A systematic review of the effectiveness of manipulative therapy in treating lateral epicondylalgia

Manual therapy and exercise for lateral elbow pain

BACKGROUND

Manual therapy and prescribed exercises are often provided together or separately in contemporary clinical practice to treat people with lateral elbow pain.

OBJECTIVES

To assess the benefits and harms of manual therapy, prescribed exercises or both for adults with lateral elbow pain.

SEARCH METHODS

We searched the databases CENTRAL, MEDLINE and Embase, and trial registries until 31 January 2024, unrestricted by language or date of publication.

SELECTION CRITERIA

We included randomised or quasi-randomised trials. Participants were adults with lateral elbow pain. Interventions were manual therapy, prescribed exercises or both. Primary comparators were placebo or minimal or no intervention. We also included comparisons of manual therapy and prescribed exercises with either intervention alone, with or without glucocorticoid injection. Exclusions were trials testing a single application of an intervention or comparison of different types of manual therapy or prescribed exercises.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted trial characteristics and numerical data, and assessed study risk of bias and certainty of evidence using GRADE. The main comparisons were manual therapy, prescribed exercises or both compared with placebo treatment, and with minimal or no intervention. Major outcomes were pain, disability, heath-related quality of life, participant-reported treatment success, participant withdrawals, adverse events and serious adverse events. The primary endpoint was end of intervention for pain, disability, health-related quality of life and participant-reported treatment success and final time point for adverse events and withdrawals.

MAIN RESULTS

Twenty-three trials (1612 participants) met our inclusion criteria (mean age ranged from 38 to 52 years, 47% female, 70% dominant arm affected). One trial (23 participants) compared manual therapy to placebo manual therapy, 12 trials (1124 participants) compared manual therapy, prescribed exercises or both to minimal or no intervention, six trials (228 participants) compared manual therapy and exercise to exercise alone, one trial (60 participants) compared the addition of manual therapy to prescribed exercises and glucocorticoid injection, and four trials (177 participants) assessed the addition of manual therapy, prescribed exercises or both to glucocorticoid injection. Twenty-one trials without placebo control were susceptible to performance and detection bias as participants were not blinded to the intervention. Other biases included selection (nine trials, 39%, including two quasi-randomised), attrition (eight trials, 35%) and selective reporting (15 trials, 65%) biases. We report the results of the main comparisons. Manual therapy versus placebo manual therapy Low-certainty evidence, based upon a single trial (23 participants) and downgraded due to indirectness and imprecision, indicates manual therapy may reduce pain and elbow disability at the end of two to three weeks of treatment. Mean pain at the end of treatment was 4.1 points with placebo (0 to 10 scale) and 2.0 points with manual therapy, MD -2.1 points (95% CI -4.2 to -0.1). Mean disability was 40 points with placebo (0 to 100 scale) and 15 points with manual therapy, MD -25 points (95% CI -43 to -7). There was no follow-up beyond the end of treatment to show if these effects were sustained, and no other major outcomes were reported. Manual therapy, prescribed exercises or both versus minimal intervention Low-certainty evidence indicates manual therapy, prescribed exercises or both may slightly reduce pain and disability at the end of treatment, but the effects were not sustained, and there may be little to no improvement in health-related quality of life or number of participants reporting treatment success. We downgraded the evidence due to increased risk of performance bias and detection bias across all the trials, and indirectness due to the multimodal nature of the interventions included in the trials. At four weeks to three months, mean pain was 5.10 points with minimal treatment and manual therapy, prescribed exercises or both reduced pain by a MD of -0.53 points (95% CI -0.92 to -0.14, I2 = 43%; 12 trials, 1023 participants). At four weeks to three months, mean disability was 63.8 points with minimal or no treatment and manual therapy, prescribed exercises or both reduced disability by a MD of -5.00 points (95% CI -9.22 to -0.77, I2 = 63%; 10 trials, 732 participants). At four weeks to three months, mean quality of life was 73.04 points with minimal treatment on a 0 to 100 scale and prescribed exercises reduced quality of life by a MD of -5.58 points (95% CI -10.29 to -0.99; 2 trials, 113 participants). Treatment success was reported by 42% of participants with minimal or no treatment and 57.1% of participants with manual therapy, prescribed exercises or both, RR 1.36 (95% CI 0.96 to 1.93, I2 = 73%; 6 trials, 770 participants). We are uncertain if manual therapy, prescribed exercises or both results in more withdrawals or adverse events. There were 83/566 participant withdrawals (147 per 1000) from the minimal or no intervention group, and 77/581 (126 per 1000) from the manual therapy, prescribed exercises or both groups, RR 0.86 (95% CI 0.66 to 1.12, I2 = 0%; 12 trials). Adverse events were mild and transient and included pain, bruising and gastrointestinal events, and no serious adverse events were reported. Adverse events were reported by 19/224 (85 per 1000) in the minimal treatment group and 70/233 (313 per 1000) in the manual therapy, prescribed exercises or both groups, RR 3.69 (95% CI 0.98 to 13.97, I2 = 72%; 6 trials).

AUTHORS' CONCLUSIONS

Low-certainty evidence from a single trial in people with lateral elbow pain indicates that, compared with placebo, manual therapy may provide a clinically worthwhile benefit in terms of pain and disability at the end of treatment, although the 95% confidence interval also includes both an important improvement and no improvement, and the longer-term outcomes are unknown. Low-certainty evidence from 12 trials indicates that manual therapy and exercise may slightly reduce pain and disability at the end of treatment, but this may not be clinically worthwhile and these benefits are not sustained. While pain after treatment was an adverse event from manual therapy, the number of events was too small to be certain.

Efficacy of neural mobilization and Maitland accessory mobilization in patients with tennis elbow- randomized controlled trial

OBJECTIVE

The objective of the study was to evaluate the efficacy of Maitland accessory mobilization and neural mobilization in patients with tennis elbow.

METHOD

Twenty-five patients meeting the selection criteria were randomly assigned to three experimental groups: Group C (conventional treatment), Group B (neural mobilization), and Group A (Maitland mobilization). Quality of life was assessed using the Patient Rated Tennis Elbow Evaluation (PRTEE), while pain, range of motion, and grip strength were evaluated using the Visual Analog Scale (VAS), a universal goniometer, and a handheld dynamometer. The interventions were administered three times per week for four weeks to the respective groups.

RESULTS

Non-parametric tests were employed to analyze the results due to the non-normal distribution of the data (p < 0.05). Both the Wilcoxon signed-rank test and the Kruskal-Wallis test were utilized to assess differences within and between groups. The results of the between-group analysis demonstrated significant differences in pain (p = 0.018) and quality of life (p = 0.045) among the three groups.

CONCLUSION

After a 4-week intervention, all three groups exhibited notable improvements in discomfort levels, grip strength, and quality of life. Notably, Group B demonstrated the most substantial increase in range of motion (ROM) compared to Groups A and C. Consequently, incorporating neural mobilization into the treatment plan is recommended for patients experiencing Tennis Elbow.

Effects of a Conventional Treatment Plus Scapular Exercises Program in Patients With Chronic Lateral Elbow Tendinopathy: A Pre-Post Single-Group Study

BACKGROUND

Weakness of the shoulder girdle muscles has been reported in patients with chronic lateral elbow tendinopathy. The aim of this study was to assess the short- and long-term effects of a conventional treatment plus scapular exercises program in patients with chronic lateral elbow tendinopathy.

METHODS

A single-group prestudy and poststudy were conducted. The primary outcome was the Patient-Rated Tennis Elbow Evaluation questionnaire score. Secondary outcomes were grip strength; Disabilities of the Arm, Shoulder, and Hand questionnaire score; Visual Analogue Scale score at rest and at grip, and presence of scapular dyskinesis.

RESULTS

A total of 65 patients (72.3% females), with a mean age of 41.8 years, were analyzed. At the end of 6 weeks, the results showed clinically and statistically significant differences (P < .05). At 1-year follow-up, the differences were: Patient-Rated Tennis Elbow Evaluation -31 points (P < .001); grip strength +33.6% (P < .001); Disabilities of the Arm, Shoulder, and Hand -34.2 points (P < .001); Visual Analogue Scale at rest -2.5 cm (P < .001); and Visual Analogue Scale at grip -2.3 cm (P < .001).

CONCLUSION

At the end of 6 weeks and at 1-year follow-up, conventional treatment plus scapular exercises program showed statistically and clinically significant differences in all functional outcomes assessed in patients with lateral elbow tendinopathy.

A Review of Physiotherapy Techniques Used in the Treatment of Tennis Elbow

Tennis elbow, a common musculoskeletal disorder also known as lateral epicondylitis, causes pain and tenderness on the outside of the elbow. Although it is frequently linked to repetitive motions, such as those in racquet sports, it can affect people in a variety of occupations and activities. Tennis elbow can be treated conservatively with physiotherapy, which focuses on pain management, functional recovery, and recurrence prevention. The goal of this review is to give a thorough overview of the physiotherapy methods used to treat tennis elbow. In order to determine the most effective treatment options, it is crucial to comprehend the pathophysiology and etiology of tennis elbow from the outset of the study. The assessment and diagnosis of tennis elbow are next covered, emphasizing the importance of physiotherapists in correctly diagnosing the ailment and distinguishing it from other musculoskeletal problems that are comparable to it. This study primarily focuses on the numerous physiotherapy therapies for tennis elbow, which may include but are not limited to, and the section examines the use of manual treatments to treat pain and enhance joint function, including joint mobilizations, soft tissue massage, and myofascial release. Exercise rehabilitation covers the value of tailored workouts to bolster the weak muscles and enhance the elbow joint's biomechanics. Numerous workout regimens are covered, such as eccentric training and progressive resistance exercises, as well as modalities. Therapeutic agents frequently make use of modalities such as ultrasound, laser therapy, and cryotherapy. It may also make use of complementary therapeutic agents such as taping and bracing. In summary, this in-depth analysis highlights the crucial role that physical therapy plays in the treatment of tennis elbow. It seeks to give practitioners a useful tool for enhancing the care and results of patients with this common and crippling ailment by summarizing the most recent research and best practices in physiotherapy approaches.

Lateral Elbow Pain and Muscle Function Impairments

Although often described as a self-limiting condition and likely to resolve on its own, high recurrence rates and extended sick leave frame a need for effective non-surgical treatment for people with lateral elbow tendinopathy. The interrelationship of histological and structural changes to the tendon, the associated impairments in motor control, and potential changes in pain processing may all drive symptoms. This clinical practice guideline covers the epidemiology, functional anatomy and pathophysiology, risk factors, clinical course, prognosis, differential diagnosis, tests and measures, and interventions for managing lateral elbow tendinopathy in the physical therapy clinic. J Orthop Sports Phys Ther 2022;52(12):CPG1-CPG111. doi:10.2519/jospt.2022.0302.

Treatment, Diagnostic Criteria and Variability of Terminology for Lateral Elbow Pain: Findings from an Overview of Systematic Reviews

Background: Lateral elbow pain (LEP) represents a musculoskeletal disorder affecting the epicondyloid region of the elbow. The terminological framework of this problem in literature, to date, is confusing. This systematic review (SR) aims to analyse the panorama of the scientific literature concerning the pathogenetic framework, treatment, and clinical diagnosis of LEP. Methods: We conducted an SR according to the guidelines of the PRISMA statement. We performed research using the electronic Medline, Epistemonikos, and Cochrane Library databases. The research started on 12 January 2022 and finished on 30 April 2022. We included all systematic reviews and meta-analyses published, in English, between 1989 and 2022. The articles’ selection was based on critical appraisal using Amstar 2. In the selected reviews we obtained the etiopathogenic terminology used to describe the symptoms, treatment, and diagnostic criteria of LEP. Results: Twenty-five SRs met the eligibility criteria and were included in the study. From these SRs, 227 RCT articles were analysed and different treatments proposals were extracted, such as exercise, manipulation corticosteroid injection, and surgery. In the selected articles, 10 different terms emerged to describe LEP and 12 different clinical tests. The most common treatments detected in this SR were a conservative multimodal approach (e.g., eccentric exercises, manual therapy, acupuncture, ultrasound), then surgery or other invasive treatments (e.g., corticosteroid injection, tenotomy). The most common term detected in this SR was “lateral epicondylitis” (n = 95, 51.6%), followed by “tennis elbow” (n = 51, 28.1%) and “lateral epicondylalgia” (n = 18, 9.4%). Among the diagnostic tests were painful palpation (n = 101, 46.8%), the Cozen test (n = 91, 42.1%), the pain-free grip-strength test (n = 41, 19.0%), and the Maudsley test (n = 48, 22.2%). A total of 43.1% of RCTs (n = 96) included subjects with LEP > 3 months, 40.2% (n = 85) included patients with LEP < 3 months, and 16.7% of the items (n = 35) were not specified by the inclusion criteria on the onset of symptoms. Conclusions: In this SR, a considerable terminological heterogeneity emerged in the description of LEP, associated with the lack of clear and recognised diagnostic criteria in evaluating and treating patients with lateral elbow pain.

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lateral epicondylitis of the humerus - Secondary publication

BACKGROUND

The guidelines presented herein provide recommendations for the management of patients with lateral epicondylitis of the humerus. These recommendations are endorsed by the Japanese Orthopaedic Association (JOA) and Japan Elbow Society.

METHODS

The JOA lateral epicondylitis guideline committee revised the previous guidelines on the basis of the "Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014", which emphasized the importance of the balance between benefit and harm, and proposed a desirable method for preparing clinical guidelines in Japan. These guidelines consist of 11 clinical questions (CQs), 9 background questions (BQs), and 3 future research questions (FRQs). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design.

RESULTS

The committee proposed recommendations for each CQ by determining the level of evidence and assessing the consensus rate. Physical therapy was the best recommendation with the best evidence. The BQs and FRQs were answered by collecting evidence based on the literature.

CONCLUSIONS

The guidelines presented herein were reviewed systematically, and recommendations were proposed for each CQ. These guidelines are expected to be widely used not only by surgeons or physicians but also by other healthcare providers, such as nurses, therapists, and athletic trainers.

The Effects of the Mulligan Concept on Adults With Lateral Epicondylalgia Compared With Traditional Physiotherapy: A Critically Appraised Topic

Focused Clinical Question: What are the effects of the Mulligan Concept combined with traditional physiotherapy on lateral elbow pain and grip strength in adults with lateral epicondylalgia (LE) compared with traditional physiotherapy? Clinical Bottom Line: Grade B evidence supports positive effects of the Mulligan Concept combined with traditional physiotherapy on LE compared with traditional physiotherapy alone. However, the effects of the Mulligan Concept as a standalone intervention in the treatment of LE are not well known. Therefore, additional research is warranted to determine the individual effects of the Mulligan Concept compared with its use in a comprehensive rehabilitation protocol to treat LE in adults.

The analgesic effect of joint mobilization and manipulation in tendinopathy: a narrative review

Objective: To summarize the available literature with regards to the potential analgesic effect and mechanism of joint mobilization and manipulation in tendinopathy. Results: The effect of these techniques in rotator cuff tendinopathy and lateral elbow tendinopathy, applied alone, compared to a placebo intervention or along with other interventions has been reported in some randomized controlled trials which have been scrutinized in systematic reviews. Due to the small randomized controlled trials and other methodological limitations of the evidence base, including short-term follow-ups, small sample size and lack of homogenous samples further studies are needed. Literature in other tendinopathies such as medial elbow tendinopathy, de Quervain's disease and Achilles tendinopathy is limited since the analgesic effect of these techniques has been identified in few case series and reports. Therefore, the low methodological quality renders caution in the generalization of findings in clinical practice. Studies on the analgesic mechanism of these techniques highlight the activation of the descending inhibitory pain mechanism and sympathoexcitation although this area needs further investigation. Conclusion: Study suggests that joint mobilization and manipulation may be a potential contributor in the management of tendinopathy as a pre-conditioning process prior to formal exercise loading rehabilitation or other proven effective treatment approaches.

Autologous blood and platelet-rich plasma injection therapy for lateral elbow pain

BACKGROUND

Autologous whole blood or platelet-rich plasma (PRP) injections are commonly used to treat lateral elbow pain (also known as tennis elbow or lateral epicondylitis or epicondylalgia). Based on animal models and observational studies, these injections may modulate tendon injury healing, but randomised controlled trials have reported inconsistent results regarding benefit for people with lateral elbow pain.

OBJECTIVES

To review current evidence on the benefit and safety of autologous whole blood or platelet-rich plasma (PRP) injection for treatment of people with lateral elbow pain.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase for published trials, and Clinicaltrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal for ongoing trials, on 18 September 2020.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) and quasi-RCTs comparing autologous whole blood or PRP injection therapy to another therapy (placebo or active treatment, including non-pharmacological therapies, and comparison between PRP and autologous blood) for lateral elbow pain. The primary comparison was PRP versus placebo. Major outcomes were pain relief (≥ 30% or ≥ 50%), mean pain, mean function, treatment success, quality of life, withdrawal due to adverse events, and adverse events; the primary time point was three months.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 32 studies with 2337 participants; 56% of participants were female, mean age varied between 36 and 53 years, and mean duration of symptoms ranged from 1 to 22 months. Seven trials had three intervention arms. Ten trials compared autologous blood or PRP injection to placebo injection (primary comparison). Fifteen trials compared autologous blood or PRP injection to glucocorticoid injection. Four studies compared autologous blood to PRP. Two trials compared autologous blood or PRP injection plus tennis elbow strap and exercise versus tennis elbow strap and exercise alone. Two trials compared PRP injection to surgery, and one trial compared PRP injection and dry needling to dry needling alone. Other comparisons include autologous blood versus extracorporeal shock wave therapy; PRP versus arthroscopic surgery; PRP versus laser; and autologous blood versus polidocanol. Most studies were at risk of selection, performance, and detection biases, mainly due to inadequate allocation concealment and lack of participant blinding. We found moderate-certainty evidence (downgraded for bias) to show that autologous blood or PRP injection probably does not provide clinically significant improvement in pain or function compared with placebo injection at three months. Further, low-certainty evidence (downgraded for bias and imprecision) suggests that PRP may not increase risk for adverse events. We are uncertain whether autologous blood or PRP injection improves treatment success (downgraded for bias, imprecision, and indirectness) or withdrawals due to adverse events (downgraded for bias and twice for imprecision). No studies measured health-related quality of life, and no studies reported pain relief (> 30% or 50%) at three months. At three months, mean pain was 3.7 points (0 to 10; 0 is best) with placebo and 0.16 points better (95% confidence interval (CI) 0.60 better to 0.29 worse; 8 studies, 523 participants) with autologous blood or PRP injection, for absolute improvement of 1.6% better (6% better to 3% worse). At three months, mean function was 27.5 points (0 to 100; 0 is best) with placebo and 1.86 points better (95% CI 4.9 better to 1.25 worse; 8 studies, 502 participants) with autologous blood or PRP injection, for absolute benefit of 1.9% (5% better to 1% worse), and treatment success was 121 out of 185 (65%) with placebo versus 125 out of 187 (67%) with autologous blood or PRP injection (risk ratio (RR) 1.00; 95% CI 0.83 to 1.19; 4 studies, 372 participants), for absolute improvement of 0% (11.1% lower to 12.4% higher). Regarding harm, we found very low-certainty evidence to suggest that we are uncertain whether withdrawal rates due to adverse events differed. Low-certainty evidence suggests that autologous blood or PRP injection may not increase adverse events compared with placebo injection. Withdrawal due to adverse events occurred in 3 out of 39 (8%) participants treated with placebo versus 1 out of 41 (2%) treated with autologous blood or PRP injection (RR 0.32, 95% CI 0.03 to 2.92; 1 study), for an absolute difference of 5.2% fewer (7.5% fewer to 14.8% more). Adverse event rates were 35 out of 208 (17%) with placebo versus 41 out of 217 (19%) with autologous blood or PRP injection (RR 1.14, 95% CI 0.76 to 1.72; 5 studies; 425 participants), for an absolute difference of 2.4% more (4% fewer to 12% more). At six and twelve months, no clinically important benefit for mean pain or function was observed with autologous blood or PRP injection compared with placebo injection.

AUTHORS' CONCLUSIONS

Data in this review do not support the use of autologous blood or PRP injection for treatment of lateral elbow pain. These injections probably provide little or no clinically important benefit for pain or function (moderate-certainty evidence), and it is uncertain (very low-certainty evidence) whether they improve treatment success and pain relief > 50%, or increase withdrawal due to adverse events. Although risk for harm may not be increased compared with placebo injection (low-certainty evidence), injection therapies cause pain and carry a small risk of infection. With no evidence of benefit, the costs and risks are not justified.

Effects of Interactive Videogames on Postural Control and Risk of Fall Outcomes in Frail and Pre-frail Older Adults: A Systematic Review and Meta-Analysis

Background: Interactive videogames (IVGs) have been used to reduce risk of falls in the older adult and improve postural control (PC) outcomes. Objective: To systematically review trials that examine whether IVGs training is effective in improving PC and managing falls in frail and pre-frail older adults. Data Sources: Four databases were searched, Scopus, Web of science, PubMed, and MEDLINE, from January 2007 to March 2019. Eligibility Criteria: Frail and pre-frail older adults aged 65+. Interventions were any Nintendo^® Wii™ training. The outcome measures were PC and risk of falls as measured by any validated outcome measure. Studies Appraisal Method: The PEDro (Physiotherapy Evidence Database) scale and Cochrane risk-of-bias tool were used by two independent authors. Results: Eleven papers were included, involving 388 participants, with a mean age of 79 ± 5.7 years. The mean duration of IVGs sessions was 8.8 ± 3.8 weeks, the mean total number of sessions was 20 ± 11.1 session, and the mean length of training was 44 ± 15.7 minutes. Meta-Analysis: IVGs achieved better results compared with traditional exercises and control on the Berg Balance Scale (mean difference [MD] 2.80; 95% confidence interval [CI] 1.21 to 4.39; P < 0.001; I² = 16%), as well as in the short term on Timed Up and Go (MD -1.23; 95% CI -2.37 to -0.09; P = 0.03; I² = 0%). Limitation: Definitive judgement could not be made due to the variability in training, training duration and outcomes measurement. Conclusion: IVGs is a promising modality that has a positive effect on PC but not on the outcome of falls, so it should be prescribed with caution among frail older adults. Systematic Review Registration: PROSPERO registration number: CRD42019129611.

The effect of lumbar spine manipulation on pain and disability in Achilles tendinopathy. A case report

BACKGROUND/PURPOSE

Cervical and thoracic spine manipulation has been found to reduce tendon pain and disability in lateral epicondylalgia and rotator cuff tendinopathy. Based on these findings, the application of lumbar spine manipulation may also provide similar improvements in Achilles tendinopathy (AT). Therefore, the purpose of this study was to evaluate the effect of lumbar spine manipulation on pain and disability in a patient experiencing AT.

CASE DESCRIPTION

A 44 years old male ex-football player presented with a 20-year history of persistent Achilles tendon pain (ATP) consistent with AT diagnosis. The patient attended 12 treatment sessions receiving a high-velocity, low amplitude lumbar spine manipulation. Outcome measures were collected at baseline, 2 weeks, 4 weeks, 3 months and 6 months and included pain in visual analogue scale, the American Orthopedic Foot and Ankle Score, the 36-Item Short Form Health Survey and the Victorian Institute of Sport Assessment-Achilles questionnaire. Pressure pain threshold was also assessed using an electronic pressure algometer.

OUTCOMES

Improvement in all outcome measures was noted 6-months post intervention. Outcome measures indicated substantial improvements in both the patient's pain and disability. The patient was able to perform activities of daily living without difficulties, suggesting higher level of function and quality of life at 6-months post initial evaluation.

CONCLUSION

These findings have demonstrated the positive effects of lumbar spine manipulation on ATP and disability. Further studies, specifically clinical trials investigating the effect of lumbar spine manipulation or combining this technique with exercises and functional activities are suggested.

The effects of Mulligan's mobilization with movement technique in patients with lateral epicondylitis

BACKGROUND

Lateral epicondylitis (LE) is a common problem of the arm. Mulligan has proposed the use of mobilization with movement for LE.

OBJECTIVES

To investigate the effects of Mulligan's mobilization with movement (MWM) in LE.

METHODS

Forty patients were included in the study and randomly assigned to group 1 (n= 20), who received MWM, exercise and cold therapy, or group 2 (n= 20), who received exercise and cold therapy. The sessions were conducted five times a week for two weeks. All measures were conducted at baseline, after treatment, at 1st and 3rd months follow-ups. Mann-Whitney U test, a visual analogue scale (VAS) for pain intensity, Patient-rated Tennis Elbow Evaluation (PRTEE) Questionnaire for pain intensity and functional disability and a dynamometer for hand grip strength were applied.

RESULTS

VAS activity pain significantly decreased in group 1 after treatment (p= 0.001), at the 1st (p< 0.001) and 3rd months (p= 0.040). There was a significant decrease in VAS night pain in group 1 (p= 0.024), and a significant increase in pain-free grip strength (p= 0.002) after treatment. PRTEE-Pain scores decreased in group 1 after treatment (p< 0.001), 1st (p< 0.001) and 3rd months (p= 0.001).

CONCLUSIONS

MWM plus exercise and cold therapy is a safe and effective alternative with positive effects on elbow pain, functional capacity, and pain-free, maximum grip strength.

The effect of manual therapy to the thoracic spine on pain-free grip and sympathetic activity in patients with lateral epicondylalgia humeri. A randomized, sample sized planned, placebo-controlled, patient-blinded monocentric trial

Background

The treatment of first choice for lateral epicondylalgia humeri is conservative therapy. Recent findings indicate that spinal manual therapy is effective in the treatment of lateral epicondylalgia. We hypothesized that thoracic spinal mobilization in patients with epicondylalgia would have a positive short–term effect on pain and sympathetic activity.

Methods

Thirty patients (all analyzed) with clinically diagnosed (physical examination) lateral epicondylalgia were enrolled in this randomized, sample size planned, placebo-controlled, patient-blinded, monocentric trial. Pain-free grip, skin conductance and peripheral skin temperature were measured before and after the intervention. The treatment group (15 patients) received a one-time 2-min T5 costovertebral mobilization (2 Hz), and the placebo group (15 patients) received a 2-min one-time sham ultrasound therapy.

Results

Mobilization at the thoracic spine resulted in significantly increased strength of pain-free grip + 4.6 kg ± 6.10 (p = 0.008) and skin conductance + 0.76 μS ± 0.73 (p = 0.000004) as well as a decrease in peripheral skin temperature by − 0.80 °C ± 0.35 (p < 0.0000001) within the treatment group.

Conclusion

A thoracic costovertebral T5 mobilization at a frequency of 2 Hz shows an immediate positive effect on pain-free grip and sympathetic activity in patients with lateral epicondylalgia.

Clinical trial registration

German clinical trial register DRKS00013964, retrospectively registered on 2.2.2018.

Potential Nervous System Sensitization in Patients With Persistent Lower Extremity Tendinopathies: 3 Case Reports

BACKGROUND

Tendinopathy is a condition often associated with pain and functional and sport performance limitations. While targeted exercise prescriptions are often effective, many patients with tendinopathy develop persistent symptoms. Emerging evidence suggests a possible link between nervous system sensitization and tendinopathy. If so, identifying and treating specific pain mechanisms may improve outcomes.

CASE DESCRIPTION

Three patients were seen in physical therapy for complaints of ongoing chronic tendon pain and self-reported disability, despite being treated previously and receiving evidence-informed care. Upon examination, each patient demonstrated signs consistent with possible dysfunction of central pain mechanisms. Joint mobilization, pain neuroscience education, and aerobic exercise were primary interventions in each case to decrease pain and improve function.

OUTCOMES

The 3 patients were treated for 5 sessions over the course of 8 weeks. Clinically significant improvement was noted in measures of pain, self-reported function, and pressure pain thresholds. At discharge, all patients were able to run without symptoms, and improvement was maintained at 1-year follow-up.

DISCUSSION

Tendinopathy, while often described as local pain and dysfunction, may be associated with dysfunction of the nervous system. Identifying and treating pain mechanisms in addition to relevant impairments may be an appropriate intervention approach for individuals with tendinopathy.

LEVEL OF EVIDENCE

Therapy, level 4. J Orthop Sports Phys Ther 2019;49(4):272-279. Epub 13 Feb 2019. doi:10.2519/jospt.2019.8600.

The effectiveness of exercise-based vestibular rehabilitation in adult patients with chronic dizziness: A systematic review

Background: Dizziness is a non-specific term used by patients to describe several symptoms ranging from true vertigo, light headedness, disorientation or sense of imbalance. Vestibular rehabilitation (VR) is a specific form of exercise-based therapy programme aimed at alleviating the primary and secondary problems of a vestibular pathology. The aim of this study was to investigate the effectiveness of exercise-based vestibular rehabilitation in adult patients with chronic dizziness.

Methods: The following five databases were searched: the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library), MEDLINE, PubMed, the Physiotherapy Evidence Database (PEDro) and Scopus (Elsevier). Two investigators independently reviewed all articles and a systematic review of literature was performed using the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). The articles were included if they met the following inclusion criteria: (1) randomised controlled trial, (2) people with chronic dizziness, (3) adults aged 18 or over, (4) exercise-based VR, (5) VR exercises compared with sham or usual care, non-treatment or placebo and (6) only studies published full text in English.

Results: The initial search identified 304 articles, four of which met the criteria for analysis. All studies involved some form of vestibular rehabilitation, including vestibular compensation, vestibular adaptation and substitution exercises. These exercises were compared with usual medical care (three studies) or placebo eye exercise (one study). The Vertigo Symptom Scale was the most commonly used outcome measure to assess subjective perception of symptoms of dizziness (three studies). According to the PEDro scale, three studies were considered to be of high quality, and one was rated as fair. 

Conclusions: This review suggests that exercise-based vestibular rehabilitation shows benefits for adult patients with chronic dizziness with regard to improvement in the vertigo symptom scale, fall risk, balance and emotional status.

Management of Chronic Lateral Epicondylitis With Manual Therapy and Local Cryostimulation: A Pilot Study

Objective

The purpose of this pilot study was to evaluate the feasibility and efficacy of adding cryostimulation to manual therapy in patients with chronic lateral epicondylitis.

Methods

The control group (n = 19) was treated with manual therapy consisting of soft-tissue therapy and radial head mobilizations. The experimental group (n = 18) received cryostimulation in addition to manual therapy care similar to that for the control group. Both protocols consisted of 8 treatments over a 4-week period. Outcome measures included pain intensity (visual analog scale), pain-free grip strength (handheld dynamometer), and functional index (Patient-Rated Tennis Elbow Evaluation questionnaire). Assessments were performed at baseline, postintervention, and 3-month follow-up. Adherence and dropout rates were also considered.

Results

Both groups exhibited significant improvements in pain intensity and functional index at postintervention assessments, which were maintained at follow-up. All participants attended the prescribed number of treatments, but 27% were lost at follow-up. Minor adverse events were reported after cryostimulation in 4 cases.

Conclusions

This study indicated that it is feasible to complete a clinical trial evaluating the efficacy of adding cryostimulation to manual therapy in patients with chronic lateral epicondylitis. On the basis of these preliminary data, the combination of cryostimulation and manual therapy care did not provide any additional benefits in both the short term and the long term. Manual myofascial point treatment and mobilization techniques yielded positive outcomes in chronic lateral epicondylitis. Further studies should focus on the sole therapeutic effect of cryostimulation in both patients with acute and those with chronic conditions.

The uses of outcome measures within multidisciplinary early childhood intervention services: a systematic review

Purpose of the article: To review the use of outcome measures, across the domains of activity, participation, and environment, within multidisciplinary early childhood intervention services.

MATERIALS AND METHODS

A systematic literature search was undertaken that included four electronic databases: Medline, CINAHL, EMBASE, and the Cochrane Library and Cochrane Database of Systematic Review. Inclusion criteria were age 0-24 months, having or at risk of a developmental disability, in receipt of multidisciplinary early childhood intervention services, and included outcome measures across all domains of the International Classification of Functioning-Child & Youth (ICF-CY). Only peer-reviewed journal articles were considered. Eligible studies were coded using the Oxford Levels of Evidence. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) Scale for randomised controlled trials and the QualSyst for non-randomised control trials.

RESULTS

Of the total of 5764 records identified, 10 were considered to meet inclusion criteria.

CONCLUSION

Fourteen outcome measures were identified, addressing the domains of activity, participation, and environment. Of these, eight have been recommended in the early intervention literature. While the methodological quality of the 10 studies varied, these papers make a contribution to the body of research that acknowledges the role of routine and enriched environments. Implications for Rehabilitation Core practice elements of multidisciplinary early childhood intervention services indicate it is necessary to select outcome measures framed within the International Classification of Functioning-Child & Youth to inform clinical decision-making for measuring intervention effectiveness across the domains of activity, participation and environment. Of the identified measures, three (Canadian Occupational Performance Measure, Pediatric Evaluation of Disability Inventory, and Goal Attainment Scaling) are well-established and identified in the literature as multidisciplinary outcome measures for children with developmental disability. The selection of an appropriate outcome measure depends on the age of the child, individual goals of the family, and the type of intervention. This requires the combination of measures as no one measure alone will capture all components of the International Classification of Functioning-Child & Youth.

The effect of visual biofeedback on balance in elderly population: a systematic review

BACKGROUND

Balance is commonly affected by multiple factors, especially among the elderly population. Visual biofeedback (VBF) is an intervention tool that can be used in balance rehabilitation.

AIM

This study aimed to systematically review randomized controlled trials that examine whether VBF training is effective in improving balance in an elderly population.

DATA SOURCES

Three databases were searched: CIAHL, EMBASE, and MEDLINE. The searches were limited to the period from 2010 to 2016.

ELIGIBILITY CRITERIA

Healthy adults, aged ≥65 years, with no specific disorders were included. Interventions were any VBF intervention with the aim of improving balance and were compared to no intervention, traditional exercises, placebo, or standard care. The outcome measures were balance as measured by any validated outcome measure.

STUDIES APPRAISAL METHOD

The Physiotherapy Evidence Database quality assessment tool and The Cochrane Collaboration tool for assessing risk of bias were used by two independent authors (HA and FM) in order to appraise the included studies.

RESULTS

The database search resulted in 879 articles, of which five papers were included. VBF was compared to no intervention, a placebo, and traditional exercise. The total number of participants in all the five included studies was 181, with a mean age of 74.3 years (standard deviation 6.7). Two studies were rated as high-quality studies, and three were rated as fair quality.

CONCLUSION

Engaging elderly people living in the community in VBF training was found to be effective and could improve their balance ability. However, the variation between studies in methodology, intervention protocol, and outcomes utilized made it difficult to inform a definitive statement regarding the potential application of VBF for balance training with the elderly. Furthermore, high-quality randomized control trials are required. The systematic review level of evidence is moderate, and the strength of recommendation is that VBF is likely to be beneficial.

Influence of expectations plus mobilization with movement in patient with lateral epicondylalgia: a pilot randomized controlled trial

The aim of this study was to determine the influence of expectations plus mobilization with movement (MWM) in kinesiophobia, perceived disability and sensorimotor variables in patients with lateral epicondylalgia. A pilot randomized controlled trial in 24 patients with lateral epicondylalgia was conducted. Perceived pain, pain-free grip strength, pressure pain detection threshold, kinesiophobia measured with the short version of Tampa Scale of Kinesiophobia, perceived disability of the upper limb measured with disability of the arm, hand and shoulder questionnaire, and perceived disability specifically for the elbow joint measured with patient-rating tennis elbow evaluation, and also satisfaction were assessed. Participants were randomized to receive written instructions in order to create positive expectations regarding the technique in one group (n=12) or neutral expectations in the other one (n=12). All patients were treated for three sessions with the MWM technique. Measures were recorded before and after treatment. The effect size was calculated by Rosenthal "r" for nonparametrical tests. There were no significant statistical differences (P>0.05) between groups after receiving the treatment for none of the physical analyzed variables. The Wilcoxon test showed statistically significant changes in kinesiophobia (Z=-2.278, r=0.47, P=0.023) and perceived disability (Z= -2.934, r=0.61, P=0.003) within positive expectations group. In conclusion this pilot study shows that a positive expectation almost given in a sealed envelope before treatment plus MWM produced changes in kinesiophobia and perceived disability in the immediate term, in patients with lateral epicondylalgia.

Multimodal approach to rehabilitation of the patients with lateral epicondylosis: a case series

Purpose

The objective of this study was to evaluate the effectiveness of mobilization with movement and kinesiotherapy in the treatment of patients with lateral epicondylosis.

Methods

This cases series included eight volunteers who had chronic lateral epicondylosis. The patients were treated with stretching, massage deep transverse at the lateral epicondyle and mobilization with movement associated with eccentric exercise. The mobilization with movement that consisted of a force of lateral glide of the proximal forearm. We performed twelve sessions, twice a week for 45 min/session. All patients underwent an evaluation with a visual analog scale and functional assessment through questionnaires patient-rated tennis elbow evaluation (PRTEE) and disabilities of the arm, shoulder and hand (DASH), before and after the treatment. Data were analyzed by student’s t test (p < 0.05).

Results

The results showed statistical differences in pain symptoms before and after treatment, in the analysis and functional assessment through both questionnaires comparing the pre and post treatment.

Conclusion

The data obtained in this study demonstrates improvement of the function and pain status of the sample investigated.

Strategies to overcome size and mechanical disadvantages in manual therapy

The practice of manual therapy (MT) is often difficult when providing care for large patients and for practitioners small in stature or with other physical limitations. Many MT techniques can be modified using simple principles to require less exertion, permitting consistency with standards of practice even in the presence of physical challenges. Commonly used MT techniques are herein described and demonstrated with alternative preparatory and movement methods, which can also be adopted for use in other techniques. These alternative techniques and the procedures used to adapt them warrant discussion among practitioners and educators in order to implement care, consistent with the best treatment evidence for many common musculoskeletal (MSK) conditions. The inclusion in educational curricula and MT training programs is recommended to enrich skill development in physical therapists (PTs), spanning entry-level practitioners to those pursuing advanced manual skills.

Manual therapy and eccentric exercise in the management of Achilles tendinopathy

Chronic Achilles tendinopathy (AT) is an overuse condition seen among runners. Eccentric exercise can decrease pain and improve function for those with chronic degenerative tendon changes; however, some individuals have continued pain requiring additional intervention. While joint mobilization and manipulation has not been studied in the management in Achilles tendinopathy, other chronic tendon dysfunction, such as lateral epicondylalgia, has responded well to manual therapy (MT). Three runners were seen in physical therapy (PT) for chronic AT. They were prescribed eccentric loading exercises and calf stretching. Joint mobilization and manipulation was implemented to improve foot and ankle mobility, decrease pain, and improve function. Immediate within-session changes in pain, heel raise repetitions, and pressure pain thresholds (PPT) were noted following joint-directed MT in each patient. Each patient improved in self-reported function on the Achilles tendon specific Victorian Institute for Sport Assessment questionnaire (VISA-A), pain levels, PPT, joint mobility, ankle motion, and single-leg heel raises at discharge and 9-month follow-up. The addition of MT directed at local and remote sites may enhance the rehabilitation of patients with AT. Further research is necessary to determine the efficacy of adding joint mobilization to standard care for AT.

LEVEL OF EVIDENCE

Case series. Therapy, Level 4.

Manipulation Therapy Relieved Pain More Rapidly Than Acupuncture among Lateral Epicondylalgia (Tennis Elbow) Patients: A Randomized Controlled Trial with 8-Week Follow-Up

Radial bone adjustment manipulation treatment may be effective to reduce pain rapidly in lateral epicondylalgia patients and the pathological tension in the biceps brachii muscle is highly concerned. To prove this hypothesis, we conducted a randomized controlled trial and included 35 patients with lateral epicondylalgia for more than 2 months. Either manipulation treatment (n = 16) or acupuncture (n = 19) was given to these patients for 2 weeks and all patients' symptoms were followed up for 8 weeks after treatment. Both groups demonstrated changes in pain VAS score, grip strength, and DASH questionnaire. Lateral epicondylalgia patients who received manipulation treatment felt pain relief sooner than those who had acupuncture treatments during the first few treatments. However, both acupuncture and manipulation are effective, while the difference has no significance at the 8-week follow-up. The trial was registered with Current Controlled Trials ISRCTN81308551 on 5 February 2016.

Effects of Expanded Coverage for Chiropractic Services on Medicare Costs in a CMS Demonstration

BACKGROUND

Moderately convincing evidence supports the benefits of chiropractic manipulations for low back pain. Its effectiveness in other applications is less well documented, and its cost-effectiveness is not known. These questions led the Centers for Medicaid and Medicare Services (CMS) to conduct a two-year demonstration of expanded Medicare coverage for chiropractic services in the treatment of beneficiaries with neuromusculoskeletal (NMS) conditions affecting the back, limbs, neck, or head.

METHODS

The demonstration was conducted in 2005-2007 in selected counties of Illinois, Iowa, and Virginia and the entire states of Maine and New Mexico. Medicare claims were compiled for the preceding year and two demonstration years for the demonstration areas and matched comparison areas. The impact of the demonstration was analyzed through multivariate regression analysis with a difference-in-difference framework.

RESULTS

Expanded coverage increased Medicare expenditures by $50 million or 28.5% in users of chiropractic services and by $114 million or 10.4% in all patients treated for NMS conditions in demonstration areas during the two-year period. Results varied widely among demonstration areas ranging from increased costs per user of $485 in Northern Illinois and Chicago counties to decreases in costs per user of $59 in New Mexico and $178 in Scott County, Iowa.

CONCLUSION

The demonstration did not assess possible decreases in costs to other insurers, out-of-pocket payments by patients, the need for and costs of pain medications, or longer term clinical benefits such as avoidance of orthopedic surgical procedures beyond the two-year period of the demonstration. It is possible that other payers or beneficiaries saved money during the demonstration while costs to Medicare were increased.

What is the clinical effectiveness and cost-effectiveness of conservative interventions for tendinopathy? An overview of systematic reviews of clinical effectiveness and systematic review of economic evaluations

BACKGROUND

Lateral elbow tendinopathy (LET) is a common complaint causing characteristic pain in the lateral elbow and upper forearm, and tenderness of the forearm extensor muscles. It is thought to be an overuse injury and can have a major impact on the patient's social and professional life. The condition is challenging to treat and prone to recurrent episodes. The average duration of a typical episode ranges from 6 to 24 months, with most (89%) reporting recovery by 1 year.

OBJECTIVES

This systematic review aims to summarise the evidence concerning the clinical effectiveness and cost-effectiveness of conservative interventions for LET.

DATA SOURCES

A comprehensive search was conducted from database inception to 2012 in a range of databases including MEDLINE, EMBASE and Cochrane Databases.

METHODS AND OUTCOMES

We conducted an overview of systematic reviews to summarise the current evidence concerning the clinical effectiveness and a systematic review for the cost-effectiveness of conservative interventions for LET. We identified additional randomised controlled trials (RCTs) that could contribute further evidence to existing systematic reviews. We searched MEDLINE, EMBASE, Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health Literature, Web of Science, The Cochrane Library and other important databases from inception to January 2013.

RESULTS

A total of 29 systematic reviews published since 2003 matched our inclusion criteria. These were quality appraised using the Assessment of Multiple Systematic Reviews (AMSTAR) checklist; five were considered high quality and evaluated using a Grading of Recommendations, Assessment, Development and Evaluation approach. A total of 36 RCTs were identified that were not included in a systematic review and 29 RCTs were identified that had only been evaluated in an included systematic review of intermediate/low quality. These were then mapped to existing systematic reviews where further evidence could provide updates. Two economic evaluations were identified.

LIMITATIONS

The summary of findings from the review was based only on high-quality evidence (scoring of > 5 AMSTAR). Other limitations were that identified RCTs were not quality appraised and dichotomous outcomes were also not considered. Economic evaluations took effectiveness estimates from trials that had small sample sizes leading to uncertainty surrounding the effect sizes reported. This, in turn, led to uncertainty of the reported cost-effectiveness and, as such, no robust recommendations could be made in this respect.

CONCLUSIONS

Clinical effectiveness evidence from the high-quality systematic reviews identified in this overview continues to suggest uncertainty as to the effectiveness of many conservative interventions for the treatment of LET. Although new RCT evidence has been identified with either placebo or active controls, there is uncertainty as to the size of effects reported within them because of the small sample size. Conclusions regarding cost-effectiveness are also unclear. We consider that, although updated or new systematic reviews may also be of value, the primary focus of future work should be on conducting large-scale, good-quality clinical trials using a core set of outcome measures (for defined time points) and appropriate follow-up. Subgroup analysis of existing RCT data may be beneficial to ascertain whether or not certain patient groups are more likely to respond to treatments.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013003593.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

The Use of the MyoDK for Mechanical Pressure in the Treatment of Chronic Lateral Epicondylalgia: A Pilot Study

INTRODUCTION

Chronic Lateral Epicondylalgia (CLE) is potentially associated with a significant reduction of the patient's quality of life; its treatment by manual Deep Transverse Friction (DTF), although widely accepted, lacks standardization. The purpose of our study was to evaluate the efficacy of the MyoDK device, which allows deep transverse pressure (DTP) monitoring, for treatment of CLE.

MATERIALS AND METHODS

This is a single centre observational study for treatment of CLE by the MyoDK device. In a given year, all patients who appeared at our institution with a diagnostic of CLE were screened for possible inclusion. Exclusion criteria were: confounding factors on pain and function of the upper limb, cognitive impairment, inability or unwilling to give informed consent or to comply with treatment protocol. Our primary outcome measure was the pain reduction measured by the VAS pain scale (VAS) at 6 weeks. Our intervention consisted in applying a pressure from 0.5 to 10kg/100mm(2) for 20 minutes, once a week for 6 weeks, using the MyoDK device.

RESULTS

Thirty patients were screened. Two were excluded for incomplete protocol, remaining 28 for analysis. Mean age was 47.3, 23 were male (82.1%), 24 were affected on their dominant side (85.7%). We had a significant reduction in VAS pain score at 12 weeks (80.8 vs 13.0; p<0.01). There were no side effects reported.

CONCLUSION

Our study showed the safety of the use of a standard protocol using the MyoDK device for treatment of CLE. We believe that further controlled studies will establish the MyoDK as a reliable option for treatment of CLE.

Determining the level of evidence for the effectiveness of spinal manipulation in upper limb pain: A systematic review and meta-analysis

BACKGROUND

The use of spinal manipulation (SM) for upper limb pain has been advocated based on the concept of regional interdependence. However, its evidence has not been established.

OBJECTIVE

To determine the level of evidence for the effectiveness of SM in patients with upper limb pain as part of the concept of regional interdependence.

METHODS

MeSH and Key words representing two broad subject areas: SM and upper limb disorders were used to conduct an electronic search in sixteen electronic databases. Randomized controlled trials and/or controlled clinical trials investigating the effects of SM in patients with upper limb pain were included. Studies including pain in the neck or scapular region and those using spinal mobilization were excluded. Meta-analysis was conducted to examine the effects of SM on upper limb pain. The overall quality of evidence was assessed using the GRADE system.

RESULTS

Out of 3307 studies, six trials met inclusion criteria for this review. Of these, three studies were included in meta-analysis. Meta-analysis results suggested there were no statistical differences between SM and other interventions in the effects on reducing upper limb pain. The overall quality of evidence was very low.

CONCLUSION

The number of studies regarding the current topic is limited. There is very low quality evidence that SM is not better nor inferior than other interventions in the management of upper limb pain.

The use of joint mobilization to improve clinical outcomes in hand therapy: a systematic review of the literature

STUDY DESIGN

Systematic review.

INTRODUCTION

Joint mobilizations are used as an intervention for improving range of motion, decreasing pain and ultimately improving function in patients with a wide variety of upper extremity diagnoses. However, there are only a limited number of studies describing this treatment for conditions affecting the elbow, wrist, and hand. Furthermore, it is unclear as to the most effective joint mobilization technique utilized and the most beneficial functional outcomes gained.

PURPOSE

Examine the current evidence describing joint mobilizations for treatment of conditions of the elbow, wrist and hand, and offer informative practical clinical guidance.

METHODS

Twenty-two studies dated between 1980 and 2011 were included in the systematic review for analysis.

RESULTS

The current evidence provides moderate support for the inclusion of joint mobilizations in the treatment of lateral epicondylalgia (LE). In particular, mobilization with movement as described by Mulligan is supported with evidence from nine randomized clinical trials as an effective technique for the treatment of pain. Other described techniques include those known as Kaltenborn, Cyriax physical therapy, and Maitland, but the evidence for these techniques is limited. There is also limited evidence for the joint mobilizations in the treatment of wrist and hand conditions.

CONCLUSIONS

The current literature offers limited support for joint mobilizations of the wrist and hand, and moderate support for joint mobilizations of the elbow for LE. There is moderate support for mobilization with movement. .

Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report

BACKGROUND

This systematic review updated and extended the "UK evidence report" by Bronfort et al. (Chiropr Osteopath 18:3, 2010) with respect to conditions/interventions that received an 'inconclusive' or 'negative' evidence rating or were not covered in the report.

METHODS

A literature search of more than 10 general medical and specialised databases was conducted in August 2011 and updated in March 2013. Systematic reviews, primary comparative studies and qualitative studies of patients with musculoskeletal or non-musculoskeletal conditions treated with manual therapy and reporting clinical outcomes were included. Study quality was assessed using standardised instruments, studies were summarised, and the results were compared against the evidence ratings of Bronfort. These were either confirmed, updated, or new categories not assessed by Bronfort were added.

RESULTS

25,539 records were found; 178 new and additional studies were identified, of which 72 were systematic reviews, 96 were randomised controlled trials, and 10 were non-randomised primary studies. Most 'inconclusive' or 'moderate' evidence ratings of the UK evidence report were confirmed. Evidence ratings changed in a positive direction from inconclusive to moderate evidence ratings in only three cases (manipulation/mobilisation [with exercise] for rotator cuff disorder; spinal mobilisation for cervicogenic headache; and mobilisation for miscellaneous headache). In addition, evidence was identified on a large number of non-musculoskeletal conditions not previously considered; most of this evidence was rated as inconclusive.

CONCLUSIONS

Overall, there was limited high quality evidence for the effectiveness of manual therapy. Most reviewed evidence was of low to moderate quality and inconsistent due to substantial methodological and clinical diversity. Areas requiring further research are highlighted.

Improving Field Observation of Spinal Posture in Sitting

Observing seated posture is important for ergonomic assessment; proper chair fit and chair adjustment should be considered for the entire context of work demands. Recommending only one seated posture presumes that all seated work has a similar location of visual targets, shoulder reach distances, and support surfaces. The nature of work tasks may influence posture more than does chair adjustment, and field observation of sitting should focus specifically on lumbar spine posture when work may cause forward movement of the torso. I suggest that the position and movement of the pelvis in relation to the torso is a reasonable and important indicator of spinal posture.

Treating lateral epicondylitis with corticosteroid injections or non-electrotherapeutical physiotherapy: a systematic review

OBJECTIVES

To evaluate the current evidence for the efficacy of corticosteroid injection and non-electrotherapeutic physiotherapy compared with control for treating lateral epicondylitis.

DESIGN

Systematic review.

PARTICIPANTS

We searched five databases in September 2012 for randomised controlled studies with a minimum quality rating. Of the 640 studies retrieved, 11 were included, representing 1161 patients of both sexes and all ages.

INTERVENTIONS

Corticosteroid injection and non-electrotherapeutic physiotherapy.

OUTCOME MEASURES

Relative risk (RR) or standardised mean difference (SMD) for overall improvement, pain and grip strength at 4-12, 26 and 52 weeks of follow-up.

RESULTS

Corticosteroid injection gave a short-term reduction in pain versus no intervention or non-steroidal anti-inflammatory drugs (SMD -1.43, 95% CI -1.64 to -1.23). At intermediate follow-up, we found an increase in pain (SMD 0.32, 95% CI 0.13 to 0.51), reduction in grip strength (SMD -0.48, 95% CI -0.73 to -0.24) and negative effect on the overall improvement effect (RR 0.66 (0.53 to 0.81)). For corticosteroid injection versus lidocaine injection, the evidence was conflicting. At long-term follow-up, there was no difference on overall improvement and grip strength, with conflicting evidence for pain. Manipulation and exercise versus no intervention showed beneficial effect at short-term follow-up (overall improvement RR 2.75, 95% CI 1.30 to 5.82), but no significant difference at intermediate or long-term follow-up. We found moderate evidence for short-term and long-term effects of eccentric exercise and stretching versus no intervention. For exercise versus no intervention and eccentric or concentric exercise and stretching versus stretching alone, we found moderate evidence of no short-term effect.

CONCLUSIONS

Corticosteroid injections have a short-term beneficial effect on lateral epicondylitis, but a negative effect in the intermediate term. Evidence on the long-term effect is conflicting. Manipulation and exercise and exercise and stretching have a short-term effect, with the latter also having a long-term effect.

Lateral epicondylalgia. A quantitative and qualitative analysis of interdisciplinary cooperation and treatment choice in the Swedish health care system

OBJECTIVE AND AIM

Interdisciplinary cooperation is essential to develop a broad range of knowledge and skills. The aim of this study was to describe health care professionals' treatment choices, their cooperation with other professionals and their perceptions of potential risks regarding treatments of acute lateral epicondylalgia (LE).

DESIGN

A quantitative descriptive study design with a summative approach to qualitative analysis.

ETHICAL ISSUES

The ethical committee was asked verbally for approval but, as this study was performed to develop an organised way to treat LE, it did not require approval. The four ethical aspects information, consent, confidentiality and the use of the study materials were all addressed.

SUBJECTS

All orthopaedic surgeons, general practitioners, physiotherapists and occupational therapists in a county.

METHODS

Questionnaire with 18 dichotomous, multiple-response, multiple-choice questions and three open-ended questions were analysed using quantitative cross-tab and qualitative content analysis with summative approach.

RESULTS

The most common treatment choices were Non Steroidal Anti Inflammatory Drugs (NSAID), corticosteroid injections, training programmes, braces and ergonomics. Advantages from interdisciplinary cooperation were higher rated than disadvantages. The qualitative findings dealt with perceptions of interdisciplinary cooperation and resulted in three categories; right level of care, increased quality of care and decreased quality of care. Almost half of the physicians felt potential risks associated with their treatment methods. The qualitative findings dealt with perceptions of the potential risks and resulted in two categories: side effects and inadequate treatment.

STUDY LIMITATIONS

The number of responses varied because some of the respondents did not answered all of the questions.

CONCLUSION

Interdisciplinary cooperation in the treatment of patients with acute LE benefits the patients by shortening the rehabilitation period and provides health care professionals the opportunity for an improved learning and exchanging experiences. These basic conditions must be met to improve health care quality.

Surgery for lateral elbow pain

BACKGROUND

Surgery is sometimes recommended for persistent lateral elbow pain where other less invasive interventions have failed.

OBJECTIVES

To determine the benefits and safety of surgery for lateral elbow pain.

SEARCH STRATEGY

We searched CENTRAL (The Cochrane Library), MEDLINE, EMBASE, CINAHL and Web of Science unrestricted by date or language (to 15 December 2010).

SELECTION CRITERIA

Randomised and controlled clinical trials assessing a surgical intervention compared with no treatment or another intervention including an alternate surgical intervention, in adults with lateral elbow pain.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials for inclusion, assessed risk of bias and extracted data.

MAIN RESULTS

We included five trials involving 191 participants with persistent symptoms of at least five months duration and failed conservative treatment. Three trials compared two different surgical procedures and two trials compared surgery to a non-surgical treatment. All trials were highly susceptible to bias. Meta-analysis was precluded due to differing comparator groups and outcome measures. One trial (24 participants) reported no difference between open extensor carpi radialis brevis (ECRB) surgery and radiofrequency microtenotomy, although reanalysis found that pain was significantly lower in the latter group at three weeks (MD -2.80 points on 10 point scale, 95% CI -5.07 to -0.53). One trial (26 participants) reported no difference between open ECRB surgery and decompression of the posterior interosseous nerve in terms of the number of participants with improvement in pain pain on activity, or tenderness on palpation after an average of 31 months following surgery. One trial (45 participants) found that compared with open release of the ERCB muscle, percutaneous release resulted in slightly better function. One trial (40 participants) found comparable results between open surgical release of the ECRB and botulinum toxin injection at two years, although we could not extract any data for this review. One trial (56 participants) found that extracorporeal shock wave therapy (ESWT) improved pain at night compared with percutaneous tenotomy at 12 months (MD 5 points on 100 point VAS, 95% CI 1.12 to 8.88), but there were no differences in pain at rest or pain on applying pressure.

AUTHORS' CONCLUSIONS

Due to a small number of studies, large heterogeneity in interventions across trials, small sample sizes and poor reporting of outcomes, there was insufficient evidence to support or refute the effectiveness of surgery for lateral elbow pain. Further well-designed randomised controlled trials and development of standard outcome measures are needed.