Upper limb muscle imbalance in tennis elbow: a functional and electromyographic assessment

Focused shock wave and ultrasound therapies in the treatment of lateral epicondylitis - a randomized control trial

Persistent symptoms of lateral epicondylitis prompt patients to seek effective conservative treatment. The study aimed to determine the effects of focused shock wave (FSWT) and ultrasound therapies for lateral epicondylitis. Sixty patients with tennis elbow were randomly divided into three equal groups: A, B, and C. Group A received a total of 3 FSWT sessions, with 7 days between treatments; Group B received ultrasound therapy in 10 sessions over 2 weeks, while patients in Group C were treated with placebo ultrasound. All patients were also given deep friction massage. Before the start of therapy, and at 1, 3, 6, and 12 weeks after its completion, pain intensity and function of the affected upper limb were assessed in all patients. Wrist extensor and flexor strength and grip strength were measured in the affected and unaffected limb. Significant reductions in pain and significant improvements in the function of the affected limb compared to baseline values were observed in all study groups at 6 and 12 weeks after the completion of therapy. Analysis of percentage changes in these variables showed significant differences between Groups A and B in favor of Group A. The strength of wrist extensors and grip strength of the affected limb at 6 and 12 weeks after treatment completion was significantly higher in Groups A and B compared to pre-therapy values. However, there were no statistically significant differences between the groups regarding percentage changes in muscle strength in the affected limb. Pain reduction and function improvement in patients with lateral epicondylitis were significantly greater after FSWT (0.2 mJ/mm2 / 4 Hz / 2000 shocks) than after sonotherapy (3 MHz / 0.5 W/cm2 / 20%). Increases in wrist extensor strength and grip strength of the affected limb were comparable after both therapies. Given the greater therapeutic effect in the subjective evaluation, we recommend a combination therapy of FSWT with deep friction massage.Trial registration The trial was prospectively registered in the ISRCTN registry (no. ISRCTN11907358 registration date 30.07.2020).

The reliability of a Biometrics device as a tool for assessing hand grip and pinch strength, in a Polish cohort-A prospective observational study

The aim of the study was to assess the external and internal compatibility of the Biometrics E-LINK EP9 evaluation system device in the area of hand grip and pinch strength in the Polish population. The testing of hand grip and pinch strength was carried out among 122 healthy students. Two examiners performed hand grip and pinch strength measurements with a Biometrics E-LINK EP9 evaluation system device. Measurements were made for the right and left hands. The same people were tested again two weeks later, under the same conditions. The scores of one rater on the first and second tests were compared for reproducibility, and the scores of the two raters were compared to assess the reliability of the instrument. The measurements were found to be highly consistent both between the investigators and between the tests in the hand grip dynamometer test. The findings show high values of the Pearson's correlation coefficient equal or close to 1, as well as the interclass correlation coefficient (ICC) >0.9. Analysis of pinch strength measurements performed using the pinchmeter also found high values of the Pearson's correlation coefficient close to 1, as well as the interclass correlation coefficient >0.9; this reflects high agreement between the measurements performed by two investigators as well as assessments performed by one investigator at time intervals. These findings were confirmed by analyses performed using Bland-Altman plots. The measurements made with the Biometrics E-link EP9 evaluation system show high internal and external consistency in hand grip and pinch strength assessment. Biometrics E-link EP9 can be recommended for daily clinical practice.

Immediate effects of counterforce brace with and without vibration on pain, muscle strength and range of motion in participants with lateral epicondylitis. A pilot study

Lateral epicondylitis is one of the most common elbow problems. Counterforce braces are commonly used to manage lateral epicondylitis. Recent studies showed that vibration can decrease pain and increase muscle strength by improving motor abilities. The aim of this study was to evaluate the effects of a counterforce brace with and without vibration on pain, muscular strength, wrist and elbow joints range of motion in the participants with lateral epicondylitis. In this repeated measure pre-post clinical trial study, 28 participants with lateral epicondylitis were included. Pain were measured with Visual Analogue Scale (VAS), wrist and elbow flexor/extensor muscles strength with digital dynamometer, wrist and elbow flexion/extension range of motion with goniometer in 3 condition baseline, counterforce brace and counterforce brace with vibration. Pain using counterforce bracing with vibration showed a significant reduction as compared with baseline and counterforce bracing (P < 0.001). Wrist flexor muscles strength (P = 0.005), elbow flexor/extensor muscles strength respectively (P = 0.04, P = 0.02), wrist flexion/extension range of motion (P < 0.001) following the use of counterforce bracing with vibration increased significantly compared with baseline. The results show that the counterforce bracing with and without vibration relieves pain and improves range of motion and muscles strength in lateral epicondylitis participants, but this improvement is more significant with the use of vibration.

Deficits in neuromuscular control of increasing force in patients with chronic lateral epicondylitis

Objective: This study investigated the neuromuscular control of increasing and releasing force in patients with chronic lateral epicondylitis (CLE). Methods: Fifteen patients with CLE (10 males, 5 females, 46.5 ± 6.3 years) and fifteen healthy participants (9 males, 6 females, 45.3 ± 2.5 years) participated in this study. In addition to power grip and maximal voluntary contraction (MVC) of wrist extension, force fluctuation dynamics and characteristics of inter-spike intervals (ISI) of motor units (MUs) with various recruitment thresholds in the extensor carpi radialis brevis (ECRB) and extensor carpi radialis longus (ECRL) during a designated force-tracking task with a trapezoidal target (0%-75%-0% MVC) were assessed. Results: Besides a smaller MVC of wrist extension, the patients exhibited significantly greater task errors (p = 0.007) and force fluctuations (p = 0.001) during force increment than the healthy counterparts. Nevertheless, no force variables significantly differed between groups during force release (p > 0.05). During force increment, the amplitudes of the motor unit action potential of the ECRB and ECRL muscles of the patients were smaller than those of the heathy counterparts (p < 0.001). The patient group also exhibited a higher percentage of motor units (MU) with lower recruitment threshold (<5% MVC) in the ECRL/ECRB muscles and a lower percentage of MU with higher recruitment threshold (>40% MVC) in the ECRB muscle, compared to the healthy group. During force increment, the patient group exhibited a higher rate of decrease in inter-spike intervals (ISIs) of motor units with lower recruitment thresholds (<10% MVC) in the ECRB and ECRL muscles, compared to the control group (p < 0.005). Conclusion: The patients with CLE exhibited more pronounced impairment in increasing force than in releasing force. This impairment in increasing force is attributed to deficits in tendon structure and degenerative changes in the larger motor units of the wrist extensors. To compensate for the neuromuscular deficits, the rate of progressive increase in discharge rate of the remaining smaller motor units (MUs) is enhanced to generate force. Significance: The deficits in neuromuscular control observed in CLE with degenerative changes cannot be fully explained by the experimental pain model, which predicts pain-related inhibition on low-threshold motor units.

Upper Extremity Muscle Activation during Drive Volley and Groundstroke for Two-Handed Backhand of Female Tennis Players

Drive volley is one of the essential backhand stroke technique trends seen in recent women's tennis competitions. Although movements of the drive volley and groundstroke are similar, activation of the internal muscles vary due to different incoming ball conditions. Most previous studies only focused on the groundstroke, however. The current study investigates the different muscle activation patterns in the upper extremity muscle during the two-handed backhand drive volley as well as the groundstroke for female tennis players. Ten elite female tennis players were measured in the muscle activation of the flexor carpi radialis (FCR), extensor carpi radialis (ECR), biceps brachii (BB), and triceps brachii (TB) from both upper extremities. Racket-head speed at impact, swing duration of each phase, and racket-head average velocity in both strokes were also recorded. Significant differences were found between the drive volley and groundstroke in the velocity profile of racket tip, swing duration of each phase (preparation, early follow-through, and late follow-through), activation patterns of upper extremity muscles, and flexor/ extensor ratios of wrist and elbow in both upper extremities. Different racket trajectory strategies were also observed between the two strokes, with greater horizontal racket velocity recorded in the groundstroke but greater vertical velocity in the drive volley. ECR and TB muscle activation during the drive volley preparation phase was greater than the groundstroke when completing a quicker backswing. In the early acceleration phase, the greater FCR leading arm activation in the drive volley assisted wrist stabilization in preparation for impact. In the late follow-through phase, less TB leading arm activity and higher ECR trailing arm activity in the drive volley showed more forward compression movement in racket contact with the ball. As it is essential for the drive volley to complete a quicker backswing and to increase shot efficiency at the end of the forward movement, coaches should consider the two strokes' muscle activation and technique differences to enhance specific techniques and fitness training programs.

Effects of multidirectional elastic tape on forearm muscle activity and wrist extension during submaximal gripping in individuals with lateral elbow tendinopathy: A randomised crossover trial

BACKGROUND

Lateral elbow tendinopathy is associated with changes to forearm muscle activity and wrist posture during gripping. Multidirectional elastic tape is thought to exert a deloading effect on underlying musculotendinous structures, which could potentially alter muscle activity or wrist posture.

METHODS

This single-blinded randomised crossover trial compared the immediate effects of tensioned multidirectional elastic tape, untensioned control tape, and no tape, in individuals with lateral elbow tendinopathy. Muscle activity of extensor carpi radialis longus and brevis, extensor carpi ulnaris, and extensor digitorum and wrist extension angle were recorded during a submaximal gripping task. Muscle activity was normalised to the maximum amplitude recorded during maximal grip. Change scores were calculated (post-condition minus baseline). Repeated-measure analyses of variance were used to examine between-condition differences.

FINDINGS

27 participants (16 males, mean age (SD): 48.6 (11.9) years) underwent all conditions. Extensor digitorum muscle activity was reduced during the multidirectional elastic tape, compared to control tape and no tape (MD -5.6% [95%CI: -9.9 to -1.3], MD -5.8% [95%CI: -10.2 to -1.4], respectively). Extensor carpi ulnaris muscle activity was reduced during the multidirectional elastic tape, compared to the control tape (mean difference [MD] -3.2% [95%CI: -5.3 to -1.1]), but increased during the control tape, compared to the no tape (MD 2.9% [95%CI: 0.8 to 5.0]). No differences were observed in extensor carpi radialis brevis or longus muscle activity, or extension wrist angle between conditions.

INTERPRETATION

A decreased in extensor carpi ulnaris and extensor digitorum muscle activity during multidirectional elastic tape may be evidence of a deloading effect during submaximal gripping.

Development of an optimised physiotherapist-led treatment protocol for lateral elbow tendinopathy: a consensus study using an online nominal group technique

OBJECTIVES

There are a wide range of physiotherapy treatment options for people with lateral elbow tendinopathy (LET); however, previous studies have reported inconsistent approaches to treatment and a lack of evidence demonstrating clinical effectiveness. This study aimed to combine the best available research evidence with stakeholder perspectives to develop key components of an optimised physiotherapist-led treatment protocol for testing in a future randomised controlled trial (RCT).

DESIGN

Online consensus groups using nominal group technique (NGT), a systematic approach to building consensus using structured multistage meetings.

SETTING

UK National Health Service (NHS).

PARTICIPANTS

10 physiotherapists with special interest in LET, 2 physiotherapy service managers and 3 patients who had experienced LET.

INTERVENTIONS

Two consensus groups were conducted; the first meeting focused on agreeing the types of interventions to be included in the optimised treatment protocol; the second meeting focused on specific details of intervention delivery. Participants were sent an evidence summary of available treatments for LET prior to the first meeting. All treatment options were discussed before anonymous voting and ranking of priority. Consensus for inclusion of each treatment option was set at ≥70% based on OMERACT guidelines. Options with 30%-69% agreement were discussed again, and a second vote was held, allowing for a change of opinion.

RESULTS

The optimised physiotherapist-led treatment package included: advice and education, exercise therapy and orthotics. Specific components for each of these interventions were also agreed such as: condition-specific advice, health-promotion advice, exercise types, exercise into 'acceptable' levels of pain, exercise dosage and type of orthoses. Other treatment options including electrotherapy, acupuncture and manual therapy were excluded.

CONCLUSION

An optimised physiotherapist-led treatment protocol for people with LET was successfully developed using an online NGT consensus approach. This intervention is now ready for testing in a future pilot/feasibility RCT to contribute much needed evidence about the treatment of LET.

TRIAL REGISTRATION NUMBER

This is the pre-cursor to the OPTimisE Pilot and Feasibility Randomised Controlled Trial. Registration: https://www.isrctn.com/ISRCTN64444585.

An Investigation of Maximal Strength of the Upper Limb Bilaterally in Individuals With Lateral Elbow Tendinopathy: A Systematic Review With Meta-Analysis

OBJECTIVE

The aim of this study was to investigate whether there is evidence of bilateral upper limb strength deficits in individuals with unilateral lateral elbow tendinopathy (LET).

METHODS

The electronic databases Medline via Ovid, PubMed, and Scopus were searched from inception to March 2020. Included studies encompassed maximal strength outcomes of any upper limb and appendicular musculature in individuals with LET and an asymptomatic comparator. Study quality was rated using a modified version of the Epidemiological Appraisal Instrument. Hedges g effect sizes (ES) and 95% CIs were calculated for comparisons of maximal strength in the LET group and an asymptomatic control group. Meta-analysis using a random-effects model was performed when possible.

RESULTS

Fourteen studies were included. Quality appraisal resulted in a mean Epidemiological Appraisal Instrument score of 46% (SD = 10%). Meta-analysis revealed strength deficits in shoulder abduction (pooled ES = -0.37 [95% CI = -0.62 to -0.12]) and shoulder external rotation (pooled ES = -0.55 [95% CI = -0.83 to -0.28]) of the symptomatic limb compared with an asymptomatic control group. Meta-analysis also revealed maximal strength deficits in the upper trapezius (pooled ES = -0.26 [95% CI = -0.49 to -0.02]) of the asymptomatic limb compared with an asymptomatic control group. There was also consistent evidence for strength deficits in the serratus anterior, lower trapezius, and wrist extensor muscles and deficits in grip strength of the symptomatic limb as well as strength deficits in the wrist extensor muscles of the asymptomatic limb in individuals with unilateral LET.

CONCLUSION

In individuals with LET, there were maximal strength deficits in shoulder abduction, shoulder external rotation, serratus anterior and lower trapezius muscles, and wrist extension, as well as deficits in grip strength of the symptomatic limb compared with an asymptomatic control group. In addition, there appeared to be strength deficits in the upper trapezius muscle, wrist extension, and metacarpophalangeal joint flexion and extension, as well as deficits in grip strength of the asymptomatic limb in individuals with LET compared with an asymptomatic control group. These results suggest bilateral strength deficits.

IMPACT

These findings highlight the importance of a thorough physical examination and appropriate strengthening intervention for the upper limb with a focus on shoulder and scapular stabilizers, in addition to forearm muscles, in individuals with LET.

LAY SUMMARY

In people with tennis elbow, widespread strength deficits, including weakness of the shoulder, forearm, and wrist muscles, may exist. Interestingly, some of these weaknesses appear on both the affected and the unaffected sides in people with tennis elbow. A physical therapist can help strengthen these areas.

Wrist flexion and extension strength in patients with work-related chronic elbow pain: the isokinetic effort factor and its implications

BACKGROUND

The validity of isokinetic strength findings relating to forearm muscles in patients with chronic elbow pain and/or epicondylitis is not well established. Furthermore, given the nature of this disorder, ensuring maximal effort in performing the tests is an essential prerequisite. The isokinetic-based DEC parameter (defined as the difference between high- and low-velocity eccentric-to-concentric ratios of a given muscle) has been shown to efficiently detect maximal effort. The purpose of this study was therefore to assess the validity of isokinetic strength tests in patients with chronic elbow pain and/or epicondylitis.

METHODS

A cohort consisting of 44 male patients with chronic elbow pain (average evolution time, 262 ± 193.04 days) was recruited. The wrist extensor and flexor concentric and eccentric isokinetic strength of the involved and uninvolved sides was measured. The involved-uninvolved and flexor-extensor (F/E) ratios, as well as the DEC (eccentric-concentric difference), were computed based on peak moment values. Work disability and relapse within the first year were registered. In maximal performers, associations between deficits, F/E ratios, work disability, and symptom relapse were explored applying multiple comparisons.

RESULTS

Of the patients, 68.2% met the maximal-effort criteria, with the involved-side muscles being significantly weaker than their uninvolved-side counterparts in most cases. Although the mean deficit in this group was not associated with either work disability or relapse, patients with a relapse of symptoms within the first year had a significantly higher F/E ratio than those without relapse.

CONCLUSION

In patients presenting with chronic elbow pain who perform at the maximal level of effort, high wrist F/E strength ratios may predict symptom relapse.

Shoulder Isokinetic Strength Deficit in Patients with Neurogenic Thoracic Outlet Syndrome

Neurogenic thoracic outlet syndrome (NTOS) is an impairing painful condition. Patients usually report upper-limb pain, weakness and paresthesia. Shoulder weakness is frequently reported but has never been described with objective strength evaluation. We aimed to compare isokinetic shoulder strength between patients with NTOS and healthy controls. Patients and controls were prospectively evaluated with an isokinetic strength test at 60 and 180°/s, and an endurance test (30 repetitions at 180°/s) of the shoulder rotators. Patients were functionally assessed with QuickDASH questionnaires. One hundred patients and one hundred healthy subjects were included. Seventy-one percent of patients with NTOS were females with a mean age of 39.4 ± 9.6. They were compared to controls, 73% females and the mean age of 38.8 ± 9.8. Patients' mean QuickDASH was 58.3 ± 13.9. Concerning the peak of strength at 60°/s, the symptomatic limbs of patients with NTOS had significantly 21% and 29% less strength than the control limbs for medial and lateral rotators, respectively (p ≤ 0.001). At 180°/s, the symptomatic limbs had significantly 23% and 20% less strength than the controls for medial and lateral rotators, respectively (p ≤ 0.001). The symptomatic limbs had significantly 45% and 30% less endurance than the controls for medial and lateral rotators, respectively (p ≤ 0.001). These deficits were correlated to the QuickDASH. Patients with NTOS presented a significant deficit of strength and endurance of the shoulder rotators correlated to disability. This highlights the interest in upper-limb strength evaluation in the diagnostic process and the follow-up of NTOS.

Assessing kinesthetic proprioceptive function of the upper limb: a novel dynamic movement reproduction task using a robotic arm

Background

Proprioception refers to the perception of motion and position of the body or body segments in space. A wide range of proprioceptive tests exists, although tests dynamically evaluating sensorimotor integration during upper limb movement are scarce. We introduce a novel task to evaluate kinesthetic proprioceptive function during complex upper limb movements using a robotic device. We aimed to evaluate the test–retest reliability of this newly developed Dynamic Movement Reproduction (DMR) task. Furthermore, we assessed reliability of the commonly used Joint Reposition (JR) task of the elbow, evaluated the association between both tasks, and explored the influence of visual information (viewing arm movement or not) on performance during both tasks.

Methods

During the DMR task, participants actively reproduced movement patterns while holding a handle attached to the robotic arm, with the device encoding actual position throughout movement. In the JR task, participants actively reproduced forearm positions; with the final arm position evaluated using an angle measurement tool. The difference between target movement pattern/position and reproduced movement pattern/position served as measures of accuracy. In study 1 (N = 23), pain-free participants performed both tasks at two test sessions, 24-h apart, both with and without visual information available (i.e., vision occluded using a blindfold). In study 2 (N = 64), an independent sample of pain-free participants performed the same tasks in a single session to replicate findings regarding the association between both tasks and the influence of visual information.

Results

The DMR task accuracy showed good-to-excellent test–retest reliability, while JR task reliability was poor: measurements did not remain sufficiently stable over testing days. The DMR and JR tasks were only weakly associated. Adding visual information (i.e., watching arm movement) had different performance effects on the tasks: it increased JR accuracy but decreased DMR accuracy, though only when the DMR task started with visual information available (i.e., an order effect).

Discussion

The DMR task’s highly standardized protocol (i.e., largely automated), precise measurement and involvement of the entire upper limb kinetic chain (i.e., shoulder, elbow and wrist joints) make it a promising tool. Moreover, the poor association between the JR and DMR tasks indicates that they likely capture unique aspects of proprioceptive function. While the former mainly captures position sense, the latter appears to capture sensorimotor integration processes underlying kinesthesia, largely independent of position sense. Finally, our results show that the integration of visual and proprioceptive information is not straightforward: additional visual information of arm movement does not necessarily make active movement reproduction more accurate, on the contrary, when movement is complex, vision appears to make it worse.

Tendinopathy

Tendinopathy describes a complex multifaceted pathology of the tendon, characterized by pain, decline in function and reduced exercise tolerance. The most common overuse tendinopathies involve the rotator cuff tendon, medial and lateral elbow epicondyles, patellar tendon, gluteal tendons and the Achilles tendon. The prominent histological and molecular features of tendinopathy include disorganization of collagen fibres, an increase in the microvasculature and sensory nerve innervation, dysregulated extracellular matrix homeostasis, increased immune cells and inflammatory mediators, and enhanced cellular apoptosis. Although diagnosis is mostly achieved based on clinical symptoms, in some cases, additional pain-provoking tests and imaging might be necessary. Management consists of different exercise and loading programmes, therapeutic modalities and surgical interventions; however, their effectiveness remains ambiguous. Future research should focus on elucidating the key functional pathways implicated in clinical disease and on improved rehabilitation protocols.

Evaluating the immediate effect of forearm and wrist orthoses on pain and function in individuals with lateral elbow tendinopathy: A systematic review

BACKGROUND

Lateral elbow tendinopathy is associated with pain during gripping, with forearm/wrist orthoses prescribed for treatment.

OBJECTIVES

To investigate the immediate effects of forearm and/or wrist orthoses on outcome measures of pain and function in individuals with lateral elbow tendinopathy.

DESIGN

Systematic review METHODS: Four electronic databases were searched to identify randomised controlled trials reporting the immediate effects of forearm and/or wrist orthoses on pain and function in individuals with lateral elbow tendinopathy. The quality of evidence was rated from high to very low, using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) for the primary outcomes. Where possible, standardised mean difference (SMD) and 95% confidence intervals were calculated to compare post measures between forearm and/or wrist orthoses and control/placebo conditions.

RESULTS

The search revealed 1965 studies, of which, seven randomised crossover trials were included. Using the GRADE approach there was low quality evidence revealing a significant decrease in pain during contraction (SMD range -0.65 to -0.83) with forearm orthoses compared to a control/placebo condition. Low quality evidence revealed improvements in pain-free grip strength with the use of a forearm orthosis (SMD range 0.24-0.38), but not maximal grip strength (SMD range 0.14-0.15). Low quality evidence revealed a static wrist orthosis did not improve pain-free grip strength (SMD -0.08) or maximal grip strength (SMD -0.22).

CONCLUSION

There is low quality evidence that forearm orthoses can immediately reduce pain during contraction and improve pain-free grip strength but not maximal grip strength in individuals with lateral elbow tendinopathy.

Step by Step Guide to Understanding the Kinetic Chain Concept in the Overhead Athlete

PURPOSE OF REVIEW

The purpose of this review will be to provide both a historical and recent review of the role of the kinetic chain for the overhead athlete. The kinetic chain concept will then be applied to clinical exercise modifications and integrations for prevention and treatment of shoulder injury.

RECENT FINDINGS

The primary conclusion reached through this review is the important role the lower extremity, trunk, and scapular region play in the development of optimal terminal segment acceleration in the overhead throwing and serving motion. Failure of any links in the kinetic chain has implications for shoulder and elbow injury in the overhead athlete. Modifications of traditional shoulder exercises emphasizing activation of the scapular stabilizers and core musculature alongside concomitant rotator cuff activation are recommended and supported in EMG research. Future research is needed to further identify risk factors and rehabilitation and prevention strategies and key clinical tests for the overhead athlete. The goal is to elucidate the important role the kinetic chain plays in both performance enhancement and injury prevention for the overhead athlete. Understanding the key role all segments of the kinetic chain play in the complex biomechanical segmental rotations required for high-level throwing and serving will assist clinicians who work with overhead athletes.

Does the educational level of women influence hand grip and pinch strength in carpal tunnel syndrome?

BACKGROUND

Grip and pinch strength are relevant functional variables for various activities of daily life and are related to the quality of life of patients with carpal tunnel syndrome (CTS).

OBJECTIVE

The main aim was to analyze the relationship between grip and pinch strength and the educational level in women with CTS.

STUDY DESIGN

Cross-sectional study.

METHODS

Thirty-one female patients with CTS awaiting surgery were assigned to the low education group if they only had primary education level (completed or not) and the high education group for those having higher education level. The assessments included: grip strength, pinch strength, Visual Analogue Scale, Quick DASH Questionnaire, Pain Catastrophizing Scale and the Tampa scale of kinesiophobia.

RESULTS

A statistically significant difference was obtained for grip strength (p = 0.027), pinch strength (p = 0.002) and catastrophizing (p = 0.038) between the two groups. No significant differences were observed for the other variables studied (p < 0.05). Grip strength was not related to individual factors: type of work, age, body mass index.

CONCLUSION

CTS patients with a low educational level exhibited reduced grip and pinch strength and more catastrophic thinking. Future studies should investigate the mechanisms involved in the loss of strength in patients with lower educational levels.

Reorganized Force Control in Elbow Pain Patients During Isometric Wrist Extension

INTRODUCTION

Reorganized force control may be an important adaptation following painful traumas. In this study, force control adaptations were assessed in elbow pain patients. Increasing the contraction demand may overcome pain interference on the motor control and as such act as an internal control. It was hypothesized that elbow pain patients compared with controls would present greater change in the direction of force when increasing the demand of the motor task.

METHODS

Elbow pain patients (n=19) and asymptomatic participants (n=21) performed isometric wrist extensions at 5% to 70% of maximum voluntary contraction. Pressure pain thresholds were recorded at the lateral epicondyle and tibialis anterior muscle. Contraction force was recorded using a 3-directional force transducer. Participants performed contractions according to visual feedback of the task-related force intensity (main direction of wrist extension) and another set of contractions with feedback of the 3 force directions. Going from the simple to the detailed force feedback will increase the demand of the motor task. Force steadiness in all 3 dimensions and force directions were extracted.

RESULTS

Compared with controls, elbow pain patients presented lower pressure pain thresholds at both sites (P<0.05). Force steadiness was not significantly different between groups or feedback methods. The change in force direction when providing simple visual feedback in contrast with feedback of all force components at all contraction levels was greater for patients compared with controls (P<0.05).

CONCLUSION

The larger change in force direction in pain patients implies redistribution of loads across the arm as an associated effect of pain.

Analysis of Muscle Load-Sharing in Patients With Lateral Epicondylitis During Endurance Isokinetic Contractions Using Non-linear Prediction

The aim of this paper is to analyze muscle load-sharing in patients with Lateral Epicondylitis during dynamic endurance contractions by means of non-linear prediction of surface EMG signals. The proposed non-linear cross-prediction scheme was used to predict the envelope of an EMG signal and is based on locally linear models built in a lag-embedded Euclidean space. The results were compared with a co-activation index, a common measure based on the activation of a muscle pair. Non-linear prediction revealed changes in muscle coupling, that is load-sharing, over time both in a control group and Lateral Epicondylitis (p < 0.05), even when subjects did not report pain at the end of the exercise. These changes were more pronounced in patients, especially in the first part of the exercise and up to 50% of the total endurance time (p < 0.05). By contrast, the co-activation index showed no differences between groups. Results reflect the changing nature of muscular activation strategy, presumably because of the mechanisms triggered by fatigue. Strategies differ between controls and patients, pointing to an altered coordination in Lateral Epicondylitis.

Comparison of scapular position and upper extremity muscle strength in patients with and without lateral epicondylalgia: a case-control study

BACKGROUND

The symptoms of lateral epicondylalgia (LE) can be persistent, and recurrence is frequent. Recurrence can be related to proximal segment impairment of the kinetic chain. Knowledge of any relation in the kinetic chain in LE may help treatment. We aimed to investigate scapular position and upper extremity muscle strength in patients with LE and to compare them with controls.

METHODS

The study enrolled 51 patients with LE and 51 age-matched controls. We assessed scapular position asymmetry using the lateral scapular slide test and measured the strength of the upper trapezius (UT), middle trapezius (MT), lower trapezius, and serratus anterior muscles in addition to shoulder abduction, external rotation, and internal rotation and grip strength.

RESULTS

The percentage of participants with scapular asymmetry was greater in the patients than in the controls (P = .005). The involved side regarding shoulder external rotation among the patients was significantly weaker than in the controls (P = .016, P = .009). The involved side of the LE patients was significantly weaker than the uninvolved side in terms of shoulder abduction, external rotation, and internal rotation (P = .013, P = .048, P = .013). The UT/MT ratio on the nondominant side of the controls was significantly greater than that on the involved side of the LE patients (P = .016).

CONCLUSION

Upper extremity muscle strength, grip strength, UT/MT ratio, and scapular position are affected in patients with LE. In addition to the elbow, focusing on the upper segments is essential in the management of LE.

Comparison of maximal isometric forearm supination torque in two elbow positions between subjects with and without limited forearm supination range of motion

Study Design: Cross-sectional comparison. Introduction: Forearm supination range of motion is often limited by short or stiff pronators. Many studies have examined maximal isometric forearm supination torque (MIFST). However, there is little research comparing MIFST in two elbow positions between subjects with and without limited forearm supination range of motion (LSR). Purpose of the Study: The purpose of this study was to compare MIFST in two elbow positions (90º flexed elbow, extended elbow) between subjects with and without LSR. Methods: Thirteen right-handed subjects (seven men, six women) with LSR and 13 age- and gender-matched healthy controls participated in this study. The forearm supination range of motion and MIFST were measured using a Smart KEMA system. Two-way repeated-measures analysis of variance was used to compare MIFST in two elbow positions between subjects with and without LSR. Results: No significant difference between groups (p > .05) was found. However, there was an interaction effect between elbow position and group on MIFST (p < .05). Independent t-tests were used to confirm the simple effects. In the LSR group, the value of MIFST was significantly lower in the elbow-extended position than in the group without LSR (p < .05). Conclusions: These findings indicate that elbow position should be considered when assessing the strength or increasing the strength of the supinator muscle, especially in patients with LSR.

Strength Reduction in Unilateral Shoulder Pain: Is the Healthy Side Really Healthy in Rotator Cuff Disease?

OBJECTIVE

The primary aim was to ascertain whether unilateral shoulder pain is implicated in strength reduction both on the ipsilateral and contralateral side. Secondarily, we aimed to determine whether strength was affected by sonographic tendon abnormalities.

DESIGN

A total of 122 subjects were evaluated. Sixty-six female subjects with unilateral shoulder pain in the dominant arm were recruited. Abduction strength was measured in both the dominant and nondominant arm. High-resolution ultrasonography was also conducted on both shoulders. A match-paired control group (n = 66) composed of healthy volunteers underwent the same strength and sonography tests. Subjects with any radiographic anomaly were excluded from the control group. A mixed analysis of variance was performed to test the effect of unilateral shoulder pain on abduction strength. The effect of tendinopathy on shoulder strength was investigated using a mixed 2 × 2 analysis of variance.

RESULTS

Analysis of variance showed that patients with dominant shoulder pain had lower shoulder strength (11.65 ± 4.05 kg) when compared with controls (14.37 ± 4.00 kg; F = 10.454, P = 0.002). No statistically significant effects were found when comparing subjects with and without tendinopathy among the study group.

CONCLUSIONS

In patients with unilateral shoulder pain, abduction strength was found to be lower both on the ipsilateral and contralateral side. The presence of tendinopathy did not affect the reduction in strength. Future research is needed to substantiate these findings.

Lateral epicondylalgia: A primary nervous system disorder

Lateral epicondylalgia (LE) is the most common chronic painful condition affecting the elbow in the general population. Although major advances have been accomplished in recent years in the understanding of LE, the underlying physiopathology is still a reason for debate. Differences in clinical presentation and evolution of the symptoms among patients, suggest the need for revisiting the current knowledge about subjacent mechanisms that attempt to explain pain and functional loss. Previous models have suggested that the condition is mainly a degenerative tendinopathy, associated with changes in pain pathways and the motor system. The hypothesis of this work is that LE is the clinical manifestation of a primary nervous system disorder, characterized by an abnormal increase in neuronal activity and a subsequent loss of homeostasis, which secondarily affects the musculoskeletal tissues of the elbow-forearm-hand complex. A new model for LE is presented, supported by an in-deep analysis of basic sciences, epidemiological and clinical studies.

The immediate sensorimotor effects of elbow orthoses in patients with lateral elbow tendinopathy: a prospective crossover study

BACKGROUND

Counterforce orthoses are used to manage lateral elbow tendinopathy, and their effectiveness in improving motor function has been documented. Little is known about the impact of bracing on sensory function. The objective of this study was to investigate the immediate effectiveness of 2 counterforce orthoses in improving the sensorimotor abilities of the hand in patients with lateral elbow tendinopathy.

METHODS

In this crossover, randomized controlled trial, elbow proprioception, pain severity, pain-free grip strength, and finger dexterity were measured in 50 participants with a diagnosis of lateral elbow tendinopathy. Outcomes were measured in 3 randomized conditions (no brace, forearm band, or elbow sleeve). Data were analyzed using 1-way repeated-measures analysis of variance for each outcome measure.

RESULTS

Better scores were observed with the forearm band, as compared with no orthosis, for multiple outcomes including joint position reproduction score at 70° of elbow flexion (P = .006), pain (P < .001), grip strength (P = .01), and dexterity (P < .001). The elbow sleeve yielded better scores than no orthosis for the following outcomes: joint position reproduction score at 110° (P < .001), pain (P < .001), and grip strength (P = .012). No statistically significant difference was found between the orthoses' effects on pain reduction and grip strength (P > .05). The forearm band showed better scores on joint position reproduction at 70° compared with the elbow sleeve (P = .006), whereas the elbow sleeve showed better scores at 110° (P < .001).

CONCLUSION

Our results support the mechanisms occurring with the use of either of the described orthotic interventions. Future randomized trials with longer-term outcomes that include sensorimotor mechanisms might enhance our understanding of the comparative effectiveness.

Forearm muscle activation, ulnar nerve at the elbow and forearm fatigue in overhand sports

This study examined the morphologic changes of the ulnar nerve in different elbow positions by ultrasonography and the effects of fatigue on forearm muscle control during overhand movements. We enrolled 12 tennis players who performed flat serves and 15 baseball pitchers who performed fastball pitching. The motion capture was conducted with 14 reflective markers attached on anatomic landmarks of the participant for tennis serve and baseball pitching data collection. The distance from the nerve to the medial condyle between the tennis players and baseball pitchers showed significant differences (p = 0.006) as the elbow flexed to 90°. The differences are due to the baseball player's repetitive pitching motion while such motion does not apply to tennis player. Activity of the extensor carpi radialis (ECR) during the cocking phase in the tennis serves showed significant differences (p = 0.022) between the nonfatigued and fatigued states; the maximal value was observed in the fatigued state. The significant increase in the ECR activity in the fatigued state might be responsible for grasp-and-release activities and maintaining the wrist joint stability when performing overhand movements. Forearm fatigue influenced their overhand motion ability in accurate ball control, although it did not decrease the ball speed.

Effects of eccentric control exercise for wrist extensor and shoulder stabilization exercise on the pain and functions of tennis elbow

[Purpose] This study aimed to conduct experiments to examine the effects of wrist eccentric control exercise or shoulder stabilization exercises after a basic direct treatment of the elbow in the treatment of tennis elbow patients in terms of pain and grip strength. [Subjects and Methods] The subjects were divided into two groups: one group conducted wrist eccentric control exercise and was comprised of 5 male and 4 female subjects, and the other group received shoulder stabilization exercise and was comprised of 5 male and 4 female subjects. [Results] In the intragroup comparison, both groups showed a significant decrease in pain level and a significant increase in the measurement of the tenderness thresholds of the upper trapezius muscle, lateral epicondyle, and grip strength. In the intergroup comparison, the shoulder stabilization exercise group showed a significantly greater increase in the measurement of the tenderness thresholds of the upper trapezius muscle and grip strength, and the differences were not significant in the pain level and tenderness threshold of the lateral epicondyle. [Conclusion] Wrist eccentric control exercise and shoulder stabilization exercises can be useful as intervention methods for relief from pain due to lateral epicondylitis and for the improvement of functions impaired by tennis elbow.

Scapholunate interosseous ligament dysfunction as a source of elbow pain syndromes: Possible mechanisms and implications for hand surgeons and therapists

Elbow pain syndromes are common upper extremity musculoskeletal disorders, and they are usually associated with repetitive occupational exposure. Ligaments are often one of the sources of musculoskeletal disorders because of their mechanical and neurological properties. The wrist ligaments are some of the ligaments most vulnerable to occupational exposure. Since most occupational tasks require wrist extension for handling tools and loading, the scapholunate interosseous ligament (SLIL) bears greater strain during loading, which results in creep deformation and hysteresis. Ligamentous creep may result in diminished ability to detect signal changes during joint movements, which impairs neuromuscular control established by ligamentomuscular reflex arcs elicited from mechanoreceptors in the ligaments. Changes in muscle activation patterns of forearm muscles due to diminished ligamentomuscular reflexes may initiate a positive feedback loop, leading to musculoskeletal pain syndromes. The relationship between elbow pain syndromes and SLIL injury will be presented through two hypotheses and relevant pain mechanisms: 1. Repetitive tasks may cause creep deformation of the SLIL, which then impairs ligamentomuscular reflexes, leading to elbow pain disorders. 2. Lateral epicondylalgia may increase the risk of SLIL injury through the compensation of the lower extensor carpi radialis muscle activity by higher extensor carpi ulnaris muscle activity, which may alter carpal kinematics, leading to SLIL degeneration over time. The differential diagnosis is usually complicated in musculoskeletal pain disorders. The failure of treatment methods is one of the issues of concern for many researchers. A key element in developing treatment strategies is to understand the source of the disorder and the nature of the injury. We proposed that the differential diagnosis include SLIL injuries when describing elbow pain syndromes, particularly, lateral epicondylalgia.

Fadiga dos músculos extensores do punho diminui a força de preensão palmar

RESUMO O objetivo deste estudo foi avaliar os efeitos de um protocolo de fadiga dos músculos extensores de punho na força de preensão e da pinça lateral através da dinamometria e eletromiografia de superfície (EMG). Foram selecionados 40 indivíduos do sexo masculino, divididos em dois grupos: preensão ou pinça lateral. O protocolo de fadiga foi baseado no teste de 1 Repetição Máxima (1-RM), seguido da realização do movimento de extensão de punho repetidas vezes com carga de 75% da 1-RM. Os voluntários realizaram as tarefas de preensão ou pinça lateral associadas à dinamometria. A EMG foi realizada para ambos os grupos, analisando o comportamento, segundo o protocolo, pela frequência mediana (FM) do extensor radial do carpo (ERC), do extensor ulnar do carpo (EUC) e do flexor superficial dos dedos (FD). A dinamometria de preensão ou pinça lateral e a EMG foram realizadas antes e após o protocolo de fadiga para ambos os grupos. O protocolo de fadiga foi eficaz na diminuição da força de preensão palmar (43,5±3,85 kgf inicial e 36,50±5,1 kgf final) e da pinça lateral (10,26±1,01 kgf inicial e 8,54±0,86 kgf final), bem como na diminuição da FM, sugerindo uma condição de fadiga do EUC no grupo preensão. Os achados do presente estudo possibilitam relacionar a fadiga dos extensores de punho à diminuição de força em atividades funcionais, como a preensão, o que pode implicar em disfunções musculoesqueléticas do membro superior.

Comparison of muscle activity of wrist extensors and kinematics of wrist joint during wrist extension in automobile assembly line workers with and without lateral epicondylitis

BACKGROUND

Overuse of the extensor carpi radialis (ECR) may play a role in the development of lateral epicondylitis (LE). However, no studies have investigated the muscle activity ratio between the ECR and extensor carpi ulnaris (ECU) associated with the kinematics during wrist extension in workers with LE.

OBJECTIVE

We compared the ratio (ECR/ECU) of muscle activity between the ECR and ECU and the kinematics of the wrist during wrist extension between workers with and without LE.

METHODS

Fifteen automobile assembly line workers with LE and 15 workers without LE participated in this study. The ratio of muscle activity was measured using surface electromyography, and wrist kinematics were measured by a three-dimensional motion analysis system while the workers extended their wrists actively to the maximum range to which they did not feel uncomfortable.

RESULTS

Significantly greater ratios of muscle activity, ranges of radial deviation, and combined motion of radial deviation and extension (CMDE) were shown in workers with LE compared to those without LE. Also, the range of wrist extension was significantly lower in workers with LE than in those without LE.

CONCLUSIONS

Quantifying the ratio of muscle activity with altered kinematics of wrist extension may help researchers to understand why overuse of ECR is occurring and explain LE development in automobile assembly line workers.

Is synergistic organisation of muscle coordination altered in people with lateral epicondylalgia? A case-control study

BACKGROUND

Lateral epicondylalgia is a common musculoskeletal disorder and is associated with deficits in the motor system including painful grip. This study compared coordination of forearm muscles (muscle synergies) during repeated gripping between individuals with and without lateral epicondylalgia.

METHODS

Twelve participants with lateral epicondylalgia and 14 controls performed 15 cyclical repetitions of sub-maximal (20% maximum grip force of asymptomatic arm), pain free dynamic gripping in four arm positions: shoulder neutral with elbow flexed to 90° and shoulder flexed to 90° with elbow extended both with forearm pronated and neutral. Muscle activity was recorded from extensor carpi radialis brevis/longus, extensor digitorum, flexor digitorum superficialis/profundus, and flexor carpi radialis, with intramuscular electrodes. Muscle synergies were extracted using non-negative matrix factorisation.

FINDINGS

Analysis of each position and participant, demonstrated that two muscle synergies accounted for >97% of the variance for both groups. Between-group differences were identified after electromyography patterns of the control group were used to reconstruct the patterns of the lateral epicondylalgia group. A greater variance accounted for was identified for the controls than lateral epicondylalgia (p=0.009). This difference might be explained by an additional burst of flexor digitorum superficialis electromyography during grip release in many lateral epicondylalgia participants.

INTERPRETATION

These data provide evidence of some differences in synergistic organisation of activation of forearm muscles between individuals with and without lateral epicondylalgia. Due to study design it is not possible to elucidate whether changes in the coordination of muscle activity during gripping are associated with the cause or effect of lateral epicondylalgia.

The Potential Risk Factors Relevant to Lateral Epicondylitis by Wrist Coupling Posture

The use of awkward wrist postures and unskilled techniques might induce lateral epicondylitis. This study thus investigated the effects of wrist deviation combined with extension and movement velocity on the dynamic performances of the wrist muscles during the coupling posture via a custom-made bi-planar isokinetic dynamometer. Thirty subjects were recruited to perform the isokinetic testing. We measured the muscle strengths and activities for the wrist extensors and flexors during concentric and eccentric contractions at three movement velocities, 30°s^-1, 90°s^-1, and 180°s^-1, combined with three wrist postures, neutral position (NP), radial deviation (RD), and ulnar deviation (UD). The root mean square (RMS) of the electromyographic signal in the extensor digitorum communis (EDC), normalized peak torque of extensors, and ratio of normalized peak torque between wrist extensors and flexors, were all greater in the NP than RD and UD in both contractions. The ratio of RMS between EDC and flexor digitorum superficialis (FDS) had a significantly greater value in RD than UD during the concentric contraction. The EDC showed significantly higher activity at the fast velocity in both contractions. Nevertheless, a significantly higher RMS of the electromyographic signal between EDC and FDS and the ratio of strength between wrist extensors and flexors were found at slow velocity in both contractions. The wrist deviation combined with extension and movement velocity of the wrist joint should thus be considered as influential factors which might alter the dynamic performances, and may result in further injury of the elbow joint.

Management of Lateral Elbow Tendinopathy: One Size Does Not Fit All

Synopsis Clear guidelines for the clinical management of individuals with lateral elbow tendinopathy (LET) are hampered by many proposed interventions and the condition's prognosis, ranging from immediate resolution of symptoms following simple advice in some patients to long-lasting problems, regardless of treatment, in others. This is compounded by our lack of understanding of the complexity of the underlying pathophysiology of LET. In this article, we collate evidence and expert opinion on the pathophysiology, clinical presentation, and differential diagnosis of LET. Factors that might provide prognostic value or direction for physical rehabilitation, such as the presence of neck pain, tendon tears, or central sensitization, are canvassed. Clinical recommendations for physical rehabilitation are provided, including the prescription of exercise and adjunctive physical therapy and pharmacotherapy. A preliminary algorithm, including targeted interventions, for the management of subgroups of patients with LET based on identified prognostic factors is proposed. Further research is needed to evaluate whether such an approach may lead to improved outcomes and more efficient resource allocation. J Orthop Sports Phys Ther 2015;45(11):938-949. Epub 17 Sep 2015. doi:10.2519/jospt.2015.5841.

Movement Evoked Pain and Mechanical Hyperalgesia after Intramuscular Injection of Nerve Growth Factor: A Model of Sustained Elbow Pain

OBJECTIVE

Lateral epicondylalgia presents as lateral elbow pain provoked by upper limb tasks. An experimental model of elbow pain provoked by movement/muscle contraction and maintained over several days is required to better understand the mechanisms underlying sustained elbow pain. This study investigated the time course and pain location induced by nerve growth factor (NGF) injection into a wrist extensor muscle, and whether movement and muscle contraction/stretch provoked pain.

METHODS

On Day 0 twenty-six painfree volunteers were injected with NGF (N = 13) or isotonic saline (randomized) into the extensor carpi radialis brevis (ECRB) muscle of the dominant arm. On Day 2 pain was induced in all participants by hypertonic saline injection into ECRB. A Likert scale and patient-rated tennis elbow evaluation (PRTEE) was used to assess pain and functional limitation (Days 0-10). Pain intensity during contraction/stretch of ECRB, and pressure pain thresholds (PPTs) were recorded before and after injections on Days 0 and 2, and Days 4 and 10.

RESULTS

Compared with isotonic saline, NGF evoked: i) greater Likert pain ratings from 12 hours post-injection until Day 6, ii) greater PRTEE scores on Days 2 and 4, iii) greater pain during ECRB contraction/stretch on Day 2, and iv) lower PPTs on Day 4.

CONCLUSIONS

This article presents a novel experimental human pain model suitable to study the sustained effects of lateral elbow pain on sensorimotor function and to probe the mechanisms underlying persistent musculoskeletal pain.

Scapular muscle performance in individuals with lateral epicondylalgia

STUDY DESIGN

Descriptive, laboratory-based, cross-sectional study.

OBJECTIVES

To describe scapular musculature strength, endurance, and change in thickness in individuals with unilateral lateral epicondylalgia (LE) compared to the uninvolved limb and the corresponding limb of a matched comparison group.

BACKGROUND

Reported poor long-term outcomes for the nonsurgical management of individuals with LE suggest a less-than-optimal rehabilitation process. Knowledge of scapular muscle function in a working population of individuals with LE may help to further refine conservative management of this condition.

METHODS

Twenty-eight patients with symptomatic LE and 28 controls matched by age and sex were recruited to participate in the study. Strength of the middle trapezius (MT), lower trapezius (LT), and serratus anterior (SA) was measured with a handheld dynamometer. A scapular isometric muscle endurance task was performed in prone. Changes in muscle thickness of the SA and LT were measured with ultrasound imaging. Analysis-of-variance models were used to determine within- and between-group differences.

RESULTS

The involved side of the group with LE had significantly lower values for MT strength (P = .031), SA strength (P<.001), LT strength (P = .006), endurance (P = .003), and change in SA thickness (P = .028) when compared to the corresponding limb of the control group. The involved side of the group with LE had significantly lower strength of the LT (P = .023) and SA (P = .016) when compared to the uninvolved limb; however, these differences were small and of potentially limited clinical significance.

CONCLUSION

When compared to a matched comparison group, there were impairments of scapular musculature strength and endurance in patients with LE, suggesting that the scapular musculature should be assessed and potentially treated in this population. Cause and effect cannot be established, as the weakness of the scapular musculature could be a result of LE.

Motor Cortex Reorganization and Impaired Function in the Transition to Sustained Muscle Pain

Primary motor cortical (M1) adaptation has not been investigated in the transition to sustained muscle pain. Daily injection of nerve growth factor (NGF) induces hyperalgesia reminiscent of musculoskeletal pain and provides a novel model to study M1 in response to progressively developing muscle soreness. Twelve healthy individuals were injected with NGF into right extensor carpi radialis brevis (ECRB) on Days 0 and 2 and with hypertonic saline on Day 4. Quantitative sensory and motor testing and assessment of M1 organization and function using transcranial magnetic stimulation were performed prior to injection on Days 0, 2, and 4 and again on Day 14. Pain and disability increased at Day 2 and increased further at Day 4. Reorganization of M1 was evident at Day 4 and was characterized by increased map excitability. These changes were accompanied by reduced intracortical inhibition and increased intracortical facilitation. Interhemispheric inhibition was reduced from the "affected" to the "unaffected" hemisphere on Day 4, and this was associated with increased pressure sensitivity in left ECRB. These data provide the first evidence of M1 adaptation in the transition to sustained muscle pain and have relevance for the development of therapies that seek to target M1 in musculoskeletal pain.

Effects of local and widespread muscle fatigue on movement timing

Repetitive movements can cause muscle fatigue, leading to motor reorganization, performance deficits, and/or possible injury. The effects of fatigue may depend on the type of fatigue task employed, however. The purpose of this study was to determine how local fatigue of a specific muscle group versus widespread fatigue of various muscle groups affected the control of movement timing. Twenty healthy subjects performed an upper extremity low-load work task similar to sawing for 5 continuous minutes both before and after completing a protocol that either fatigued all the muscles used in the task (widespread fatigue) or a protocol that selectively fatigued the primary muscles used to execute the pushing stroke of the sawing task (localized fatigue). Subjects were instructed to time their movements with a metronome. Timing error, movement distance, and speed were calculated for each movement. Data were then analyzed using a goal-equivalent manifold approach to quantify changes in goal-relevant and non-goal-relevant variability. We applied detrended fluctuation analysis to each time series to quantify changes in fluctuation dynamics that reflected changes in the control strategies used. After localized fatigue, subjects made shorter, slower movements and exerted greater control over non-goal-relevant variability. After widespread fatigue, subjects exerted less control over non-goal-relevant variability and did not change movement patterns. Thus, localized and widespread muscle fatigue affected movement differently. Local fatigue may reduce the available motor solutions and therefore cause greater movement reorganization than widespread muscle fatigue. Subjects altered their control strategies but continued to achieve the timing goal after both fatigue tasks.

Spatial localization of electromyographic amplitude distributions associated to the activation of dorsal forearm muscles

In this study we investigated whether the spatial distribution of surface electromyographic (EMG) amplitude can be used to describe the activation of muscle portions with different biomechanical actions. Ten healthy subjects performed isometric contractions aimed to selectively activate a number of forearm muscles or muscle subportions. Monopolar electromyographic signals were collected with an electrode grid of 128 electrodes placed on the proximal, dorsal portion of the forearm. The monopolar EMG amplitude [root mean square (RMS) value] distribution was calculated for each contraction, and high-amplitude channels were identified through an automatic procedure; the position of the EMG source was estimated with the barycenter of these channels. Each of the contractions tested was associated to a specific EMG amplitude distribution, whose location in space was consistent with the expected anatomical position of the main agonist muscle (or subportion). The position of each source was significantly different from the others in at least one direction (ANOVA; transversally to the forearm: P < 0.01, F = 125.92; longitudinally: P < 0.01, F = 35.83). With such an approach, we could distinguish the spatial position of EMG distributions related to the activation of contiguous muscles [e.g., extensor carpi ulnaris (ECU) and extensor digitorum communis (EDC)], different heads of the same muscle (i.e., extensor carpi radialis (ECR) brevis and longus) and different functional compartments (i.e., EDC, middle, and ring fingers). These findings are discussed in terms of how forces along a given direction can be produced by recruiting population of motor units clustered not only in specific muscles, but also in muscle sub-portions. In addition, this study supports the use of high-density EMG systems to characterize the activation of muscle subportions with different biomechanical actions.

Middle and lower trapezius strengthening for the management of lateral epicondylalgia: a case report

STUDY DESIGN

Case report.

BACKGROUND

Addressing weakness of the shoulder region, especially the rotator cuff and scapular musculature, is often suggested clinically for the treatment of individuals with lateral epicondylalgia. However, to our knowledge, the clinical effectiveness of this approach has not been established.

CASE DESCRIPTION

The patient was a 54-year-old woman with a 5-month history of right lateral elbow pain, whose symptoms were reproduced with clinical tests typically used to diagnose lateral elbow tendinopathy. The patient also demonstrated weakness in her middle and lower trapezius muscles, and the medial border of her scapula, measured with a tape measure, was 11 cm lateral from the spinous processes of the thoracic spine with the patient standing in relaxed stance. Based on improved grip strength and reduced associated elbow pain when tested with the scapula manually corrected in a more adducted position, treatment focused solely on strengthening of the middle and lower trapezius muscles over a 10-week period.

OUTCOMES

Following the intervention, the patient presented with improved scapular position, with the medial border of the scapula being 9 cm lateral to the midthoracic spine. The patient's middle and lower trapezius strength improved from 3+/5 and 4-/5, respectively, to 5/5, and her grip strength from 26.1 to 42.2 kg. The patient's scores on the Disabilities of the Arm, Shoulder and Hand questionnaire also improved from 44.2 at the initial evaluation to 0 at the completion of therapy, with the patient being able to perform all of her daily activities in a pain-free manner.

DISCUSSION

The results of this case report suggest that assessment and treatment of scapular musculature warrant consideration in the management of individuals with lateral epicondylalgia.

LEVEL OF EVIDENCE

Therapy, level 4.

Should we think about wrist extensor after flexor tendon repair?

OBJECTIVE

To evaluate the activity of wrist extensor muscle, correlating with wrist motion during gripping after flexor tendon repair.

DESIGN

Cross-sectional clinical measurement study.

SETTING

Laboratory for biomechanics and rehabilitation.

SUBJECTS

A total of 11 patients submitted to rehabilitation by early passive motion of the fingers with wrist flexion position were evaluated after 8 weeks of fingers flexor tendon repair and 11 healthy volunteers, all ranging from 20 to 37 years of age.

INTERVENTION

Volunteers performed an isometric standardized gripping task.

MAIN MEASURES

We used electrogoniometry to analyze wrist range of motion and surface electromyography, considering 100% maximum voluntary contraction to represent the amplitude of electromyographic activity of the extensor carpi radialis and flexor digitorum superficialis.

RESULTS

Patients with flexor tendon repair showed co-activation deficit between wrist extensor (extensor carpi radialis) and flexor finger muscles (flexor digitorum superficialis) during gripping in the intermediate phase of rehabilitation, despite some recovering mobility for wrist extension (p ≤ 0.05). A moderate correlation between range of motion and extensor carpi radialis was present only for injured group (r = 0.32). Total active motion score, which represents finger active excursion, was regular or poor in 65% of cases, all with nerve repair associated.

CONCLUSION

Wrist extensors have an important synergist role at handgrip, although some imbalance can be present after flexor tendon repair. These preliminary findings suggest that emphasis could be directed to add synergistic wrist motion in rehabilitation protocols after flexor tendon repair. Future studies with early active rehabilitation are necessary.