Combine Massage and Physiotherapeutic Exercise for Recovering Pain, Increasing Strength, and Flexibility

Background: Chronic hip, knee, and ankle injuries are very common issues in the whole world. increasing athlete’s performance. This research is quasi-experimental with: quantitative approach. The sample of this study was 15 patients with chronic hips, knee and ankle injuries, taken by purposive sampling technique. The data were collected using measurement and treatment with combine massage and physiotherapeutic exercise. Data were analyzed using the descriptive statistics, independent sample t-test, paired sample t-test, and correlation among items using SPSS Amos.23. The result showed that there is a significant difference between pre-test-posttest strength measurement with P value (0.003<0.05). A significant difference between pre and posttest of all kinds of movement flexibilities is with the P value < 0.05. There is a strong correlation between combine massage and physiotherapeutic to the chronic knee, knee, and ankle with r >0.5. In conclusion , massage and physiotherapeutic exercise were found to be a vital part to improve human body health and it can be used by everybody.


Introduction
Chronic hips, knee, and ankle instability are very common issues in the whole world. This common problem takes origin from many sources: first daily activities such as sports for athletes and coaches, second degenerative disease, and it is noted that the aging is the one of factors which causes the chronic hips, knee, and ankle instability. Next the unbalance between input and output has a high average in causing the later problem [1], in time-honored work or expert associated with posture and long-time taken at some point of working are several reasons of persistent hips, knee, and ankle instability [2]. Knee and ankle disorders can lead to a discount in useful ability, increased dependency, decreased participation in fundamental everyday things to do and extensive fitness to many exclusive researches have been carried out to make up proper how the nature of work or career is very severe on the appearing of the sickness of hips, knee, and ankle [3]. The continual ankle and knee injuries are among the most common accidents sustained and they are 726 Combine Massage and Physiotherapeutic Exercise for Recovering Pain, Increasing Strength, and Flexibility additionally among the most severe.
Neuromuscular dysfunction of the leg and thigh musculature, along with lowered power and postural control, is common in sufferers with continual ankle instability [4] Nevertheless Osteoarthritis (OA) is a growing public fitness hassle across the globe, affecting more than half of of the over sixty five population. In the past, OA was viewed a wear and tear disease, leading to the loss of articular cartilage and joint disability [5]. Ankle strain and sprain are very a whole lot common each in the wearing activities and the everyday community. Ankle sprain is mentioned to be among the most frequent recurrent injuries. About 20% of acute ankle sprain patients boost chronic ankle instability. The failure of useful rehabilitation after acute ankle sprain leads to the development of continual ankle instability [6]. A number of posture taken in the course of working in an every field existing a distinct risk of harm due to the excessive exposure to bent postures [7]. Low back pain (LBP) is one of the very best incidence issues of public health. Low back pain (LBP) influences up to 85% people worldwide. Somebody will be affected at much less in one point of his life. LBP symbolizes a full-size economic burden on society; its complete value includes: direct scientific costs, work absenteeism, insurance, misplaced manufacturing and disability advantages. Low back pain (LBP) is the most frequent incapacity worldwide and turning into Chronic low returned pain which its regular is already elevated [8]. Musculoskeletal disabilities are established and their affects are pervasive. They are the most common cause of severe longterm ache and physical disability, and they have an effect on heaps of millions of humans around the world.
Aging is additionally a strong component of the most common websites for musculoskeletal disorder of continual knee and ankle. In 2010, The European Agency for Safety and Health at Work (OSHA) said that Musculo-Skeletal Disorders (MSDs) had been the most frequent work related fitness hassle in Europe, affecting tens of millions of workers [9]. In the learn about executed with its objectives to check the incidence and depth of musculoskeletal pain as a danger thing for decreased work ability. With sampling 1449 workers participated in the study, 64% had been youthful workers (<45 years old, M 31.4); 36% had been getting old employees (>45 years old, M 50.3), The outcomes of the find out about confirmed that even though in the each groups, i.e., younger and growing older workers, the occurrence and depth of ache in decrease lower back muscle mass two have been a full-size component which decreased work ability intensity, in growing older workers only the occurrence of pain in the lower again generated greater risk elements for reduced work potential (WAI < 37) [10] Musculoskeletal issues (MSDs) are a significant and increasing occupational health issues in the workplace worldwide. The causes of work-related MSDs are normally multifactorial including physical, ergonomic, and psychosocial factor.
According to the ageing knee is the most physique phase affected by using musculoskeletal issues like many diseases, the occur disorder and pathogenesis of osteoarthritis (OA) are multidimensional Anterior cruciate ligament (ACL) injuries are common, extreme knee injuries that result in a excessive chance of growing knee osteoarthritis (OA) in the affected individuals. As proof of excessive influence forces applied to cartilage and bone at the time of injury, tense bone marrow lesions and osteochondral fractures, positioned predominantly in the lateral tibiofemoral compartment, are oftentimes related with an ACL injury. The subsequent danger of OA may be intently associated with the knee harm mechanism and the panorama of accidents in the knee sustained at the onset of injury [5].
Daily activities are the most cause of chronic injuries and generative chronic injuries. Treatment of chronic injuries is important because chronic injury at early age or aging brings on two types of consequences on physical and mental health. For example, an early sports chronic injury can hinder physical activity for the rest of life and can also affect attitudes toward sport and physical activity. But also it can make severe the physical condition and psychological, so the wellbeing of human body will considerably decrease. With strong participation in the different field: sports and work, the need for injury treatment becomes paramount. In order to reduce sports chronic injuries, work chronic injuries and generative chronic injuries, it is necessary to identify and describe the nature.
However musculoskeletal issues (MSDs) are a predominant health troublesome among human beings of Klaten, and the prevalence is especially excessive on every age. But in Klaten, there is no statistics on hand among fitness professionals. There is a need for treatment research to heal human against the potential negative consequences from work or degenerative diseases. A prerequisite for the development of treatment strategies is a sufficient understanding of the incidence and determinants (risk factors) work and degenerative injuries. The most the number of participants in every field increases, the most risk of chronic injury increases. Thus, the control of intrinsic and extrinsic factors associated with work and generative injuries have to be suggested because the chronic injury rate and the demands of the daily activities (sports, work… etc.,) are high, a rehabilitation program should include massage, exercises therapy that will train the participant as a whole and reduce the pain of further injury, increase flexibility and strength.

Methods
This research is a quasi-experimental with mixed method: quantitative and qualitative approaches. The research sample was 15 patients with musculo-skeletal disorder located on Hips, Knee, and Ankle taken by purposive sampling. Data collection technique with playground by applying combine massage and physiotherapeutic exercise program. Data were analyzed with independent t-test.

Procedures
To treat the musculo-skeletal disorder located on Hips, Knee, and Ankle (MSDs), to evaluate the strength, and the range of motion, the research applied a new combine massage and Physiotherapeutic program.
The table 1 explained the whole instructions, volume, and intensity used for treatment. It's required to pay attention before to use the following program, everybody need to read it and understand it in order to expect the full benefit from the program.  The table 2 gave more information about the applied program therapeutic exercise which has been combined with the massage to improve human health, all the instructions are explained in the table 1 The research combine the two programs: combine massage and physiotherapeutic exercise to evaluate the pain, strength, and range of motion (ROM). The researcher showed the physiotherapeutic exercise image.  The figure 1 showed how patient must apply the therapeutic exercise, all the positions were shown, about the volume, and intensity they are clarified in the table 2.
The figure 2 is the following of the therapeutic exercise patient need to follow all instructions given in the table 2 The combine massage and physiotherapeutic exercise model have been valid with 6 experts in massage (5 University Lecturers, and 1 physiotherapist with more than 10 years of practice, 2 experts in Sport and Health, and 1 expert in physical training. Both of the two program have been approved with 9 experts. The two program have met the very high validity before it was applied in the field of patients.

Result
The result data will be presented respectively: (1) the influence of combine massage and physiotherapeutic exercise on the strength, (2) the impact of the later on the pain level, and (3) the effect of combine massage and physiotherapeutic exercise on the range of motion.

Effect of Combine Massage and Physiotherapeutic
Exercise on the Strength To evaluate the impact of the later program the research applied first the pre-test of lower member's strength using leg dynamometer, after treatment of 5 weeks 3 times per week, he did the post-test of the strength. The result is presented in table 3.
The table 3 showed the values of patients before and after treatment. The strengthen measurements were taken with leg dynamometer After the registration of the date from the treatment, the researcher made the analysis with T-test to assess the different before and after the treatment.
From the data above in the table 4, it can be seen that Levine's test showed that P value is superior than 0.05 (P: 0.315>0.05). In statistics, Levene's check is an inferential statistic used to check the equality of variances for a variable calculated for sample. Thus, the null hypothesis of equal variances is rejected when P value is superior than 0.05. From the above result, it can be concluded that there was a significant difference between the variances in the population. In this study, the null hypothesis was that there is no difference between pre-test and posttest has been rejected and the alternative hypothesis that there is a significant different between the data before and after treatment has been automatically accepted. Test Equal variances assumed (0.003) and Equal variances not assumed (0.004) all of them were inferior than 0.05 which support that combine massage and physiotherapeutic exercise were very benefit in increasing low extremity strength. In fact, combine massage was very great also to improve blood flow, muscle relaxation, decreasing the muscle, ligament pain and by the way it allows the facility of strengthen exercise.

Effect of Combine Massage and Physiotherapeutic Exercise on Lower Extremity Members Pain
To evaluate the pain, the researcher used the numeric scale graduated from 1 to 10. The pain was classified in 4 groups: from 0-3: minor; 4-6: medium; 7-9: severe; 10: very severe. Before and after the result has been taken as the following table 5. The table 5 showed that the combine massage and physiotherapeutic exercise were very good applied and found out that all the different kinds of pain have been carried out with P value < 0.05. The subjects have low back pain, knee pain, and ankle pain after applying the treatment during 5 weeks 3 times per week, a post-test has been conducted and showed that there was a significant different in the hand of pain level

Discussion
The result showed that massage contribute for healing chronic hips, knee and ankle injuries from different case. Most of the subjects have low back pain; it was very difficult to apply some movements like: right flexion, left flexion, flexion-extension of the hips. The treatment was firstly effleurage to allow the blood flow. Massage can grant a number of benefits to the body. These consist of accelerated blood flow, reduced muscle pressure [11]. Secondly Petrissage (kneading, rolling, and lifting), kneading). Technique was used to relaxing the muscle tension. Petrissage is assumed to impact circulation as nicely as interstitial drainage of each superficial and deep tissue [12]. The Tapotement (percussion rhythmic tapping) technique was applied and it procured the wellbeing and relieved the muscle pain. Myofascial pain syndrome was treated with Friction (with fibres or cross-fibres wringing or small circular movements), while Vibration / Shaking rocking and shaking movements.
The balance of the knee joint is maintained via four ligaments, thick bands of tissue that stabilize the joint. The medial collateral ligament (MCL) and lateral collateral ligament (LCL) are on the facets of the knee and prevent the joint from sliding sideways. The anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) shape an "X" on the internal of the knee and prevent the knee from sliding returned and forth. These boundaries on knee motion enable the knee to listen the forces of the muscular tissues on flexion and extension. Trigger point massage and soft tissue massage were applied to take off the knee chronic injuries. During five weeks of treatment, the result showed that there was a significant different according to the Range of Motion of the hips, knee but also the ankle ROM has increased. The P value of the following movements ( right flexion hips, left flexion hips, right extension hips, left extension hip, right and left knee flexion; right and left knee extension; right and left back flexion ankle; right and left plantar ankle; right and left back inversion ankle; right and left eversion ankle) was inferior to 0.05. The last P value meant that there was a significant different. Massage was very benefit in healing chronic hip, knee, and ankle.
Many researches have been done to show how massage is effective to the treatment of injuries. Swedish massage regimen was used to relieve Osteoarthritis of the Knee (OA) during 8 weeks [13]. For the combined massage in five weeks, the pain was almost fixed. The research done showed that manipulation of body tissues with rhythmical pressure and stroking for the purpose of advertising health and well-being [14]. Massage is defined as systematic manual manipulation of the body via movements such as rubbing, kneading, pressing, roll, slap and tap for therapeutic purposes. These actions promote blood and lymphatic circulation, muscle relaxation, pain relief, restoration of metabolic balance and various physical and mental benefits. Combined massage is a strong tool to treat or healing chronic hips, knee, and ankle injuries After massage the patients flowed the physiotherapeutic exercise program, because of the longue time of the injuries, some human parts were not totally used, at the end the muscles fibres lost their capacity. The researcher applied a pre-test first to know before the weakness of muscles and joints. To improve strength and flexibility a group of exercise like: (1) Knee life, (2) Hips and lower back stretch, (3) Double hips rotation, (4) Bridging, (5) External hips rotation, (6) Chair stand, (7) Hips abduction, (8) Hips flexion have been used The treatment has been done three times per week during five weeks. The moderate intensity was used; the time used was six minutes (6 min) for the hips, for whom has both of injuries (hips, knee, and ankle), after the first session a rest of one minute (1 min) has been taken before applying the knee and ankle treatment during seven minutes each other, but a rest of one minute must be respected between the sessions. The whole time of treatment were 20 minutes. In the research done by Sangam showed that Stretching of hamstring and strengthening of quadriceps muscle can enhance the pain and energy of the muscle mass [15]. Hip injuries were associated with age, life activities, but a therapeutic exercise of myofascial muscle could decrease pain [16]. Therapeutic exercise can remedy hip and knee osteoarthritis [17]. In this research, the proposed exercises were very benefit because they increased the hip, knee flexion and strength at the same time. Secondly a game of exercise like: (1) Hamstring stretch, (2) Straight leg raise, (3) Quad set, (4) Pillow Squeeze, (5) Prone Straight leg raises, (6) Side leg raise, (7) One leg balance, (8) Wall Squats. The different exercises used were respected during five weeks, three times per week. The time was seven minutes. It was found that those exercises were very easy and helpful in increasing strength and knee flexibility. The study by Page showed that Human movement is dependent on the amount of range of motion (ROM) reachable in synovial joints. In general, ROM might also be confined by means of 2 anatomical entities: joints and muscles. Joint restraints include joint geometry and congruency as well as the capsule ligamentous structures that encompass the joint [18]. Next a group of exercise like: (1) Ankle alphabet (2) Towel tissue scrunches, (3) Heel raise, (4) Heel-to-buttock exercise, (5) Elastic band pull, (6) Calf Stretch, (7) One-leg balance, the previous exercises were applied on ankle injuries. It was found that there was an increasing of strength and ankle flexibility. Analysis of the pre-test and posttest data from the hips, knee, and ankle showed that the was a significant different between them before and after the treatment. In other word, therapeutic exercise was very benefited on healing chronic hip, knee, and ankle injuries. Sprain and strain can be relieved by soft tissue massage but we need to complete the recovering with strength exercise [19]. At the end the posttest of strength and have been done and the outcomes showed that there was an improving of them comparing to the pre-test data. In conclusion based on the result and the relevant studies, combine massage and physiotherapeutic exercise were very benefit on the strength and flexibility improving.
Only variety three has a precise on inversion and eversion due to the fact he didn't join two periods which confirmed that much less than 5 meeting there is no right and left inversion and eversion enhancement for anybody who has continual ankle injury.
The table 8 gave the great information about the pre-test and post-test, the result showed that there was a great different after treatment, the conclusion has been taken after making a compared mean.
The table 9 showed that the mean of the pre and post test about the hip's ROM were totally different which attested that the program applied was great for improving flexibility.
The table 10 and 11 showed the result which tasted that the program applied has a great influence on increasing strengthen. The different between the mean of pre and post was high but the standard of deviation was great which showed that the program was helpfully.   The table 12 and 13 showed that the combine massage and physiotherapeutic exercise applied were benefit in increasing ROM about flexion, and extension of the knee, all the P value were inferior than 0.05 which means that there was a significant different between the pre-test and post-test.
The desk 14 and 15 confirmed that the combine rubdown and physiotherapeutic exercising utilized had been advantage in growing ROM about flexion, and plantar of the ankle, all the P value had been inferior than 0.05 which skill that there used to be a vast extraordinary between the pre-test and post-test. The desk 16 and 17confirmed that the combine rubdown and physiotherapeutic exercising utilized had been advantage in growing ROM about flexion, and extension of the knee, all the P value had been inferior than 0.05 which skill that there used to be a vast extraordinary between the pre-test and post-test