Bilaterally decreased motor performance of arms in patients with chronic tennis elbow

Interhemispheric Inhibition Between Primary Motor Cortices is Not Altered in Individuals With Chronic Lateral Epicondylalgia

Lateral epicondylalgia (LE), commonly referred to as tennis elbow, is a musculoskeletal condition characterized by pain and sensorimotor dysfunction. In some individuals with chronic unilateral LE, sensorimotor symptoms develop on the unaffected side despite no evidence of tissue damage. Altered interhemispheric inhibition (IHI) is one mechanism that could underpin this phenomenon. The aim of this cross-sectional study was to examine IHI between the primary motor cortices (M1) in individuals with chronic LE and healthy controls. In 20 individuals with chronic LE and 20 healthy participants, transcranial magnetic stimulation was used to assess 1) short and long-latency IHI from the affected (corresponding to the injured side) to the unaffected M1 and 2) corticomotor excitability of the affected and unaffected M1. Sensorimotor function was evaluated bilaterally at the extensor carpi radialis brevis muscle using pressure pain threshold, grip strength, 2-point discrimination, and temporal summation tests. Short- and long-latency IHI from the affected to the unaffected M1 and corticomotor excitability of the affected and unaffected M1 were not altered in individuals with LE compared with healthy participants. No differences in sensorimotor function were observed for the affected or unaffected extensor carpi radialis brevis muscles when individuals with LE were compared with healthy participants. IHI is not altered in individuals with chronic LE. Further studies are required to determine the mechanisms that underpin the development of bilateral sensorimotor symptoms in unilateral LE. PERSPECTIVE: IHI is unaltered from the affected M1 (corresponding to the painful muscle) to unaffected M1 in individuals with LE compared to healthy controls. The absence of bilateral sensorimotor dysfunction and low pain severity in this cohort of individuals with LE may explain this finding.

Joint position sense, motor imagery and tactile acuity in lateral elbow tendinopathy: A cross-sectional study

BACKGROUND

Impairments of sensorimotor function are evident in individuals with lateral elbow tendinopathy (LET), although understanding of the mechanisms for this is lacking.

OBJECTIVES

To determine if motor imagery, tactile acuity and wrist joint position sense (JPS) are impaired in participants with unilateral LET compared to controls, whether deficits are localised to the affected side, and whether deficits relate to severity of pain.

DESIGN

Cross-sectional study with control group.

METHODS

14 participants with unilateral LET of 6 weeks or longer and 14 matched control participants were assessed bilaterally for motor imagery (left/right hand judgement task), tactile acuity (two-point discrimination test) and wrist JPS (reposition test for flexion and extension). Pain levels were measured using a numeric rating scale.

RESULTS

Significant differences in JPS were observed for wrist extension only, such that participants with LET adopted less extended postures with their affected side when compared to their unaffected side (MD = 2.97°; p = 0.01) and to the matched-affected side of controls (MD = 4.89°; p < 0.01). No differences in tactile acuity or motor imagery were observed.

CONCLUSION

Altered wrist extension JPS, but not motor imagery or tactile acuity, was found in the affected side of patients with unilateral LET when compared to non-injured side and asymptomatic controls.

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.

Sensory Processing in People With and Without Tendinopathy: A Systematic Review With Meta-analysis of Local, Regional, and Remote Sites in Upper- and Lower-Limb Conditions

OBJECTIVE

To synthesize results of somatosensory processing tests in people with upper- and lower-limb tendinopathy, compared to controls.

DESIGN

Systematic review with meta-analysis.

LITERATURE SEARCH

Four electronic databases (MEDLINE, CINAHL Plus, SPORTDiscus, and Embase) were searched.

STUDY SELECTION CRITERIA

Included studies measured a domain of sensory processing and compared a tendinopathy group to a healthy control group.

DATA SYNTHESIS

Meta-analysis was conducted for outcomes with homogeneous data from at least 2 studies. Upper- and lower-limb conditions were compared and outcomes were examined by measurement site (local, regional, or remote to location of pain).

RESULTS

Of the 30 studies included, 18 investigated lateral elbow tendinopathy. The most commonly assessed outcome measures were pressure pain threshold (PPT) and thermal pain threshold. There was moderate evidence for local and regional reduction of PPT in upper-limb tendinopathies, but not at remote sites. In lower-limb tendinopathies, there was conflicting evidence regarding reduced PPT at local sites and limited evidence of normal PPT at remote sites. There was moderate evidence of sensitization of thermal pain threshold at local sites in upper-limb tendinopathies and limited evidence of no difference in thermal pain threshold in lower-limb tendinopathies. Findings across other domains were variable.

CONCLUSION

Sensory processing was different between upper-limb tendinopathy and lower-limb tendinopathy. Upper-limb tendinopathies showed signs consistent with primary and secondary hyperalgesia, but lower-limb tendinopathies did not. There was mixed evidence for primary hyperalgesia and limited evidence against secondary hyperalgesia. J Orthop Sports Phys Ther 2021;51(1):12-26. doi:10.2519/jospt.2021.9417.

Bilateral sensory and motor as well as cognitive differences between persons with and without musculoskeletal disorders of the wrist and hand

BACKGROUND

Sensory and motor disturbances are characteristic of musculoskeletal injuries and conditions. Rehabilitation interventions aimed at remediating these disturbances are traditionally exclusively targeted to the affected area. However, there is some evidence of bilateral changes in sensory and motor function associated with unilateral injuries and conditions suggesting central changes. Deficits on specific cognitive tasks have also been documented in persons with chronic pain.

PURPOSE

The purpose of the present study was to determine if participants with unilateral pain arising from heterogeneous wrist/hand injuries and conditions demonstrate bilateral changes in sensory and motor functions as well as cognitive deficits.

DESIGN/METHODS

Sensory (Pressure Pain Thresholds, Two Point Orientation Discrimination), Motor (grip strength and Purdue Pegboard), and Cognitive function (Stroop test and mental rotation task) were measured in 30 participants with wrist/hand pain and 30 healthy control participants in an observational cross-sectional study.

RESULTS

Participants with unilateral wrist/hand pain demonstrated differences in cognitive function measured with the Stroop test (p = 0.03). They also demonstrated bilateral sensorimotor differences in pressure pain thresholds (p = 0.03), grip strength (p = 0.00) and Purdue pegboard test (p = 0.03) results compared to healthy control participants.

CONCLUSION

Cognitive as well as bilateral alterations in sensory and motor function in participants with musculoskeletal injuries and conditions suggest central changes are involved in their pathophysiology. These findings in persons with heterogeneous injuries/conditions suggest that these changes are not specific to an injury/condition. Bilateral sensorimotor changes have important implications with regards to the pathophysiology of musculoskeletal disorders of the wrist/hand, for rehabilitative interventions and research.

The effect of eccentric exercise and delayed onset muscle soreness on the homologous muscle of the contralateral limb

High intensity eccentric exercise induces muscle fiber damage and associated delayed-onset muscle soreness (DOMS) resulting in an impaired ability of the muscle to generate voluntary force. This study investigates the extent to which DOMS, induced by high intensity eccentric exercise, can affect the activation and performance of the non-exercised homologous muscle of the contralateral limb. Healthy volunteers performed maximal voluntary contractions of knee extension and sustained isometric knee extension at 50% of maximal force until task failure on both the ipsilateral exercised limb and the contralateral limb. Surface electromyography (EMG) was recorded from the ipsilateral and contralateral knee extensor muscles (vastus medialis, rectus femoris, and vastus lateralis). Maximal isometric knee extension force (13.7% reduction) and time to task failure (38.1% reduction) of the contralateral non-exercised leg decreased immediately after eccentric exercise, and persisted 24 h and 48 h later (p < 0.05). Moreover, the amplitude of muscle activity recorded from the contralateral knee extensor muscles was significantly lower during the post exercise maximal and submaximal contractions following high intensity eccentric exercise of the opposite limb (p < 0.05). Unilateral high intensity eccentric exercise of the quadriceps can contribute to reduced neuromuscular activity and physical work capacity of the non-exercised homologous muscle in the contralateral limb.

Three-dimensional motion analysis in the elbow joint position sense in children

[Purpose] The purpose of this study was to investigate the difference in elbow joint position sense in children. [Subjects and Methods] Nineteen healthy children volunteered as subjects for this study. Joint position sense was assessed by asking the children to flex their elbows between 30° to 110° while blindfolded. The error range of elbow movement was analyzed with Compact Measuring System 10 for three-dimensional motion. To analyze data, descriptive statistics and paired t-test analysis were performed by using IBM SPSS Statistics 20.0. [Results] A significantly lower error was found in 30° right elbow flexion than 110° right elbow flexion (p<0.05). No significant difference was found between 30° and 110° left elbow flexion. [Conclusion] These results indicate that in children, joint position sense errors decrease as joint angles approach 30° flexion.

Muscle Activity during Rapid Wrist Extension in People with Lateral Epicondylalgia

BACKGROUND

Individuals with lateral epicondylalgia (LE) have delayed upper limb reaction time (RT); however, it is unknown if the mechanisms of this dysfunction are related to neural processing or the affected forearm muscles. The aim of this study was to examine the timing of processes that occur before and after forearm muscles are activated during the RT task.

METHODS

Eleven LE (42 ± 11 yr) and 11 healthy controls (42 ± 11 yr) performed rapid wrist extension in response to an audio cue. Intramuscular EMG was obtained from extensor carpi radialis brevis (ECRB), extensor digitorum communis (EDC), extensor carpi ulnaris (ECU), and anconeus. Premotor time (PMT) was the duration from an audio cue to the onset of muscle activity, and motor time (MT) was the onset of muscle activity to the onset of wrist extension. Standard clinical assessments of LE were also performed.

RESULTS

RT was significantly slower (33; 95% CI, 1-66 ms) in the LE group. There were no group differences in PMT and the order of muscle activation. Instead, the MT of ECRB (18; 95% CI, 6-31 ms), EDC (12; 95% CI, 1-23 ms), ECU (28; 95% CI, 9-46 ms), and anconeus (33; 95% CI, 11-56 ms) showed significant delay in LE group. Regression analyses revealed that the duration of LE could predict RT, ECRB, and anconeus PMT, whereas cold pain threshold predicted ECRB MT.

CONCLUSIONS

Delayed RT in LE was predominantly caused by deficits in ECRB and EDC MT. This study provides preliminary evidence that in the people with longer LE symptoms, duration appeared to have faster RT, although confirmation of this finding is required before firm conclusions can be drawn.

Sensorimotor interventions and assessments for the hand and wrist: a scoping review

STUDY DESIGN

Scoping review.

INTRODUCTION

Sensorimotor deficits can impair function and may be present in individuals with common upper extremity conditions.

PURPOSE OF THE STUDY

To provide clinicians with an understanding of the usefulness of the assessments to evaluate sensorimotor function and the interventions reported in the literature to effect positive change in our patients with sensorimotor deficits affecting the hand and wrist.

METHODS

A systematic search produced seventeen studies involving sensorimotor retraining and assessment of sensorimotor performance for the upper extremity.

RESULTS

Sensorimotor interventions and assessments found in the literature vary in regards to their effectiveness in restoring sensorimotor function in subjects with a number of conditions that affect hand and wrist function.

CONCLUSIONS

There is a potential value of sensorimotor interventions for individuals with specific upper extremity conditions. There is a need for further studies to improve treatment of sensorimotor deficits and understanding of sensorimotor interventions.

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.

Relationships between biomechanics, tendon pathology, and function in individuals with lateral epicondylosis

STUDY DESIGN

Single-cohort descriptive and correlational study.

OBJECTIVES

To investigate the relationships between tendon pathology, biomechanical measures, and self-reported pain and function in individuals with chronic lateral epicondylosis.

BACKGROUND

Lateral epicondylosis has a multifactorial etiology and its pathophysiology is not well understood. Consequently, treatment remains challenging, and lateral epicondylosis is prone to recurrence. While tendon pathology, pain system changes, and motor impairments due to lateral epicondylosis are considered related, their relationships have not been thoroughly investigated.

METHODS

Twenty-six participants with either unilateral (n = 11) or bilateral (n = 15) chronic lateral epicondylosis participated in this study. Biomechanical measures (grip strength, rate of force development, and electromechanical delay) and measures of tendon pathology (magnetic resonance imaging and ultrasound) and self-reported pain and function (Patient-Rated Tennis Elbow Evaluation) were performed. Partial Spearman correlations, adjusting for covariates (age, gender, weight, and height), were used to evaluate the relationship between self-reported pain, function, and biomechanical and tendon pathology measures.

RESULTS

Statistically significant correlations between biomechanical measures and the Patient-Rated Tennis Elbow Evaluation ranged in magnitude from 0.44 to 0.68 (P<.05); however, no significant correlation was observed between tendon pathology (magnetic resonance imaging and ultrasound) measures and the Patient-Rated Tennis Elbow Evaluation (r = -0.02 to 0.31, P>.05). Rate of force development had a stronger correlation (r = 0.54-0.68, P<.05) with self-reported function score than with grip strength (r = 0.35-0.47, P<.05) or electromechanical delay (r = 0.5, P<.05).

CONCLUSION

Biomechanical measures (pain-free grip strength, rate of force development, electromechanical delay) have the potential to be used as outcome measures to monitor progress in lateral epicondylosis. In comparison, the imaging measures (magnetic resonance imaging and ultrasound) were useful for visualizing the pathophysiology of lateral epicondylosis. However, the severity of the pathophysiology was not related to pain and function, indicating that imaging measures may not provide the best clinical assessment.

The effect of lateral epicondylosis on upper limb mechanical parameters

BACKGROUND

Lateral epicondylosis is a prevalent and costly musculoskeletal disorder characterized by degeneration of the common extensor tendon origin at the lateral epicondyle. Grip strength is commonly affected due to lateral epicondylosis. However, less is known about the effect of lateral epicondylosis on other functional parameters such as ability to react to rapid loading.

METHODS

Twenty-nine lateral epicondylosis participants and ten controls participated in a case-control study comparing mechanical parameters (mass, stiffness and damping), magnetic resonance imaging signal intensity and grip strength of injured and uninjured limbs. A mixed effects model was used to assess the effect of dominance and injury on mechanical parameters and grip strength.

FINDINGS

Significant effect of injury and dominance was observed on stiffness, damping and grip strength. An injured upper limb had, on average, 18% less stiffness (P<0.01, 95% CI [9.8%, 26%]), 21% less damping (P<0.01, 95% CI [11%, 31%]) and 50% less grip strength (P<0.01, 95% CI [37%, 61%]) than an uninjured upper limb. The dominant limb had on average 15% more stiffness (P<0.01, 95% CI [8.0%, 23%], 33% more damping (P<0.01, 95% CI [22%, 45%]), and 24% more grip strength (P<0.01, 95% CI [6.6%, 44%]) than the non-dominant limb.

INTERPRETATION

Lower mechanical parameters are indicative of a lower capacity to oppose rapidly rising forces and quantify an important aspect of upper limb function. For individuals engaged in manual or repetitive activities involving the upper limb, a reduction in ability to oppose these forces may result in increased risk for injury or recurrence.

Effect of lateral epicondylosis on grip force development

STUDY DESIGN

Case-Control.

INTRODUCTION

Although it is well known that grip strength is adversely affected by lateral epicondylosis (LE), the effect of LE on rapid grip force generation is unclear.

PURPOSE OF THE STUDY

To evaluate the effect of LE on the ability to rapidly generate grip force.

METHODS

Twenty-eight participants with LE (13 unilateral and 15 bilateral LE) and 13 healthy controls participated in this study. A multiaxis profile dynamometer was used to evaluate grip strength and rapid grip force generation. The ability to rapidly produce force is composed of the electromechanical delay and rate of force development. Electromechanical delay is defined as the time between the onset of electrical activity and the onset of muscle force production. The Patient-rated Tennis Elbow Evaluation (PRTEE) questionnaire was used to assess pain and functional disability. Magnetic resonance imaging was used to evaluate tendon degeneration.

RESULTS

LE-injured upper extremities had lower rate of force development (50 lb/sec, confidence interval [CI]: 17, 84) and less grip strength (7.8 lb, CI: 3.3, 12.4) than nonnjured extremities. Participants in the LE group had a longer electromechanical delay (- 59% , CI: 29, 97) than controls. Peak rate of force development had a higher correlation (r = 0.56; p<0.05) with PRTEE function than grip strength (r = 0.47; p<0.05) and electromechanical delay (r = 0.30; p>0.05) for participants with LE. In addition to a reduction in grip strength, those with LE had a reduction in rate of force development and an increase in electromechanical delay.

CONCLUSIONS

Collectively, these changes may contribute to an increase in reaction time, which may affect risk for recurrent symptoms. These findings suggest that therapists may need to address both strength and rapid force development deficits in patients with LE.

LEVEL OF EVIDENCE

3B.

Optimising corticosteroid injection for lateral epicondylalgia with the addition of physiotherapy: a protocol for a randomised control trial with placebo comparison

Background

Corticosteroid injection and physiotherapy are two commonly prescribed interventions for management of lateral epicondylalgia. Corticosteroid injections are the most clinically efficacious in the short term but are associated with high recurrence rates and delayed recovery, while physiotherapy is similar to injections at 6 weeks but with significantly lower recurrence rates. Whilst practitioners frequently recommend combining physiotherapy and injection to overcome harmful effects and improve outcomes, study of the benefits of this combination of treatments is lacking. Clinicians are also faced with the paradox that the powerful anti-inflammatory corticosteroid injections work well, albeit in the short term, for a non-inflammatory condition like lateral epicondylalgia. Surprisingly, these injections have not been rigorously tested against placebo injections. This study primarily addresses both of these issues.

Methods

A randomised placebo-controlled clinical trial with a 2 × 2 factorial design will evaluate the clinical efficacy, cost-effectiveness and recurrence rates of adding physiotherapy to an injection. In addition, the clinical efficacy and adverse effects of corticosteroid injection beyond that of a placebo saline injection will be studied. 132 participants with a diagnosis of lateral epicondylalgia will be randomly assigned by concealed allocation to one of four treatment groups – corticosteroid injection, saline injection, corticosteroid injection with physiotherapy or saline injection with physiotherapy. Physiotherapy will comprise 8 sessions of elbow manipulation and exercise over an 8 week period. Blinded follow-up assessments will be conducted at baseline, 4, 8, 12, 26 and 52 weeks after randomisation. The primary outcome will be a participant rating of global improvement, from which measures of success and recurrence will be derived. Analyses will be conducted on an intention-to-treat basis using linear mixed and logistic regression models. Healthcare costs will be collected from a societal perspective, and along with willingness-to-pay and quality of life data will facilitate cost-effectiveness and cost-benefit analyses.

Conclusion

This trial will utilise high quality trial methodologies in accordance with CONSORT guidelines. Findings from this study will assist in the development of evidence based practice recommendations and potentially the optimisation of resource allocation for rehabilitating lateral epicondylalgia.

Trial registration

Australian New Zealand Clinical Trials Register ACTRN12609000051246

Sensorimotor deficits remain despite resolution of symptoms using conservative treatment in patients with tennis elbow: a randomized controlled trial

OBJECTIVES

To evaluate the time course of sensorimotor deficits in lateral epicondylalgia (LE; tennis elbow) and how these deficits may be influenced by common conservative treatments.

DESIGN

Single-blind randomized controlled trial.

SETTING

University laboratory, Australia.

PARTICIPANTS

A total of 198 participants with unilateral LE of a minimum 6 weeks duration and normative data from a group of 40 healthy participants.

INTERVENTIONS

Participants with LE were randomly assigned to physical therapy, corticosteroid injection, or a wait-and-see approach with ergonomic advice.

MAIN OUTCOME MEASURES

Upper-limb reaction time (simple, 1-choice and 2-choice reaction time) and speed of movement were assessed at baseline and 6 and 52 weeks of follow-up.

RESULTS

Patients with LE exhibited delayed reaction times (P<.001) and slower movement speeds (P<.001) for both the affected and unaffected arm at baseline, compared with normative data. Despite some improvement over time, significant bilateral deficits remained compared with healthy participants, with no significant differences between the affected and unaffected arm. Overall, there was no significant difference between the 3 treatment groups over time.

CONCLUSIONS

Sensorimotor deficits remain relatively unchanged over time and are present bilaterally in patients with unilateral LE. Treatment did not influence the time course of the sensorimotor deficits. This prompts conjecture as to the relationship and clinical relevance of sensorimotor deficits in LE. It should be noted that treatment evaluated in this study did not specifically target sensorimotor function, and further investigation into the significance of sensorimotor deficits in patients with LE is required.

Bilateral thumb's active range of motion and strength in de Quervain's disease: comparison with a normal sample

The aims of the present study were to characterize the thumb active range of motion (AROM) and strength impairments resulting from unilateral de Quervain's disease; to verify the adequacy of standard clinical assessment tools to quantify impairments resulting from this pathology; and to validate the utilization of the asymptomatic thumb as a reference to quantify the symptomatic thumb's deficits by comparing the performances of asymptomatic to control thumbs. The thumb's AROM and strength were evaluated bilaterally in 31 participants with unilateral de Quervain's disease and 18 control participants using clinical assessments involving the flexors and adductors of the thumb and experimental assessment devices measuring strength and mobility in several directions of the thumb's movements. A comparison was made between the results obtained from the symptomatic, asymptomatic, and control thumbs. The AROM performance of symptomatic thumbs was found to be reduced when compared to the asymptomatic and control thumbs for maximal thumb flexion (p=0.008 and 0.003, respectively) and total circumduction displacement (p<0.001). The strength performance of the symptomatic thumb was also found to be reduced when compared to the asymptomatic and control thumbs for palmar pinch strength (p<0.001 and 0.002, respectively) and for maximal voluntary effort in all directions (p<0.001). Differences in performance were also found between the asymptomatic and control thumbs, reaching the significance level for some movement parameters of the thumb circumduction evaluations and when palmar pinch strength results are normalized (p<0.001 and 0.009, respectively). This study revealed bilateral impairments of thumb AROM and strength for participants with de Quervain's disease, the impairments being more pronounced on the symptomatic side. This finding may question the validity of using the asymptomatic thumb as a standard measure to identify the symptomatic thumb's impairments associated with de Quervain's disease. The study also demonstrated the validity of using clinical evaluations when assessing impairments associated with this disease.

Poorer elbow proprioception in patients with lateral epicondylitis than in healthy controls: a cross-sectional study

Two groups of women, 15 patients with lateral epicondylitis and 21 healthy controls, were studied to compare proprioception in the elbows and knees between the groups. Outcome measures were absolute error and variable error for joint position sense and for threshold to detection of a passive movement. Both absolute error and variable error of threshold to detection of a passive movement were greater in the lateral epicondylitis-diagnosed elbows than in the controls' elbows (lateral epicondylitis, 1.8 degrees vs controls 1.1 degrees, P = .026; lateral epicondylitis, 0.8 degrees vs controls 0.3 degrees, P = .015), and there was a tendency toward a greater absolute error of joint position sense compared with the control elbows (lateral epicondylitis, 8.2 degrees vs controls, 5.6 degrees; P = .078). Absolute error of joint position sense was greater in the elbows than in the knees of the lateral epicondylitis patients, but no group differences were found for knees. Proprioception seems, therefore, to be poorer in elbows with lateral epicondylitis elbows than in the controls' elbows. This needs to be taken into consideration in the management of lateral epicondylitis.

An isokinetic eccentric programme for the management of chronic lateral epicondylar tendinopathy

BACKGROUND

Lateral epicondylitis represents a frequent overuse injury. In spite of many conservative treatment procedures, prolonged symptoms and relapse are frequently observed.

OBJECTIVE

To compare the outcome of patients performing an isokinetic eccentric training with that of age-, gender-, activity-matched patients receiving a non-strengthening classical rehabilitation.

METHODS

Ninety-two patients with unilateral chronic lateral epicondylar tendinopathy (mean duration of symptoms 8+/-3 months) were assigned either to a control group (n = 46) or to an eccentrically trained group (n = 46). The control group underwent a passive standardised rehabilitation programme that excluded strengthening exercises. In addition to this programme, the trained group also performed eccentric exercises based on the repetitive lengthening of the active musculo-tendinous unit. The latter exercises started with submaximal contraction intensity and slow speed movement. Modalities were progressively intensified (increase in intensity contraction and speed movement) over a long period of treatment. Programme effectiveness was assessed through pain score evaluation, a disability questionnaire, muscle strength measurement and ultrasonographic examination.

RESULTS

Compared to the non-strengthening control group, the following observations were made in the eccentrically trained group: (1) a significantly more marked reduction of pain intensity, mainly after one month of treatment; (2) an absence of strength deficit on the involved side through bilateral comparison for the forearm supinator and wrist extensor muscles; (3) an improvement of the tendon image as demonstrated by decreasing thickness and a recovered homogenous tendon structure; and (4) a more marked improvement in disability status during occupational, spare time and sports activities.

CONCLUSION

These results highlight the relevance of implementing isokinetic adapted eccentric training in the management of chronic lateral epicondylar tendinopathy.

Assessment of fine motor control in patients with occupation-related lateral epicondylitis

Lateral epicondylitis (LE) is a common overuse injury related to a mechanical overload of the wrist extensors' origin; however, some patients also complain of clumsiness suggesting a possible motor control problem. The purpose of this study was to examine for differences in fine motor control ability between subjects with LE and matched control subjects. Subtests of the Purdue Pegboard Test (PPT) and the Complete Manual Dexterity Test (CMDT) were administered to 28 subjects with LE, and 28 age, gender, and hand dominance-matched control subjects. The LE group demonstrated a significant decrease in fine motor control ability on both measures, compared with the control group on both the PPT, F(1,52)=9.98, P=0.003, and the CMDT, F(1,52)=18.11, P=0.001. There appeared to be no effect for the length of time since injury. There were significant differences in fine motor control ability between individuals with LE and a matched control group for both measures used. These results suggest that tests of fine motor control should be considered in the assessment of clients with LE. The mechanism related to the deficit is unknown and warrants further research.

Bilateral Sensorimotor Abnormalities in Unilateral Lateral Epicondylalgia

OBJECTIVE

To evaluate impairments in motor function of the upper limb in unilateral lateral epicondylalgia.

DESIGN

Assessor-blinded, case-controlled study.

SETTING

University laboratory.

PARTICIPANTS

Forty participants with lateral epicondylalgia and 40 age- and sex-matched controls were recruited from the general community.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Wrist posture adopted during a grip test, grip strength force, as well as upper-limb reaction times and speed of movement.

RESULTS

Participants with unilateral lateral epicondylalgia adopted wrist postures that were on average 11 degrees less extended, bilaterally, than controls (P<.000). This was paralleled by increased upper-limb reaction times and reduced speed of movement (mean differences, 2%-15%) in both affected and unaffected limbs. Pain-free grip strength was reduced on the involved side (mean difference, 170N; 95% confidence interval, 144-195N).

CONCLUSIONS

Motor deficits may be modifiable through exercise and postural retraining. Although further work is required to evaluate the clinical efficacy of such an approach, health care practitioners have an emerging evidence base on which to base their management of lateral epicondylalgia.

Sensory and motor effects of experimental muscle pain in patients with lateral epicondylalgia and controls with delayed onset muscle soreness

This study compares the effect of experimental muscle pain on deep tissue sensitivity and force attenuation in the wrist extensors of patients with lateral epicondylalgia (n=20), and healthy controls (n=20) with experimentally induced sensori-motor characteristics simulating lateral epicondylalgia. Delayed onset muscle soreness (DOMS) in wrist extensors of healthy controls was induced by eccentric exercise in one arm 24h prior to injection (Day 0). Saline-induced pain intensity (visual analogue scale, VAS), distribution, and quality were assessed quantitatively in both arms for both groups. Pressure pain thresholds (PPT) were assessed at three different sites in the wrist extensors. Maximal grip force and wrist extension force were recorded. In response to saline-induced pain in the extensor carpi radialis brevis, regardless of arm, the patient group demonstrated a significantly quicker pain onset (P<0.01), mapped larger pain areas and more referred pain areas, compared to healthy controls (P<0.03). Pain persisted significantly longer in the sore arm of the patient group, compared with all other arms (P<0.02). Patients demonstrated significant bilateral hyperalgesia at extensor carpi radialis brevis during and post saline-induced pain compared to pre-injection and healthy controls (P<0.04). The sore arm in patients and the DOMS arms in healthy subjects showed significantly reduced maximal force (P<0.0001), at all Day 1 times compared with the control arms. In patients, the bilateral increase in deep tissue sensitivity and enlarged referred pain areas during saline-induced pain might suggest involvement of central sensitisation.

Effectiveness of manual physical therapy to the cervical spine in the management of lateral epicondylalgia: a retrospective analysis

DESIGN

Retrospective ex-post facto design.

OBJECTIVES

To retrospectively review the management of patients with lateral epicondylalgia, and to compare self-reported outcomes to assess the potential benefit of manual physical therapy to the cervical spine.

BACKGROUND

It has been postulated that dysfunction of the cervical spine may contribute to the symptoms associated with lateral epicondylalgia; however, the literature assessing the effectiveness of manual physical therapy to the cervicothoracic region in this patient population has been inconclusive. Documentation and analysis of outcomes of management strategies focusing on the cervical spine may lead to determining the most effective and efficient clinical practices.

METHODS AND MEASURES

Of the 213 charts reviewed, 112 satisfied inclusion-exclusion criteria and were divided into 2 groups: those who received treatment solely directed at the elbow (local management [LM]), or those who received treatment directed at the elbow and cervical manual therapy (LM+C). Telephone follow-up interviews were used to determine the number of successful outcomes. Percentages of successful outcomes in each group were compared using chi-square analysis. An independent samples t test was used to compare the total number of visits per group.

RESULTS

Sixty-one of the 112 patients were in the LM group, while 51 received LM+C. Seventy five percent of the patients available for follow-up in the LM group and 80% in the LM+C group reported a successful outcome. Patients in the LM group received a greater number of visits (mean, 9.7; SD, 2.4) than patients in the LM+C group (mean, 5.6; SD, 1.7; P<.01).

CONCLUSIONS

The results of this retrospective review suggest that most patients had successful outcomes regardless of the inclusion of manual therapy interventions to the cervical spine. The LM+C group achieved the successful long-term outcome in significantly fewer visits.

The immediate effects of tension of counterforce forearm brace on neuromuscular performance of wrist extensor muscles in subjects with lateral humeral epicondylosis

STUDY DESIGN

Within-subject repeated-measures study.

OBJECTIVES

To examine the immediate effects of counterforce forearm brace on isokinetic strenght stretch reflex, passive stretching pain threshold of the wrist extensors, and proprioception of the wrist in subjects with lateral humeral epicondylosis for different strap tensions of a forearm brace.

BACKGROUND

Counterforce forearm bracing has been used for treating lateral humeral epicondylosis, but the effect of brace tension has not been well reported.

METHODS AND MEASURES

Fifteen subjects diagnosed with lateral humeral epicondylosis on their dominant arm were tested under 4 randomized conditions: (1) no brace, (2) brace with minimal tension, (3) brace with 25-N tension, and (4) brace with 50-N tension. The tests included isokinetic wrist extensors strength, passive stretching force in wrist flexion to elicit pain in the wrist extensors, wrist proprioception, and stretch reflex latency of the extensor carpi ulnari. A repeated-measures MANOVA was used to analyze the data and significant results were further analyzed with post hoc linear contrasts (alpha = .05).

RESULTS

Among the 4 conditions, significant differences were found in wrist proprioception P = .032) and pain threshold to passive stretching of the wrist extensors (P = .05), but were not found in wrist extension isokinetic strength and stretch reflex latency of the extensor carpi ulnaris.

CONCLUSION

A forearm counterforce brace, as applied in this study, affects wrist joint proprioception and increases the pain threshold to passive stretching of the wrist extensors in subjects with lateral humeral epicondylosis, but it has no effect on wrist extensor strength and stretch reflex latency of the extensor carpi ulnaris.

Lateral epicondylalgia: a musculoskeletal physiotherapy perspective

Tennis elbow or lateral epicondylalgia (LE) is a challenging musculoskeletal condition to treat. This is largely due to the lack of research-based evidence of the clinical efficacy of the myriad of treatment approaches espoused in the literature. In view of this, successful rehabilitation of LE is based on choosing treatments that address the physical impairments found during clinical examination. The primary physical impairment in LE is a deficit in grip strength predominately due to pain and its consequences on motor function. Hence the mainstay of successful management of this condition is therapeutic exercise, providing it is not pain provocative. Adjunctive procedures such as manipulative therapy and sports taping techniques have recently been shown to provide substantial initial pain relief. Early relief of pain in the rehabilitation program helps accelerate recovery and most importantly motivates the client to persist with the therapeutic exercise program. The manipulative therapy and taping treatments presented in this masterclass warrant consideration in the clinical best practice management of LE, and serve as a model for other similar musculoskeletal conditions.

Motor control impairment of the contralateral wrist in patients with unilateral chronic wrist pain

OBJECTIVE

Assessment of the quality of fine motor control in patients with unilateral chronic wrist pain seldom focuses on the possibility that control of movements is effector independent at the cerebral level. This mechanism may be involved in an impairment of motor function in the unaffected wrist. We studied the possible motor impairment in the unaffected wrist in patients with chronic wrist pain.

DESIGN

Eighteen patients with chronic wrist pain in their dominant hand and 20 healthy controls performed, using their nondominant hand, back-and-forth, left-to-right stroke patterns with a pen on a digital writing tablet connected to a computer. Fluency of movement, defined as the number of zero-crossings of the acceleration curve (pZC), average stroke size, and average velocity were calculated.

RESULTS

The controls moved significantly more fluently than the patients (pZC, 0.26+/-0.07 for controls and 0.46+/-0.20 for patients; P < 0.001), suggesting that long-term afferent disturbances may compromise cerebral motor control mechanisms.

CONCLUSIONS

This result is in accordance with the view that chronic pain complaints may be maintained by persistently abnormal cerebral motor control. This finding opens a new perspective on the understanding and treatment of chronic wrist pain.

Specific manipulative therapy treatment for chronic lateral epicondylalgia produces uniquely characteristic hypoalgesia

The treatment of lateral epicondylalgia, a widely-used model of musculoskeletal pain in the evaluation of many physical therapy treatments, remains somewhat of an enigma. The protagonists of a new treatment technique for lateral epicondylalgia report that it produces substantial and rapid pain relief, despite a lack of experimental evidence. A randomized, double blind, placebo-controlled repeated-measures study evaluated the initial effect of this new treatment in 24 patients with unilateral, chronic lateral epicondylalgia. Pain-free grip strength was assessed as an outcome measure before, during and after the application of the treatment, placebo and control conditions. Pressure-pain thresholds were also measured before and after the application of treatment, placebo and control conditions. The results demonstrated a significant and substantial increase in pain-free grip strength of 58% (of the order of 60 N) during treatment but not during placebo and control. In contrast, the 10% change in pressure-pain threshold after treatment, although significantly greater than placebo and control, was substantially smaller than the change demonstrated for pain-free grip strength. This effect was only present in the affected limb. The selective and specific effect of this treatment technique provides a valuable insight into the physical modulation of musculoskeletal pain and requires further investigation.

Mobilization with movement applied to the elbow affects shoulder range of movement in subjects with lateral epicondylalgia

Clinical observations have suggested a relationship between shoulder range of movement (ROM) and lateral epicondylalgia. This study reports the effect of a single intervention of a mobilization with movement (MWM) applied to the elbow, on shoulder rotation ROM in subjects with lateral epicondylalgia. Twenty-three subjects with lateral epicondylalgia were included. In a one-group pretest-post-test design, ROM of shoulder internal and external rotation were measured by goniometer before and after the application of the MWM, of both the unaffected and the affected limbs. Significant differences in pre-intervention external rotation ROM were found between unaffected and affected shoulders of subjects with lateral epicondylalgia, but no significant difference remained post-intervention. It may be concluded that restriction of shoulder rotation ROM is present in patients with lateral epicondylalgia, probably due to a facilitated level of shoulder rotator muscle tone. Shoulder internal and external rotation ROM increases significantly following MWM to the elbow, in subjects with unilateral lateral epicondylalgia. Surprisingly, these ROM increases are also apparent on the 'unaffected' limb. These findings suggest that the MWM causes a neurophysiologically mediated decrease in resting muscle tone.

Chronic lateral epicondylitis of the elbow: A prospective study of low-energy shockwave therapy and low-energy shockwave therapy plus manual therapy of the cervical spine

OBJECTIVE

To compare the effects of extracorporeal shockwave therapy (ESWT) alone with a combination of ESWT and manual therapy of the cervical spine in treating chronic tennis elbow.

DESIGN

Prospective, matched single-blind control trial.

SETTING

University hospital clinic.

PATIENTS

Thirty patients with unilateral chronic tennis elbow, an unsuccessful conservative therapy during the 6 months before referral, and clinical signs of cervical dysfunction (eg, pressure pain at the C4-5 and/or C5-6 level, protraction of the head).

INTERVENTIONS

Three times at weekly intervals all patients received 1000 shockwave impulses of an energy flux density of.16mJ/mm(2) at the lateral elbow. Additionally, they underwent manual therapy of the cervical spine and the cervicothoracic junction 10 times (group I). For each patient, a control matched by age (3-yr range) and gender at first conservative treatment was drawn at random from 127 patients who had undergone low-energy shockwave therapy in the same unit in the past 3 years (group II). Follow-up examinations took place at 12 weeks and at 12 months.

MAIN OUTCOME MEASURES

The Roles and Maudsley outcome score at 12 months, defining an excellent or good result with no or only occasional discomfort without limitation of activity and range of motion.

RESULTS

Neither group differed statistically before the study, with a poor rating for all patients (p >.05). At 12 months, there was still no significant difference, with the outcome being excellent or good in 56% in group I, and in 60% in group II (p >.05). Each group showed significant improvement compared with the respective prestudy evaluation (p <.0001).

CONCLUSION

ESWT may be an effective conservative treatment method for unilateral chronic tennis elbow. The efficacy of additional cervical manual therapy for lateral epicondylitis remains questionable.

Fine motor assessment in chronic wrist pain: the role of adapted motor control

OBJECTIVE

To show whether a difference in fine motor control exists between patients with chronic, undiagnosed wrist pain (CUWP) and healthy controls. Furthermore, a method to assess fine motor function of the wrist is evaluated.

DESIGN

A case-control study.

SETTING

The Academic Medical Center in Amsterdam, the Netherlands.

SUBJECTS

Twenty-seven CUWP patients were compared with 50 healthy control subjects.

INTERVENTIONS

Subjects performed horizontal stroke patterns on a digital writing tablet connected to a computer. The control subjects were tested twice to obtain test-retest reliability. A visual analogue scale was used to assess subjective pain.

MAIN OUTCOME MEASURES

Fluency of movement and average velocity were measured. Intraclass correlation, ANOVA repeated measures statistics and Pearson correlation were calculated.

RESULTS

There is a significant difference in fluency of motion between patients and controls, possibly due to a disturbed motor control, since there is no relationship between pain and test score, nor do CUWP patients have any abnormality in the wrist that can explain the disturbance in motor function. The test method is reliable (ICC = 0.78) and valid.

CONCLUSIONS

The disturbed fine motor control in CUWP patients is suggested to maintain chronic wrist pain through 'strain injury, causing' pain evasive adaptation of the motor control system. This might lead to new perspectives regarding treatment of CUWP patients.