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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE, KARNATAKA
BANGLORE
ANNEXURE – II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1.
NAME OF THECANDIDATE
KACHARIYA BHAVESH N.
AND ADDRESS
(IN BLOCK LETTERS)
SHREE DEVI COLLEGE OF PHYSIOTHERAPY,
MANGALORE
2
NAME OF INSTITUTON
SHREE DEVI COLLEGE OF PHYSIOTHERAPY,
BALLALBAGH, MANGALORE -575003
3
COURSE OF STUDY AND
MASTERS OF PHYSIOTHERAPY (M.P.T)
SUBJECT
2 YEARS DEGREE COURSE
PHYSIOTHERAPY IN MUSCULOSKELETAL
DISORDERS AND SPORTS PHYSIOTHERAPY
4
DATE OF ADDMISSION TO
COURSE
5
TITLE OF TOPIC
A COMPARITIVE STUDY BETWEEN TENS
WITH NERVE TISSUE MOBILISATION (NTM)
AND TENS WITH MUSCLE ENERGY
TECHNIQUES (MET) IN PIRIFORMIS
SYNDROME RELETED WITH SCIATICA
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BRIEF RESUME OF THE INTENTED WORK:
6.1
INTRODUCTION:
Piriformis syndrome is a condition in which the piriformis muscle becomes tight or
spasms, and irritates the sciatic nerve. This causes pain in the buttocks region and may
even result in referred pain in the lower back and thigh. Patients often complain of pain
deep within the hip and buttocks, and for this reason, piriformis syndrome has also been
referred to as "Deep Buttock" syndrome.
Piriformis syndrome is predominantly caused by a shortening or tightening of the
piriformis muscle, and while many things can be attributed to this, they can all be
categorized into two main groups: Overload (or training errors); and Biomechanical
Inefficiencies.
The inability to recognize the herniation of the nucleus pulpous as the most common
cause of sciatica in the beginning of the previous century led to the study of the possible
association of the piriformis muscle in pathophysiology of sciatica. Yeoman, based on the
intimate anotomatic relationship of the sacroiliac joint (SU), the piriformis muscle (PM)
and the sciatic nerve, reported that sciatica may be caused by a so called “periarthritis”
involving the anterior sacroiliac liagament, the PM and the adjacent branches of the sciatic
nerve.2
In 1938 Beaton and Anson3 examined 240 human cadavers, they described six
variations of sciatic nerve exit and considered that the close relationship of the piriformis
muscle and the nerve affects the latter in cases of muscle infection or generally in cases of
muscle spasm, specifically when the PM is pierced by the nerve.
Commonly muscles covering posterior aspects of the hip joint form two layers i.e.
outer layer consist of gluteus maximus and tensor fasciae latae, while inner layer consists
of short external rotators of hip such as piriformis, superior gemellus, obturator internus,
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inferior gemellus and the quadratus femoris. The piriformis is the abductor and external
rotator of the hip and is a flexor of the hip in walking. It arises from the pedicles of the II,
III and IVth sacral vertebrae and adjacent portion of the bone lateral to the sacral
foramina. The muscle passes the greater sciatic foramen and coursing laterally is inserted
by a round tendon into the superior border of the greater trochanter. So, it is in contact
with the anterior ligament of the sacroiliac joint and the root of the first, second and third
sacral nerves. Its lower border is closely related to the whole of the sciatic nerve
(elements 1985). 4
Although the syndrome was described originally in 19475, there was no universal
agreement
about
its
diagnosis
and
treatment,
thus
affecting
epidemiologic
analysis.1Bernard et al6 in their review of 1293 patients referred to their clinic, with low
back pain, cited an incidence of 0.33% for piriformis syndrome.
While Pace and Nagle7 reported 45 patients with piriformis syndrome gleaned from
750 patients the literature reveals that piriformis syndrome is more often encountered in
patients 30 to 40 years old and sporadically in patients younger than 20 years3 and the ratio
between male: female is 1:6.
Robinson has been credited with introducing the term “piriformis syndrome” in
1947.5 He stated that sciatica is a symptom and not a disease, because it is seldom caused
by a primary neuritis, and he defined that the term piriformis syndrome should be applied
to the type of sciatica that is caused by an abnormal condition of the piriformis muscle that
is usua7lly traumatic in origin.5 He stated that piriformis muscle and fascia become
compressed between the swollen muscle fiber and the bony pelvis, leading to an
entrapment neuropathy. He also found that the piriformis was stretched after a few degree
of leg rising, so that with muscular spasm or inflammation, the sciatic nerve may be
directly compressed by the piriformis muscle.
3
The etiology of this syndrome is thought to be an injury of the piriformis muscle
resulting in spasm, edema and contractures of the muscle and subsequent compression and
entrapment of sciatic nerve.
4
Yeoman (1928) stated that any lesion of the SI joint may
cause inflammatory reaction of the piriformis muscle and its fascia.4 The other possible
causes of piriformis syndrome are a history of blunt trauma in the gluteal region such as
fall, activities that increases activities of hip rotators (contractions of hip rotators),
prolonged sitting on hard surfaces, idiopathic, pregnancy, unusual overload of the muscle
which may be caused by attempting to refrain from a fall, repetitive strain or sacroiliac
dysfunction, complications of pelvic, and hip or other surgery due to rough handling
during anesthesia, extreme unusual positioning of the hips or prolonged weight bearing on
the buttocks during the surgical procedure.
6.2 NEED FOR STUDY
In muscle energy technique that Stretching exercises are common in physiotherapy
practice for contracted or tight soft tissues including muscle. Many authors have
recommended stretching of piriformis muscle components incases for tightness. Passive
stretching of piriformis muscle for short or hypertrophied piriformis muscle has been
advised by Carrie M Hall and Lorithein Brody. 8 Leon chaitow and Judith Walker Delany9
has also recommended use of MET in stretching of piriformis muscle and other external
rotators of the hip.
One of the muscle energy technique that is post isometric relaxation (PIR) technique
which works on neurophysiological principles, states that after a muscle is contracted, it is
automatically in a relaxed state for a brief latent period. The effect of PIR, which causes a
sustained contraction on the golgi tendon organs, seems pivotal. The response to such a
contraction seems to be to set the tendon and the muscle to a new length by inhibiting it.
4
Lewitt K, in 1984 had stated about usefulness of MET in treatment of trigger points in
the myofacial pain. He found that MET is very effective in treating myofacial pains and
restoring resting length of the affected muscle.10
Transcutaneous electrical nerve stimulation (TENS) appears to have an immediate
effect in decreasing pain intensity in myofascial trigger point of buttock and lower leg,
high intensity tens is effective in reducing myofacial Pain.17 Literature on effectiveness of
TENS reports wide range of outcome TENS provides initial relief of treatment in 70-80%
Of patients , High frequrency may benefit myofascial pain , currently there is insufficient
Evidence from well-designed control trials to support this use ,18,19 hence there is a need of
Further study .
6.3 RESEARCH QUESTIONS:
Is there a significant difference in the effectiveness between nerve tissue mobilization with
TENS and muscle energy techniques with TENS in piriformis syndrome related with
sciatica?
HYPOTHESIS

NULL HYPOTHESIS:
There is no significant difference in the effectiveness between nerve tissue mobilization
with TENS and muscle energy techniques with TENS in piriformis syndrome related with
sciatica.

ALTERNATE HYPOTHESIS:
It is assumed that there is significant difference in pain relief in a group of piriformis
syndrome with sciatica who are treated with nerve tissue mobilization with TENS V/S a
group of piriformis syndrome with sciatica who are treated with muscle energy techniques
with TENS in piriformis syndrome related with sciatica.
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6.4 REVIEW FOR LITERATURE
In 1934 Freiberg and Vinke 11 also considered the inflammation of the sacroiliac joint as
the basic pathology that caused sciatica, assuming that the lesions of the SIJ may cause
inflammatory reaction of the piriformis muscle and its fascia and the overlying
lumbosacral plexus. They also stated that biochemical irritation of the sciatic nerve
epineurium may play a role in the pathogenesis of sciatica. Their aim was to identify the
pathophysiogic mechanism of the Lasegue sign, whereas they later introduced a sign
known as the Freiberg sign that is believed to be derivative of piriformis muscle spasm
Later on, Robinson5 was given honour of introducing the term “piriformis syndrome” in
1947. He acknowledged that sciatica is a symptom and not a disease, because it is seldom
caused by a primary neuritis, and he defined that the term piriformis syndrome should be
applied to the type of sciatica that is caused by an abnormal condition of the piriformis
muscle that is usually traumatic in origin .5 He presented two cases of piriformis syndrome
and stated cardinal features of piriformis syndrome.
In 1996 Parziale JR et al16 stated that the sciatic nerve may be compressed within the
buttock by the piriformis muscle with pain increased by muscular contraction, palpation or
prolonged sitting.
In 2004 authors such as E.C. Papadopoulos and S.N. Khan12 in their article suggested
the following classification for the piriformis syndrome complex. They stated that primary
piriformis syndrome should be termed for all pathology intrinsic to the piriformis muscle,
such as myofascial pain, pyomyositis and myositis ossificans secondary to an inciting
event such as trauma. While secondary piriformis syndrome or pelvic outlet syndrome
should be reserved for all other cases in which the symptoms of posterior buttock pain
with or without radiation down the leg depends on the location of the pathology in relation
to the structures adjacent to the sciatic notch, provided that spinal pathology is excluded.
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In 2004 Villejo Mc et al14 presented a case for diagnosis pathogenesis and treatment of
piriformis syndrome where there as persistent buttock and hip pain after spinal anesthesia
in a 29 years old women after caesarian delivery. Back pain with radiation into the buttock
after spinal anesthesia is frequently attributed to the spinal procedures itself. However
prolonged sitting and weight bearing in the upright position after caesarian delivery can
cause sciatic nerve compression at the SI joint with concomitant irritation, inflammation
and spasm of piriformis muscle. Piriformis syndrome is frequently under diagnosed in the
obstetric population.
Again in 2004 Papadopoulous E C and S.N. Khan12 stated that piriformis syndrome
includes buttock pain and tenderness which is exacerbated in prolonged sitting. Specific
physical findings like tenderness in sciatic notch, buttock pain in flexion, adduction, and
internal rotation. Physical therapy aims at stretching,, the muscle and reducing vicious
cycle of pain and spasm.20
In 1991 Pamela M. Barton13 said that the recent reports suggested that bone scans may
show increased uptake of radioactivity in the affected piriformis muscle and
electrodiagnostic studies may reveal denervation in a diagnostic distribution with
supporting changes in H-reflex, F-waves and somatosensory evoked potentials. MRI and
CT scan may demonstrate atrophy or fibrous tissue replacement of the piriformis muscle
in long standing cases. Higher resolution MRI may show local areas of scarring or edema
within the piriformis muscle.
Chen WS et al16 in 1992 stated that piriformis muscle syndrome is diagnosed on the
basis of history of sciatia, clinical findings such as tender point at sciatic notch and around
and over the piriformis muscle by palpation of gluteal region.
In 1989 Justard ME 15 in their study proved that stretching exercise and reduced activity
had relieved piriformis syndrome.
7
In 1984 Lewit K et al8 stated that the post isometric technique by placing muscle in a
stretched position. Then an isometric contraction is exerted against minimal resistance.
Relaxation and the gentle stretch follow as the muscle releases. This technique was
applied to tight, tender muscles that are commonly associated with musculoskeletal pain
and he tested the above on 351 muscle groups in 244 patients. He stated that MET (PIR)
produced immediate pain relief in 94%, lasting pain relief in 63% as well as lasting relief
of point tenderness in 23% of the sites treated, respectively. Patients practicing auto
therapy on a home program were more likely to realize lasting relief pain was relived in
the muscle itself
Elvey R, Hall T. 2004 Journal of Manual & Manipulative Therapy,Volume 12, Number
3, 2004 , pp. 143-152(10) Effectiveness of Neural Mobilization in the Treatment of a
Patient with Lower Extremity Neurogenic Pain
Elias C. Papadopoulos, MD Orthopedic Clinics of North America - Volume 35, Issue 1
(January 2004) Piriformis syndrome and low back pain: a new classification and review of
the literature
Graff Radford SB ReevesJL , Baker RL, conducted study on effect TENS on myofascial
trigger points and concluded that high intensity is effective in reducing myofascial pain
and these pain reduction does not reflect changes in local trigger point sensitivity .
Kruger LR van der linden WJ cleaton jones pt conducted study on effect of TENS &
conservative therapy on myofascial pain dysfunction a single blind trial session was
conducted & concluded that TENS did not increase the symptom.
Phero JC conducted study on effect of TENS &myoneural injection therapy for
management of myofascial pain and concluded that TENS therapy is a safe & non
invasive technique in treating myofascial pain
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THE OBJECTIVE EXAMINATION CONSIST OF:
1.Detailed history
2.Examination of posture
3.Evaluation of pain characteristics
4.Palpation
5.Neurological examination
6.Diagnostic test
7.Evaluation of functional status
OBJECTIVES OF STUDY:
1. To evaluate the effectiveness of nerve tissue mobilization with TENS in piriformis
syndrome related with sciatica..
2. To evaluate the effectiveness of muscle energy techniques with TENS in piriformis
syndrome related with sciatica.
3. To compare the effectiveness among the two groups of people which were given the
above mention treatment.
7.
MATERIALS AND METHODS
7.1 SOURSCE OF DATA:
1. Shree Devi college outpatient department
2. Government wenlock hospital
3. SCS hospital
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7.2 METHOD OF COLLECTION DATA:
40 Patients will be chosen based on inclusion and exclusion criteria. Both female
and male patient between 20 to 60 years will be taken.
Study design: comparative study
Sample size: 40 subject (20 in each)
Sample method: Random sampling technique
Inclusion criteria:
1. Both males and females between the ages of 20 to 60 years
2. All patients diagnosed with piriformis syndrome
3. Piriformis sign positive*
4. Lasegue sign positive*
5. Freiberg sign positive*
6. Pace sign (FAIR TEST) positive*
7. Beatty test result positive*
(*Minimum three signs should be positive out of five signs to confirm the diagnosis of
piriformis syndrome)
Exclusion criteria:
1. Age less than 20 years or more than 60 years
2. Any pathology around the hip
3. Pain due to neurological, spinal or pelvic origin
4. Any other referred pain to hip and SI joint
5. Any recent injuries around the hip and knee
6. Limb length discrepancy
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Statistics:
1. All data will be analysed on an intention-to-treat basis, using SPSS statistical
software.
2. All baseline characteristics will be compared between the groups by Student t test
and the characteristics will be assessed by chi-square test.
3. Paired t-test will be used within group.
4. Unpaired t-test will be used in between group.
Outcome measures :
1. Visual analogue scale
2. Lower extremity functional scale
3. Oswestry Low Back Pain Scale
4. Aberdeen Low Back Pain Scale
METHODOLOGY:
7.3 Intervention to be conducted on participants
Subjects who fulfill the inclusion and exclusion criteria will be divided into two groups.
Group A and Group B. Informed concern will be taken from each of the subjects prior to
participation. Instructions are given to the subjects about techniques performed.
A total of 40 subjects will be divided equally in to two groups by random lottery method.
Group A (n=20) and Group B (n=20).
GROUP A- TENS + Nerve tissue mobilization (NTM)
GROUP B- TENS+ Muscle energy techniques (MET)
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TENS:This will consist of 40 patients of both genders and they will be administred with TENS
amplitude of current at a comfortable low intensity just above the threshold for duration of
20-30 mins with pulse duration of 50 microsecond & frequency of 40-50 hz
GROUP A – WILL BE RECEIVING. TENS + Nerve tissue mobilization (NTM)
Neural tension testing will be performed in both the lower extremity for comparison using
tests similar to those proposed for the sciatic nerve the sciatic nerve testing will be
performed using 5 different sequence

Ankle dorsiflexion

Ankle plantar flexion or inversion

Hip adduction

Hip internal rotation

Passive neck flexion.
The mobilization were performed gently extending the knee only for 2 seconds just in the
range where the patient felt tension but no pain then flexing the knee to the point where
the patient felt no pain just 6- 7 repetition given. If pain or discomfort or any signs such
as tingling in the lower limb were produced then the range of knee extension was
reduced.
GROUP B- WILL BE RECEIVING. TENS+ Muscle energy techniques (MET)
Post isometric relaxation technique for 5 times with a hold of 10 sec. Subject will be
positioned for post isometric relaxation technique in supine lying and the pelvis must be
stabilized as the knee is adducted to stretch piriformis following as isometric contraction.
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Stretching for 5 times with a hold of 10 sec each after the application of hot pack for
10 min. Subject will be positioned for stretching in supine lying with hip and knee flexed,
adducted, and internal rotated. The stretching should be performed by bringing the foot of
the affected side across and above the knee of the other leg.
Materials required :
1. Marker pen
2. Vas rating
3. LEFS questionnaire
4. Oswestry Low Back Pain Scale
5.
Aberdeen Low Back Pain Scale
6. Electrode gel
7. Cotton
8. Towel
9. TENS machine
10. Pillow
7.3 Does the study require any investigations or interventions to be conducted on
patients or other humans or animals? If so, describe briefly.
Yes, the study will be done on two groups of samples and prior consent will be taken
7.4 Has ethical clearance been obtained from your institution in case of 7.3?
Yes. Ethical clearance has been obtained from the institution.
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REFERENCES:
01. Silver JK, Leadbetter WB, Piriformis syndrome: assessment of current practice and
literature review (see comments). Orthopedics 1998; 21: 1133-5.
02. Yeoman W. The relation of arthritis of the sacroiliac joint to sciatica, with an analysis
of 100 cases. Lancet 1928; 2: 1119-22.
03. Beaton LE, Anson B. The sciatic nerve and the pyriformis muscle; their interrelation a
possible causes of coccygodynia. J. Bone Joint Surg (Am) 1938; 20: 686 –8.
04. Hui Wan Park, Jun Seop Jahina and Woo Hyeonglee. Piriformis syndrome case report.
Yonsei Medical Journal 1991; 32:1 64 – 68.
05. Robinson DR. Pyriformis syndrome in relation to sciatic pain Am J Surg 1947;
73: 335 – 58.
06. Bernard Jr TN, Kirkaldy –Willis WH. Recognizing specific characteristics of
nonspecific low back pain. Clin Orthop 1987; 217: 266-80.
07. Pace JB, Nagle D. Piriform Syndrome. West J Med 1976; 124: 435-9.
08. Carrie M. Hall and Lorithein Brody. Therapeutic Exercise (Moving towards function):
2nd edition: P. 481.
09. Leon Chaotow and Judith Walker Delany. Clinical Application of Neuro Muscular
technique (Volume-2, the lower body). Churchill Livingstone Publication, China, P. 429431.
10. Lewit K, Simons D. Myofascial pain relief by post isometric relaxation. Arch phys med
rehabil 1984; 65(8): 452-6.
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11. Freiberg AH, Vinke TH. Sciatica and the sacroiliac joint. J Bone Joint Surg (Am) 1934;
16: 126-36.
12. Elias C. Papadospoulos, Safdar N. Khan: Piriformis syndrome and low back pain: A
new classification and review of the literature. Orthop Clin N Am 2004; 35: 65-71.
13. Barton PM. Piriformis syndrome: a rational approach to management. Pain 1991; 47 :
345 – 52
14. Vallejo MC et al. Piriformis syndrome in a patient after caesarian section under spinal
anesthesia Anaesth Pain Med 2004; 29(4): 364-7.
15. Justard ME. Piriformis Syndrome. A rational approach to management of pain 1991; 9
: 345 – 52
16. Chen WS et al, Sciatica caused by piriformis syndrome –report of 2 cases, J Formos
Med Assoc 1992; 91 (6): 647 – 50.
17.Valdimir Kay , MD :- TENS e-medicine
18. Johnson MI, Ashton CH, Thompson JW, in depth study of lon term users of TENS
Implication for clinical use of TENS. pain mar1991
19. Cheing GL, Hui-Chan CW, TENS non parallel anti nociceptive effects on chronic
clinical pain &acute experimental pain. Archphys Med Rehabil.March1999,80
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SIGNATURE OF THE CANDIDATE
10
REMARKS OF THE GUIDE
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11.1 NAME AND DESIGNATION
Dr. MURALEEDHARAN A.
OF GUIDE (IN BLOCK LETTERS)
ASSOCIATE PROFESSOR
11.2 SIGNATURE
11.3 CO-GUIDE(IF ANY)
11.4 SIGNATURE
11.5 HEAD OF THE DEPARTMENT
Dr. VIJAY P.
PRINCIPAL, SHREE DEVI COLLEGE OF
PHYSIOTHERAPY,
MANGALORE
11.6 SIGNATURE
12
REMARKS OF THE CHAIRMAN
AND PRINCIPAL
13
SIGNATURE
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