm). The

information and consent forms stipulated that the participant’s privacy was protected

by ensuring their anonymity (no names/personal information were taken) and

standard doctor-patient confidentiality was ensured for the duration of the study. The

participant was provided with a research number and a research file that was kept

safe within the chiropractic clinic to ensure confidentiality. After the study, all the

information was converted to data and could not be traced back to the participant.

Participants were informed that their participation was on a voluntary basis only and

that they were free to withdraw at any stage during the study without penalty. Results

of the study will be made available to participants on request.

Risk regarding with ischemic compression therapy and percussive massage therapy

with a device is minimal. Some participants experienced slight discomfort and pain

during ischemic compression and percussive massage, which is normal. Some

participants reported itching with the percussive massage device. The pain,

discomfort and itching never exceeded the participant’s pain tolerance. Post-

treatment stiffness, pain and red temporary discoloration of the skin were expected,

as these are normal responses.

Professor Christopher Stein (Chairperson of the Faculty of Health Sciences

Research Ethics Committee at the University of Johannesburg) was asked for

permission to use students on the campus as participants in this study, which was

granted. The treatment took place on the University of Johannesburg Doornfontein

campus after the necessary Higher Degrees Committee clearance letter (Appendix

33

K) and Ethics Committee clearance letter (Appendix L) were obtained. Participants

were referred to appropriate health care professionals when necessary.

A similarity report for this study has been obtained through the Turnitin programme

of the University of Johannesburg (Appendix M). This dissertation has been edited

by a qualified language practitioner (Appendix N).

34

CHAPTER FOUR: RESULTS

4.1 INTRODUCTION

The results presented in this chapter were obtained during the clinical study. The

sample group consisted of 30 participants, 15 of whom received ischemic

compression (group A) and 15 of whom received therapeutic massage with a

percussive device (group B).

All the subjective and objective data captured were analysed and tabulated in order

to capture any clinically or statistically significant improvements that occurred in each

of the individual treatment groups as well as to determine any significant differences

between the two treatment groups.

The analyses of this study were based on three readings that were recorded at the

initial visit, visit four and visit seven and included:

Demographical data analysis of age and gender

Subjective data analysis

o NPRS

Objective data analysis

o pressure algometer

o baseline goniometer

The probability value (p-value) for all the test was set at 0.05, representing the level

of significance. Therefore, only a p-value that that was ≤ 0.05 was statistically

significant.

The method used for the clinical analysis of the data with regards to the percentage

increase or decrease of the mean values over a treatment period was as follows:

Percentage increase of the mean value over a treatment period:

𝑃𝑒𝑟𝑐𝑒𝑛𝑡𝑎𝑔𝑒 𝑖𝑛𝑐𝑟𝑒𝑎𝑠𝑒 =New Amount−Original Amount

Original Amount 𝑥 100

35

Percentage decrease of mean value over treatment period:

𝑃𝑒𝑟𝑐𝑒𝑛𝑡𝑎𝑔𝑒 𝑑𝑒𝑐𝑟𝑒𝑎𝑠𝑒 =Original Amount−New Amount

Original Amount 𝑥 100

4.1.1 Normality testing

The Shapiro-Wilk test was used to establish the normality, and is used for sample

sizes of ≤ 50 participants. The statistics found were not normally distributed, due to

the small sample size and independent sample groups, therefore non-parametric

testing was applied for inter-and intragroup analysis.

4.1.2 Descriptive and clinical analysis

The descriptive and clinical statistics were used to summarise and describe the data

collected.

4.1.3 Intragroup analysis

The Friedman test, a non-parametric test, was used for the intragroup analysis. It

was used to determine if there was a significant difference in any of the two individual

groups as well as the total sample over a time period. To determine when these

differences occurred, i.e. between which visits, the non-parametric Wilcoxon signed-

rank test was done to establish any statistical significance.

4.1.4 Intergroup analysis

The intergroup analysis was done using the Mann-Whitney U test, a non-parametric

test used to establish the mean equivalence. The test compares the mean rank

values of the two individual groups, to determine whether one group is superior to

the other.

36

4.2 DEMOGRAPHIC DATA ANALYSIS

The sample group of this study consisted of 15 males and 15 females. Group A

consisted of 15 participants; seven females and eight males. Group B consisted of

15 participants; eight females and seven males. The mean age, demonstrated in

table 4.1, was 24.93 years for group A and 25.2 years for group B, making the total

sample group mean age 25.07 years.

Table 4.1 Demographic Data within the Sample of 30 Participants

Data Group A Group B Combined Total

Age Distribution (Years)

23-30 21-32 21-32

Mean age (Years)

24.93 25.2 25.07

Gender distribution

3.6 Female

8 Male 3.7 Female

7 Male 15 Female

15 Male

4.3 SUBJECTIVE DATA ANALYSIS

The subjective data for this study were obtained using the NPRS.

4.3.1 Intragroup analysis of the Numerical Pain Rating Scale

The NPRS was used to capture the participants’ perceived pain intensity on a scale

of 0 to 10. The Friedman test was used to compare that results from each individual

group over time. To detect exactly where any differences occurred over the time

within each individual group, the Wilcoxon signed-rank test was used. The test was

37

able to detect the differences between the first and fourth visits, fourth and seventh

visits as well as the first and seventh visits.

4.3.1.1 Numerical Pain Rating Scale statistics for group A

Group A had a mean value of 5.80 at the first consultation, 3.93 at fourth consultation

and at 1.47 at the seventh. Based on the mean NPRS values obtained for group A,

a percentage was calculated in order to determine whether there was an overall

improvement or a lack thereof. Group A showed a 74.66% change.

Table 4.2 Friedman Test Changes in NPRS Values of Group A

Group A: Friedman Test

Visit Mean Rank P-Value

Visit 1 2.97 0.000 Visit 4 2.03

Visit 7 1.00

As table 4.2 demonstrates, group A had a mean rank value of 2.97 at visit 1, 2.03 at

visit 4 and 1.00 at visit 7. The Friedman test for group A showed a p-value of 0.000, which was statistically significant (p≤0.05).

To detect exactly where any differences occurred over the time within group A, the

Wilcoxon signed-rank test was used. The test was able to detect the differences

between the first and fourth visits, the fourth and seventh visits, and the first and

seventh visits.

38

Table 4.3 Wilcoxon Signed-Rank Test for Group A

Group A: Wilcoxon Signed-Rank Test

Visit P-Value

Visit 1 – Visit 4 0.001



The NPRS values for group A demonstrated in table 4.3 show a statistically

significant improvement for the intervals between the first and fourth visits (p=0.001),

between the fourth and seventh visits (p=0.001), and between the first and seventh

visits (p=0.001). Therefore, the change in scores from group A showed a significant

difference (p≤0.05) that occurred over the time intervals.

4.3.1.2 Numerical Pain Rating Scale Statistics for group B

Group B had a mean value of 5.87 at the first consultation, 3.93 at the fourth

consultation and 1.40 at the seventh consultation.

Based on the mean NPRS values obtained for group B, a percentage was calculated

in order to determine whether there was an overall improvement or a lack thereof.

Group B showed a 76.15% change.

Table 4.4 Friedman Test Changes in NPRS Values of Group B

Group B: Friedman Test

Visit Mean Rank P-Value

Visit 1 2.97 0.000 Visit 4 2.00

Visit 7 1.03

39

To detect exactly where any differences occurred over the time within group B, the

Wilcoxon signed-rank test was used. The test was able to detect the differences

between the first and fourth visits, the fourth and seventh visits, and the first and

seventh visits.

Table 4.5 Wilcoxon Signed-Rank Test for Group B

Group B: Wilcoxon Signed-Rank Test

Visit P-Value




The NPRS values for group B demonstrated in table 4.5 show a statistically

significant improvement for the intervals between the first and fourth visits (p=0.001),

the fourth and seventh visits (p=0.001) and the first and seventh visits (p=0.001).

Therefore, group B showed a significant improvement (p≤0.05), which occurred over

all time intervals.

40

4.3.1.3 Clinical analysis

Figure 4.1 Bar Graph Representing the NPRS Values of Each Visit for Both Groups

Figure 4.1 compares the NPRS mean values for both groups over time. The x-axis

represents the NPRS results at the first, fourth and seventh visits. The y-axis

represents the improvement seen on the scale of 0 to 10. These values were

discussed

4.3.2 Intergroup analysis of the Numerical Pain Rating Scale

A comparison was made between the two groups at specific intervals using the

Mann-Whitney U test. Comparisons between group A and group B were made

between the intervals of the first, fourth and seventh visits. Results showed that the

scores from the first visit had a p-value of 0.708, the fourth visit had a p-value of

0.931 and the seventh visit had a p-value of 0.983. Therefore, no significant

differenced (p>0.05) occurred between the two groups at the specific time intervals.

5.8

3.93

1.47

5.87

3.93

1.4

0

1

2

3

4

5

6

7

Visit 1 Visit 4 Visit 7

NPR

S Va

lues

Visits

Group A Group B

41

4.4 OBJECTIVE DATA ANALYSIS

Objective data for this study was obtained using the pressure algometer and

baseline goniometer.

4.4.1. Intragroup analysis of pressure algometer

4.4.1.1 Pressure algometer statistics for group A

Table 4.6 Group A Column Statistics of the Pressure Algometer

Group A: Pressure Algometer kg/cm²

Readings Mean Maximum Minimum Median Std. Deviation

Visit 1 5.04 6.0 4.5 5.0 0.38

Visit 4 6.21 8.5 4.0 6.0 1.00

Visit 7 7.43 9.0 5.5 7.3 1.04

Table 4.6 illustrates the pressure algometer mean, maximum, minimum, median and

standard deviation values of group A. Group A at the first visit had a mean pressure

algometer reading of 5.04 kg/cm², 6.21 kg/cm² at the fourth visit, and 7.43 kg/cm² at

the seventh visit. Therefore, the mean percentage increase in pain pressure

threshold measured by the pressure algometer for group A was 47.42 %.

42

Table 4.7 Group A Friedman Test for Changes in Pressure Algometer Mean Values


Group Reading Mean Rank P-Value

Group A

Visit 1 1.13 0.000 Visit 4 2.0

Visit 7 2.87

Table 4.7 demonstrates the non-parametric Friedman test used to determine if there

were any changes of any statistical significance in pain pressure threshold measured

by the pressure algometer within group A over the trial period.

Group A had a mean rank pressure algometer value of 1.13 at the first visit, 2.0 at

the fourth visit, and 2.87 at the seventh visit. The p-value of 0.00 shows the

improvement was statistically significant (p≤0.05).

Table 4.8 Group A Wilcoxon Signed-Rank Test for Changes over Time (Pressure Algometer)


Visits P-Value




Table 4.8 demonstrates the results of the Wilcoxon signed-rank test, a non-

parametric test used to determine between which visits the statistically significant

improvement in pain pressure threshold measured by the pressure algometer

occurred in group A. Results indicate that the statistically significant difference

43

(p≤0.05) was found between visit 1 and visit 4 (p=0.001), between visit 4 and visit 7

(p=0.003), and between visit 1 and visit 7 (p=0.001).

4.4.1.2 Pressure algometer statistics for group B

Table 4.9 Group B Column Statistics of the Pressure Algometer

Group B: Pressure Algometer (kg/cm²)


Visit 1 4.54 5.7 3.2 4.7 0.748

Visit 4 5.99 7.3 4.7 6.0 0.729

Visit 7 7.25 8.5 5.7 7.0 0.835

Table 4.9 illustrates the pressure algometer mean, maximum, minimum, median and

standard deviation values of Group B. Group B had a mean pressure algometer

reading of 4.54 kg/cm² at the first visit, 5.99 kg/cm² at the fourth visit, and 7.25 kg/cm²

at the seventh visit. Therefore, the mean percentage increase in pain pressure

threshold measured by the pressure algometer for group B was 59.69%.

Table 4.10 Group B Friedman Test for Changes in Pressure Algometer Mean Values



Group B

Visit 1 1.00 0.000 Visit 4 2.00

Visit 7 3.00

44

Table 4.10 demonstrates the results of the non-parametric Friedman test, which was

used to determine if there were changes of any statistical significant in pain pressure

threshold measured by the pressure algometer within group B over the trial period.

Group B had a mean rank pressure algometer value of 1.0 at the first visit, 2.0 at the

fourth visit, and 3.0 at the seventh visit. The p-value of 0.00 ≤ shows that the


Table 4.11 Group B Wilcoxon Signed-Rank Test for Changes over Time (Pressure Algometer)


Visits P-Value




Table 4.11 demonstrates the results from the Wilcoxon signed-rank test, a non-

parametric test, used to determine between which visits the statistically significant

improvement in pain pressure threshold measured by the pressure algometer

occurred in group B.

The statistically significant difference (p≤0.05) was found between the visit first and

fourth visits (p=0.001), between the fourth and seventh visits (p=0.001), and

between the first and seventh visits (p=0.001).

45


Figure 4.2 Changes in the Mean Pain Threshold of the Pressure Algometer for Group A and Group B

Figure 4.2 illustrates the mean values of the pressure algometer in kg/cm² for the

first, fourth, and the seventh visits. It indicates an overall increase in pain pressure

threshold.

4.4.2 Intergroup analysis of the pressure algometer

Table 4.12 Mann-Whitney U Test for Pressure Algometer Mean Values

Mann-Whitney U Test: Pressure Algometer

Readings Group A Group B

Visit 1 Mean Rank 18.43 12.57

p-value 0.065 thus p > 0.05




5.04

6.21

7.43

4.54

5.99

7.25

0

1

2

3

4

5

6

7

8

Visit 1 Visit 4 Visit 7Pre

ssur

e A

lgom

eter

Mea

n V

alue

s (k

g/cm

²)

Group A Group B

46

p-value 0.65 thus > 0.05

Table 4.12 demonstrates the results from the non-parametric Mann-Whitney U test

that was used to compare mean rank pressure algometer values of the two groups.

The test determined whether the difference between the groups was purely by

chance or if it was statistically significant and revealing of the more superior

treatment.

The baseline reading of the p-value at visit 1 was 0.065, therefore the groups started

off comparable. The p-value remained greater at visit 4 (0.36) and at visit 7 (0.65). These results indicate no statistically significant difference (p>0.05) in the mean

pressure algometer readings between group A and group B.

4.4.3 Intragroup analysis of the baseline goniometer

4.4.3.1 Baseline goniometer statistics of group A

Table 4.13 Group A Column Statistics of the Baseline Goniometer

Group A: Baseline Goniometer (Degrees)


Visit 1 29.47 50 15 30 8.236

Visit 4 22.53 37 5 20 9.702

Visit 7 17.20 30 3 20 9.049

Table 4.13 illustrates the baseline goniometer mean, maximum, minimum, median

and standard deviation values of group A. The popliteal angle was measured from

90 degrees to 0 degrees. A decrease in degrees indicates an increase in hamstring

flexibility. Group A had a mean baseline goniometer reading of 29.47° at the first

visit, 22.53° at the fourth visit and 17.20° at the seventh visit. The mean percentage

47

change in hamstring extensibility measured by the baseline goniometer for group A

was 71.34 %.

Table 4.14 Group A Friedman Test for Changes in Baseline Goniometer Mean Values



Group A

Visit 1 2.60 0.001 Visit 4 2.07

Visit 7 1.33

Table 4.14 demonstrates the results of the non-parametric Friedman test used to

determine if there were changes of any statistical significant in hamstring extensibility

measured by the baseline goniometer within group A over the trial period.

Group A had a mean rank baseline goniometer value of 2.60 at the first visit, 2.07 at

the fourth visit and 1.33 at the seventh visit. The p-value of 0.001 shows that the


Table 4.15 Group A Wilcoxon Signed-Rank Test for Changes over Time (Baseline Goniometer)


Visits P-Value

Visit 1-Visit 4 0.017

Visit 4- Visit 7 0.029


48

Table 4.15 demonstrates the results of the Wilcoxon signed-rank test, used to

determine between which visits the statistically significant improvement in hamstring

extensibility measured by the baseline goniometer occurred in group A.

Results showed that statistically significant difference (p≤0.05) was found between

the first and the fourth visits (p=0.017), between the fourth and seventh visits

(p=0.029) and between the first and the seventh visits (p=0.002).

4.4.3.2 Baseline goniometer statistics of group B

Table 4.16 Group B Column Statistics of the Baseline Goniometer

Group B: Baseline Goniometer


Visit 1 35 55 20 35 9.636

Visit 4 22.67 35 5 25 8.633

Visit 7 20.13 40 5 19 10.253

Table 4.16 illustrates the baseline goniometer mean, maximum, minimum, median

and standard deviation values of Group B. The popliteal angle was measured from

90 degrees to 0 degrees. A decrease in degrees indicates an increase in hamstring

flexibility. At the first visit Group B had a mean baseline goniometer reading of

35.00°, at the fourth visit group B had a mean baseline goniometer reading of 22.67°, and at the seventh visit group B had a mean baseline goniometer reading of 20.13°. The mean percentage changes in hamstring extensibility measured by the baseline

goniometer for Group B was 73.87 %.

49

Table 4.17 Group B Friedman Test for Changes in Baseline Goniometer Mean Values



Group B

Visit 1 2.93 0.000 Visit 4 1.73

Visit 7 1.33

Table 4.17 demonstrates the results of the non-parametric Friedman test used to

determine if there were changes of statistical significant in hamstring extensibility

measured by the baseline goniometer within group B over the trial period.

Group B had a mean baseline goniometer value of 2.93 at the first visit, 1.73 at the

fourth visit and 1.33 at the seventh visit. The p-value of 0.00 shows that the


The individual groups displayed a p-value of 0.00 ≤ 0.05. This indicates that over the

course of the trial, the improvement in hamstring extensibility measured by the

baseline goniometer was statistically significant. Further evaluation is necessary to

establish between which visits the improvement occurred. The Wilcoxon signed-rank

test was used to evaluate where the improvement occur.

Table 4.18 Group B Wilcoxon Signed-Rank Test for Changes over Time (Baseline Goniometer)


Visits P-Value


Visit 4- Visit 7 0.220

50


Table 4.18 demonstrates the results of the Wilcoxon signed-rank test, a non-

parametric test used to determine between which visits the statistically significant

improvement in hamstring extensibility measured by the baseline goniometer

occurred in group B.

The statistically significant difference (p≤0.05) was found between the first and fourth

visits (p=0.001), and between the first and seventh visits (p=0.001). There was no

statistically difference (p>0.05) between visit four and visit seven (p=0.220).


Figure 4.3 Changes in the Mean Readings of Baseline Goniometer

Figure 4.3 illustrates the mean values of the baseline goniometer of both groups of

the first, fourth, and the seventh visits. It indicates an overall increase in hamstring

extensibility.

29.47

22.53

17.2

35

22.6720.13

0

5

10

15

20

25

30

35

40

Visit 1 Visit 4 Visit 7

Bas

elin

e G

onio

met

er (D

egre

es)

Group A Group B

51

4.4.4 Intergroup analysis of the baseline goniometer

Table 4.19 Mann-Whitney U test for Comparison of Baseline Goniometer Mean Values

Mann-Whitney U Vest: Baseline Goniometer

Readings Group A Group B




P-value 0.93 thus p >0.05


p-value 0.59 thus > 0.05

Table 4.19 demonstrates the results of the non-parametric Mann-Whitney U test that

was used to compare mean rank baseline goniometer values of the two groups. The

test determined whether the difference between the groups was purely by chance or

if it was statistically significant and revealing of the more superior treatment.

The baseline reading of the p-value at visit 1 (p=0.063) greater was than 0.05. The

p-value remained greater at visit 4 (0.93) and at visit 7 (0.59). Thus, there was no

statistically significant difference (p>0.05) in the mean baseline goniometer readings

between group A and group B.

52

CHAPTER FIVE: DISCUSSION

5.1 INTRODUCTION

The results presented in chapter four will be discussed in this chapter, particularity

those results that were of statistical significance. These findings will be compared

with the findings of previous research as discussed in the literature review presented

in chapter two, together with additional relevant research.

5.2 DEMOGRAPHIC DATA

5.2.1 Age and gender analysis

Participants between the ages of 18 and 50 years were used for this study. As

illustrated in table 4.1, the sample group was composed of 15 male and 15 female

participants, with a mean age of 25.07 years of age. The minimum age was 21 and

the maximum age was 32 years.

According to Vecchiet (2002), persons under the age of 50 years are the most likely

to have active myofascial trigger points, owing to the fact that persons of this age

group are the most active, therefore their muscles are more likely to be overused,

and have resulting micro-trauma.

5.3 SUBJECTIVE DATA

5.3.1 Intragroup analysis of the Numerical Pain Rating Scale

The results indicated that the ischemic compression group and the percussive

massage device group both demonstrated a statistically significant improvement

with regards to the NPRS values that were obtained over time. These statistically

significant changes were consistent throughout the treatment period.

53

5.3.1.1 Numerical Pain Rating Scale statistics for the ischemic compression group

The results from the Wilcoxon signed-rank test, demonstrated in table 4.3, indicated

that the ischemic compression group had a statistically significant improvement

(p≤0.05) over time from the first to the seventh treatment (p=0.001). Ischemic

compression on an active hamstring trigger point proved to have a statistically

significant improvement from the first visit to the fourth visit regarding pain perception

(p=0.001), as well as from the fourth visit to the seventh visit (p=0.001). The clinical

analysis also demonstrated that the ischemic compression group had a positive

affect over time, with decreasing pain perception of 74.66% when comparing the

measurements taken at the beginning of the trial to those taken at the end.

5.3.1.2 Numerical Pain Rating Scale statistics for the percussive massage device group

The results of the Wilcoxon signed-rank test, demonstrated in table 4.5, indicated

that the percussive massage device group had a statistically significant improvement

(p≤0.05) over time when comparing the results taken at the first visit to those from

the seventh (p=0.001). The test revealed that therapeutic massage with a percussive

device on an active hamstring trigger point proved to have a statistically significant

improvement regarding pain perception when comparing the results from the first

visit to those from the fourth visit (p=0.001), and the fourth visit to the seventh visit

(p=0.001). Clinical interpretation also showed that the percussive massage group

had a positive affect over time, with a decreasing pain perception of 76.15% from

the beginning of the trial to the end.

54

5.3.2 Intergroup analysis of the Numerical Pain Rating Scale


Mann-Whitney U test. Comparisons between the ischemic compression group and

the percussive massage group were made between the intervals of the first, fourth

and seventh visits. The first measurement had a p-value of 0.708, the fourth

measurement had a p-value of 0.931 and the seventh measurement had a p-value

of 0.983. Therefore, no significant differences (p>0.05) occurred between the two

groups at the specific time intervals with regards to pain perception.

5.3.3 Subjective data discussion

The results were conclusive in that there was a definite improvement in the extent of

the subjective pain perception experienced by both groups. When considering the

NPRS, the results indicate that both groups improved between the first and the

seventh visits. The ischemic compression group showed a more favorable

improvement than the percussive massage device group.

5.3.3.1 The effect of ischemic compression on pain perception

Ischemic compression is a non-invasive treatment method that causes temporary

decrease in blood within the myofascial trigger point in order to ultimately increase

the blood flow. The increase in blood to the myofascial trigger point flushes out the

waste product and the inflammatory exudate molecules from the myofascial trigger

point (Fritz and Grosenbach, 2009). This phenomenon then leads to an increase in

the local oxygen supply to the myofascial trigger point, allowing the affected tissue

to initiate the healing process (Arnau-Masanet et al., 2010).

Ischemic compression creates a mechanical disruption of the actin-myosin myofibril

cross links that are locked within the trigger point (Mense and Simons, 2000; Perle

et al., 1999). This disruption causes a decrease in sensory afferent input of noxious

55

stimuli to the brain via the pain gate theory (Mense et al., 2000). The pain relief

associated with ischemic compression is also linked with alternating spinal reflex

mechanisms that cause a decrease in muscle spasm (Ingbur, Kostopoulos, Larkin

and Nelson, 2008).

Behrangrad and Kamali (2017) similarly demonstrated a statistically significant

improvement (p ≤ 0.05) using the NPRS in a comparative study between ischemic

compression and lumbar pelvic manipulation as trigger point therapy for

patellofemoral pain syndrome in young adults. Ischemic compression showed to be

superior to lumbopelvic manipulation therapy in both the short and the long term with

regards to effectiveness for the treatment of patellofemoral pain syndrome.

Hou, Tsai, Cheng, Chung, and Hong (2002) investigated the immediate effect of

physical therapeutic modalities on myofascial pain in the upper trapezius muscle and

found that ischemic compression provided an immediate relieve in pain perception

and decreased the sensitivity of the myofascial trigger point.

5.3.3.2 The effect of therapeutic massage with a percussive device on pain perception

One of the reported benefits of device-assisted soft tissue manipulation is an

analgesic effect, which is a temporarily reduction or elimination of pain perceived.

Device-assisted soft tissue manipulation provides a noxious stimulation for pain

modulation, leading to an analgesic response. The pain gate theory asserts that the

pain signals are then inhibited, which could be a possible explanation for the

analgesic effect. Consequently, reduced pain lead to muscle relaxation, which allows

for normalised neuromuscular movement and improvement of the function of the soft

tissue. Soft tissue mechanotherapy is effective in treating pain, leading to muscle

relaxation (Weerapong, Hume and Kolt, 2005).

According to Frey, Evans, Knudtson, Nus, Scholl and Sluka (2008), device-assisted

soft tissue manipulation causes friction between the tissues that disrupt the tissue

56

and causes fibroblastic proliferation to the soft tissue, which results in tissue

regeneration and recovery. Scar tissue is broken down, which reinitiates the healing

process. This process begins with the increase of blood flow to the tissue, bringing

healing substances phagocytosed by white blood cells to the micro-injury site (area

of tissue disruption caused by the treatment). The repair process of the tissue leads

to less painful tissue.

5.4 OBJECTIVE DATA

5.4.1 Intragroup analysis of the pressure algometer

The results from the pressure algometer statistical analysis showed that both the

ischemic compression group and the percussive massage device group had

significant differences in the pressure algometer readings over time.

5.4.1.1 Pressure algometer statistics for the ischemic compression group

The results using the Wilcoxon signed-rank test, demonstrated in table 4.8, indicated


(p≤0.05) over time when comparing the results from the first to the seventh treatment

(p=0.001). Ischemic compression on an active hamstring trigger point proved to

have a statistically significant improvement with regards to pressure pain threshold

between the first visit and the fourth visit, (p=0.001), and between the fourth and the

seventh visit (p=0.003). The clinical interpretation also proved that ischemic

compression had a positive affect over time, with the group showing an increased

pressure pain threshold of 47.42% from the beginning of the trial to the end.

57

5.4.1.2 Pressure algometer statistics for the percussive massage device group

The results from the Wilcoxon signed-rank test, demonstrated in table 4.8, indicated


(p≤0.05) over time from the first visit to the seventh (p=0.001). The test revealed that

therapeutic massage with a percussive device on an active hamstring trigger point

proved to have a statistically significant improvement with regards to pressure pain

threshold between the first visit and the fourth visit (p=0.001), and the fourth visit and

the seventh visit (p=0.001). The clinical interpretation also proved that the

percussive massage device had a positive affect over time, with the group showing

and increased pressure pain threshold of 59.69% from the beginning of the trial to

the end.

5.4.2 Intergroup analysis of the pressure algometer


Mann-Whitney U test. Comparisons were made between the ischemic compression

group and the percussive massage group at the intervals of the first, fourth and

seventh visits. The first measurement had a p-value of 0.065, the fourth

measurement a p-value of 0.360 and the seventh a p-value of 0.650. Therefore, no

significant differences (p>0.05) occurred between the two groups at the specific time

intervals with regards to pressure pain threshold.

5.4.3 Discussion of pressure algometer results

5.4.3.1 The effect of ischemic compression on pain threshold

Dearing and Hamilton (2008) established that ischemic compression was a more

effective technique than the muscle energy technique in decreasing pressure pain

threshold in trigger points in asymptomatic patients. The effect of ischemic

compression therapy in increasing the pressure pain threshold may be attributed to

58

the reactive hyperemia caused by the temporarily occlusion of blood supply (Hou et

al., 2002). This reaction helps in flushing the muscle of inflammatory exudates and

pain metabolites, breaking down scar tissue and reducing muscle tone. Applying

direct ischemic compression diminishes the sensitivity of nodules (Travell and

Simons, 1999) and may restore the length of sarcomeres in the myofascial trigger

point (Simons, 2002). These changes may result in normal resting length of muscles.

5.4.3.2 The effect of a percussive massage device on pain threshold

According to Costantino, Galuppo, and Romiti (2017), vibration and percussion

devices have an effect in the pain gate theory by affecting the afferent discharge

from fast-adapting mechanoreceptors and muscle spindles, therefore decreasing the

pressure pain threshold.

It is thought that when vibration or percussion devices are applied directly on the

skin, the large afferent nerve fibers are activated and the small afferent nerve fibers

are inhibited. This process allows signals to be sent to the spinal cord from the large

fibers and not the small fibers, which normally transmit signals of pain, therefore

reducing the pain perceived as well as the pressure pain threshold (Magee,

Zachazewski and Quillen, 2007).

5.4.4 Intragroup analysis of the baseline goniometer

5.4.4.1 Baseline goniometer statistics for the ischemic compression group



(p≤0.05) over time when comparing the results from the first treatment to those of

the seventh treatment (p=0.002). The test revealed that ischemic compression on

an active hamstring trigger point proved to have a statistically significant

improvement with regards to pressure pain threshold between the first visit and the

59

fourth visit, (p=0.017), and the fourth visit and the seventh visit (p=0.029). The

clinical interpretation also proved that ischemic compression had a positive affect

over time, with this group showing an increased hamstring extensibility of 71.34 %

from the beginning of the trial to the end.

5.4.4.2 Baseline goniometer statistics for the percussive massage device group



(p≤0.05) over time when comparing results of the first visit to those of the seventh

(p=0.001). The test revealed that therapeutic massage with a percussive device on

an active hamstring trigger point proved to have a statistically significant

improvement with regards to pressure pain threshold between the first visit and the

fourth visit (p=0.001).There was no statistically difference between (p>0.05) the

fourth and the seventh visits (p=0.220). The clinical interpretation also proved that

percussive massaging had a positive affect over time, with this group showing an

increased hamstring extensibility of 73.87 % from the beginning of the trial to the

end.

5.4.5 Intergroup analysis of the baseline goniometer


Mann-Whitney U test. Comparisons between the ischemic compression group and

the percussive massage group were made between the intervals of the first, fourth

and seventh visits. The first measurement had a p-value of 0.063, the fourth

measurement had a p-value of 0.930 and the seventh measurement had a p-value

of 0.590. Therefore, no significant differences (p>0.05) occurred between the two

groups at the specific time intervals with regards hamstring extensibility.

60

5.4.6 Discussion of the baseline goniometer results

5.4.6.1 The effect of ischemic compression on hamstring extensibility

Desai and Jeswani (2018) compared the effectiveness of myofascial release and

ischemic compression on acute trapezitis in young adults between the ages of 18

and 30. The results show that both the techniques were effective in reducing pain

and neck disability and increasing cervical lateral flexion in the tested subjects.

Aguilera, Martin, Masanet, Botella, Soler and Morell (2009) compared the immediate

effects of ischemic compression and ultrasound for the treatment of latent myofascial

trigger points in the trapezius muscle. The results revealed an immediate decrease

in electrical activity of the trapezius muscle and a decrease of myofascial trigger

point sensitivity after both types of treatment, while improvement in the active

cervical range of motion was only noted in the ischemic compression group only.

As mentioned in section 5.4.3.1, ischemic compression therapy increases the

pressure pain threshold due to reactive hyperemia caused by the temporarily

constriction of blood supply (Hou et al., 2002), which then flushes the muscle of

inflammatory exudates and pain metabolites, breaks down scar tissue and reduces

muscle tone. These processes then reduce the of sensitivity of the myofascial trigger

point (Travell and Simons, 1999) and restore the length of sarcomeres in the

myofascial trigger point (Simons, 2002). These changes may result in normal resting

length of muscles, therefore increasing the flexibility of the muscle.

5.4.6.2 The effect of a therapeutic massage with a percussive device on hamstring extensibility

Issurin (2005) suggests that percussive massage devices may enhance excitatory

inflow from the muscle spindles to the alpha motor neuron pools and control the

recruitment thresholds and firing rates of motor units. They also decrease the

inhibitory impact of the Golgi tendon organs, providing more flexibility.

61

Furthermore, Bakhtiary et al. (2011) report a general increase in range of motion and

flexibility of the hamstring muscle in their investigation of the application of device-

assisted soft tissue manipulation on hamstring extensibility.

Finally, percussive massage devices create mechanical pressure on the muscle

tissue in order to decrease adhesions in the tissue. Mobilising and elongating

shortened or adhered connective tissue may increase muscle-tendon compliance.

Improved muscle compliance results in a less stiff muscle-tendon unit. These effects

help to restore muscle flexibility and restoring range of motion (Imtiyaz, Veqar,

Shareef (2014).

62

CHAPTER SIX: CONCLUSION AND RECOMMENDATIONS

6.1 CONCLUSION

The aim of this study was to compare the efficacy of ischemic compression with that

of therapeutic massage with a percussive device in the treatment of active hamstring

trigger point pain. The outcome of this study suggested that patients with hamstring

trigger point pain were treated effectively with either, as active trigger points respond

well to both ischemic compression and therapeutic massage with a percussive

device. Both groups showed a reduction in self-reported pain, an increase in pain

pressure threshold and an increase in hamstring extensibility over active hamstring

trigger points.

The results of this study showed that the clinical difference was statistically

insignificant (p<0.05). In conclusion, no treatment intervention was superior to the

other in treating active hamstring trigger points. Statistical results indicate that both

treatment interventions are effective in reducing hamstring pain and increasing the

hamstring extensibility.

This study thus indicated that both ischemic compression and therapeutic massage

with a percussive device were used to treat hamstring trigger point pain effectively

provided that no contraindications were present. In the case of patient being

contraindicated to one treatment intervention, the other is a suitable alternative.

The clinical importance of this study provides the chiropractic profession with two

different treatment interventions to effectively treat patients with hamstring

myofascial trigger point pain. Numerous studies have been done to determine the

effect of chiropractic manipulative therapy on myofascial trigger points, as it is the

profession’s primary treatment intervention. Ischemic compression and therapeutic

massage with a device, however, could serve as an effective post manipulative or

alternative treatment interventions to spinal manipulation. The device-assisted soft

tissue manipulation could also help prevent or reduce fatigue and injuries in manual

therapists.

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6.2 RECOMMENDATIONS

The following recommendations should be taken into consideration for further

research regarding the treatment of active hamstring myofascial trigger points:

A larger sample size should be used to offer generalisability.

The long-term effects of both treatment interventions can be investigated by

increasing the treatment period or adding a one month follow-up after the

completion of the six treatments.

The effect of a combination of ischemic compression and therapeutic

massage with a percussive massage should be examined in the treatment of

active hamstring myofascial trigger points.

A research study should be done with two sample groups, one receiving a

sacroiliac chiropractic manipulation and ischemic compression, with the other

receiving chiropractic sacroiliac manipulation and therapeutic massage with

a percussive device. Doing so could provide a comparison of chiropractic

manipulation interventions.

An additional objective measurement could be added to assess range of

motion or muscle strength. Doing so could provide more information on the

different physiological effects of the two treatment interventions.

64

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APPENDIX A: ADVERTISEMENT

Research study Are you between the ages of 18-50? Do you suffer from hamstring pain?

Are you currently not receiving any treatment for your pain?

You may be eligible to participate in my research study, which aims to compare the effects of ischemic compression with therapeutic massage with a percussive

device in treating hamstring pain.

The research will be conducted at the Chiropractic Clinic at the University of Johannesburg Doornfontein Campus.

If you are interested in taking part, please contact: Charlize Jonker

[email protected] 0784707514

Ethics clearance number: REC-241112-035

mailto:[email protected]

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APPENDIX B: INFORMATION LETTER

DEPARTMENT OF CHIROPRACTIC

RESEARCH STUDY INFORMATION LETTER

Good Day,

My name is Charlize Jonker. I WOULD LIKE TO INVITE YOU TO PARTICIPATE in a research study, on ‘The effect of ischemic compression versus therapeutic massage with a percussive device in treating hamstring myofascial pain dysfunction.’

Before you decide on whether to participate, I would like to explain to you why the research is being done and what it will involve for you. I will go through the information letter with you and answer any questions you have. This should take about 10 to 20 minutes. The study is part of a research project being completed as a requirement for a Master’s Degree in Chiropractic through the University of Johannesburg.

THE PURPOSE OF THIS STUDY is to compare the effects of ischemic compression versus therapeutic massage with a percussive device in treating active myofascial hamstring trigger points.

Below, I have compiled a set of questions and answers that I believe will assist you in understanding the relevant details of participation in this research study. Please read through these. If you have any further questions I will be happy to answer them for you.

DO I HAVE TO TAKE PART? No, you don’t have to. It is up to you to decide to participate in the study. I will describe the study and go through this information sheet. If you agree to take part, I will then ask you to sign a consent form.

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WHAT EXACTLY WILL I BE EXPECTED TO DO IF I AGREE TO PARTICIPATE? You must be between ages of 18-50, with localised pain that is concentrated in the hamstring region. You will not be included in to the study if you have any of the following: trauma or surgeries to the region, tumors or infection, or a rupture of any of the hamstring muscle. If you qualify to participate in this study, you would not be able to participate in any other research studies during this time nor take any medications that may influence the outcomes of this study. Not all medications may be a problem, so please be open with me regarding any medication or supplements you are using. Also, please be open with me regarding your health history, since you may otherwise harm yourself by participating in this study.

You will be allocated to one of two groups consisting of 15 participants. You will then be assigned to your group by drawing a number from a hat. The hat will contain 30 pieces of paper labelled A or B (representing the group numbers). The number you draw is the group you will be allocated to. Group A will only receive treatment in the form of ischemic compression on hamstring myofascial trigger points, meaning the researcher will apply localised pressure on the hamstring muscle trigger point. Group B will receive a therapeutic massage with a device that vibrates on the hamstring muscle.

A case history, physical examination and a lower back examination will be performed. A series of tests will be gathered for data collection. The first test is a Numerical Pain Rating Scale. You will be asked to rate your pain on a scale of 0 to 10, i.e. from no pain and to the worse pain you have ever experienced. Thereafter the researcher will locate a trigger point that reproduces the pain on the hamstring region. The researcher will the preform a test with a pressure algometer to record your pain threshold. Thereafter you will be positioned on your back with your knee and your hip bend to 90 degrees. The researcher will use a baseline goniometer to measure the popliteal angle, e.g. you will try to straighten your leg as far as possible and the researcher will measure the angel of your knee.

Thereafter you will be treated for the duration of 60 seconds. You will be treated over a three-week period, twice per week, and the seventh visit will be for data collection only.

WHAT WILL HAPPEN IF I WANT TO WITHDRAW FROM THE STUDY? If you decide to participate, you are free to withdraw your consent at any time without giving a reason and without any consequences. If you wish to withdraw your consent, you must please inform me as soon as possible.

IF I CHOOSE TO PARTICIPATE, WILL THERE BE ANY EXPENSES FOR ME, OR PAYMENT DUE TO ME? You will not be paid to participate in this study and you will not bear any expenses either.

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RISKS INVOLVED IN PARTICIPATION: Ischemic compression and therapeutic massage with a vibrating device are not harmful to the participant. The massage device may cause some itching or a warm sensation due to the increasing blood flow to the area. You might also have slight discomfort over the trigger point, which is completely normal. With the ischemic compression group, you might have a slight discomfort when the pressure is applied on the point of pain. You might a small bruise but the chances of bruising are minimal.

BENEFITS INVOLVED IN PARTICIPATION: Therapeutic massage with a vibrating device is aimed at decreasing muscle spasm and pain, increasing the blood flow to the area, which will stimulate healing and improve the function of the muscle. During ischemic compression the researcher will apply pressure to the myofascial trigger point causing hypoxia (decrease of blood flow) to the trigger point. The pressure will be released after 60 seconds, causing an influx of blood to stimulate healing.

WILL MY PARTICIPATION IN THIS STUDY BE KEPT CONFIDENTIAL? Yes. Names on the data sheet will be removed once analysis starts. All data and back-ups thereof will be kept in password-protected folders and/or locked away as applicable. Only I or my research supervisor will be authorised to use and/or disclose your anonymised information in connection with this research study. Any other person wishing to work with you anonymised information as part of the research process (e.g. an independent data coder) will be required to sign a confidentiality agreement before being allowed to do so.

OR

WILL MY TAKING PART IN THIS STUDY BE ANONYMOUS? Yes. Anonymous means that your personal details will not be recorded anywhere by me. As a result, it will not be possible for me or anyone else to identify your responses once these have been submitted.

WHAT WILL HAPPEN TO THE RESULTS OF THE RESEARCH STUDY? The results will be written into a research report that will be assessed. In some cases, results may also be published in a scientific journal. In either case, you will not be identifiable in any documents, reports or publications. You will be given access to the study results if you would like to see them, by contacting me.

WHO IS ORGANISING AND FUNDING THE STUDY? The study is being organised by me, under the guidance of my research supervisor at the Department of Chiropractic in the University of Johannesburg. All funding for the study will be provided by the supervisor-linked bursary.

WHO HAS REVIEWED AND APPROVED THIS STUDY? Before this study was allowed to start, it was reviewed in order to protect your interests. This review was

79

done first by the Department of Chiropractic, and then by the Faculty of Health Sciences Research Ethics Committee at the University of Johannesburg. In both cases, the study was approved.

WHAT IF THERE IS A PROBLEM? If you have any concerns or complaints about this research study, its procedures or risks and benefits, you should ask me. You should contact me at any time if you feel you have any concerns about being a part of this study. My contact details are:

Charlizé Jonker 078 470 7514 [email protected]

You may also contact my research supervisor:

Dr Chris Yelverton [email protected]

If you feel that any questions or complaints regarding your participation in this study have not been dealt with adequately, you may contact the Chairperson of the Faculty of Health Sciences Research Ethics Committee at the University of Johannesburg:

Prof. Christopher Stein Tel: 011 559-6564 Email: [email protected] FURTHER INFORMATION AND CONTACT DETAILS: Should you wish to have more specific information about this research project information, or have any questions, concerns or complaints about this research study, its procedures, risks and benefits, you should communicate with me using any of the contact details given above.

Researcher:

_______________________

Charlizé Jonker



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APPENDIX C: CONSENT FORM

DEPARTMENT OF CHIROPRACTIC

RESEARCH CONSENT FORM

The effects of ischemic compression versus therapeutic massage with a percussive device in treating hamstring myofascial pain dysfunction

Please initial each box below:

I confirm that I have read and understand the information letter dated 19/07/2016 for the above study. I have had the opportunity to consider the information and ask questions, and have had these answered satisfactorily.

I understand that my participation is voluntary and that I am free to withdraw from this study at any time without giving any reason and without any consequences to me.

I agree to take part in the above study.

_______________________ _________________________ ________________

Name of Participant Signature of Participant Date

_______________________ _________________________ ________________

Name of Researcher Signature of Researcher Date

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APPENDIX D: CASE HISTORY

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83

84

85

APPENDIX E: PHYSICAL EXAMINATION

86

87

88

89

90

APPENDIX F: LUMBAR SPINE REGIONAL

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92

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APPENDIX G: NUMERICAL PAIN RATING SCALE Visit 1: Patient Instructions

Please indicate the intensity of current, best, and worst pain levels over the past 24

hours on a Scale of 0 (no pain) to 10 (worst pain imaginable) |______|______|______|______|______|______|______|______|______|______|

0 1 2 3 4 5 6 7 8 9 10

No pain Mild Pain Moderate Pain Worst

Visit 4: Patient Instructions



0 1 2 3 4 5 6 7 8 9 10


Visit 7 Patient Instructions



0 1 2 3 4 5 6 7 8 9 10


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APPENDIX H: HAMSTRING TRIGGER POINT EXAMINATION

File Number:

Date:

L R

Spot Tenderness: Yes / No

Referred Pain: Yes / No

Where:

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APPENDIX I: PRESSURE ALGOMETER AND GONIOMETER READINGS

Research file number:

Hamstring muscle trigger point:

Readings Date Algometer (kg/cm²)

Goniometer Degrees

Visit 1

Visit 4

Visit 7

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APPENDIX J: LETTER OF REQUEST

To the division for institutional planning, evaluation and monitoring management, I would like to ask permission to perform my research on the University of Johannesburg Doornfontein Campus. The research will take place at the Chiropractic Clinic with possible involvement of students studying on this campus. The study is titled ‘The effect of ischemic compression versus therapeutic massage with a percussive device on hamstring myofascial pain dysfunction.’ Thirty participants will be involved in twice-a-week consultation for three weeks.

This study has been approved by the University of Johannesburg’s Ethics

Committee. Ethics clearance number: REC-241112-035 Kind Regards Charlize Jonker Master’s Student 078 470 7514

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APPENDIX K: ETHICS CLEARANCE LETTER

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APPENDIX L : HIGHER DEGREES LETTER

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APPENDIX M: SIMILARITY REPORT

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APPENDIX N: EDITOR’S LETTER

22/02/2019

To whom it may concern,

This letter serves to confirm that the attached dissertation, “The effects of ischemic

compression versus therapeutic massage with a percussive device in treating hamstring

myofascial pain dysfunction”, has been edited by a qualified language practitioner. For

further verification, I may be contacted by email: [email protected] or by phone:

0616150292.

Kind regards,

Kelly-Anne Gilbertson

BA (Hons, Cum laude), MA (Cum laude), PhD


The Effects of Ischaemic Compression versus Therapeutic Massage ...

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