Effectiveness of non-invasive therapies on pain, maximum grip strength, disability, and quality of life for lateral elbow tendinopathy: A systematic review and meta-analysis

BACKGROUND

Lateral elbow tendinopathy is a common musculoskeletal disorder. Effectiveness of non-invasive therapies for this health condition are unclear.

OBJECTIVE

To investigate the effectiveness of non-invasive therapies on pain, maximum grip strength, disability, and quality of life for lateral elbow tendinopathy.

METHODS

Searches were conducted on MEDLINE, Embase, CINAHL, AMED, PEDro, Cochrane Library, SPORTDiscus and PsycINFO without language or date restrictions up to May 3rd, 2023. Randomized trials investigating the effectiveness of any non-invasive therapy compared with control or other invasive interventions were included. Two independent reviewers screened eligible trials, extracted data, and assessed the risk of bias of included trials and certainty of the evidence.

RESULTS

Twenty-two different therapies investigated in 47 randomized trials were included in the quantitative analysis. Moderate certainty evidence showed that betamethasone valerate medicated plaster may reduce disability (mean difference -6.7; 95% CI -11.4, -2.0) in the short-term when compared with placebo. Low certainty evidence showed that acupuncture may reduce disability (MD -9.1; 95% CI -11.7, -6.4) in the short-term when compared with sham. Moderate to very low certainty of evidence also showed small to no effect of non-invasive therapies on pain intensity, maximum grip strength, and disability outcomes in the short-term compared to control or invasive interventions. Most therapies had only very low certainty of evidence to support their use.

CONCLUSIONS

Decision-making processes for lateral elbow tendinopathy should be carefully evaluated, taking into consideration that most investigated interventions have very low certainty of evidence. There is an urgent call for larger high-quality trials.

A systematic review of the effectiveness of wrist manipulative therapy in patients with lateral epicondylitis

STUDY DESIGN

Systematic review.

INTRODUCTION

Several treatment methods treat lateral epicondylitis, but there is no consensus regarding the most effective method. Research has suggested that joint mobilizations may help recover patients with lateral epicondylitis.

PURPOSE OF THE STUDY

To determine if wrist joint manipulations effectively improve pain, grip strength, ROM, and functional outcome in adults with lateral epicondylitis.

METHODS

Searches were performed in 6 databases to identify relevant clinical trials. Three reviewers independently extracted data and assessed the methodological quality using the PEDro scale. Standard data were extracted and summarized.

RESULTS

A total of 4 studies met the inclusion criteria. A best-evidence synthesis was used to summarize the results. The included studies found effectiveness in favor of wrist manipulations given for at least 3 weeks to reduce pain in lateral epicondylitis against comparison groups comprising ultrasound, laser, friction massage, and exercises. Functional outcomes varied considerably among studies. Grip strength showed varied results, and no effect was seen on wrist ROM.

CONCLUSION

The evidence is convincing that wrist joint manipulations positively affect pain in the short term, compared to comparison groups in the management of lateral epicondylitis. Future high-quality studies are recommended.

Validity and reliability of the Duruöz Hand Index in patients with lateral epicondylitis

Objectives

This study aims to investigate the validity, reliability and clinimetric features of the Duruöz Hand Index (DHI) in patients with lateral epicondylitis.

Patients and methods

Between October 2019 and January 2020, a total of 78 patients (28 males, 50 females; mean age: 46.4±9.4 years; range, 20 to 65 years) who presented with pain in the forearm and were diagnosed with lateral epicondylitis were included in the study. The patients were evaluated using the Visual Analog Scale (VAS), Health Assessment Questionnaire (HAQ), the Patient-Rated Tennis Elbow Evaluation Questionnaire (PRTEEQ), the Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire at Weeks 0, 1 and 4. The DHI reliability (Cronbach alpha, intraclass correlation [ICC]), validity and factor analyses were performed with the data of 70 and 49 patients who attended to follow-up visit at Weeks 1 and 4. The effect size (ES), standard response mean (SRM), and minimum detectable change (MDC) values of the DHI were calculated.

Results

Of the patients, 84.6% were right-handed. The ICC coefficients of DHI were found to be perfect with the test-retest method (ICC; total=0.943). It showed a well-excellent consistency with the internal consistency method (Cronbach alpha; total=0.90). In the structural validity of the DHI, it was very strongly correlated with the DASH (r=0.801; p<0.01), strongly correlated with the PRTEEQ and HAQ total scores (r=0.793; p<0.01; r=0.785; p<0.01), and acceptably correlated with PRTEEQ pain score (r=0.570; p<0.01). The DHI was acceptably correlated with the VAS and grip strength as measured by the hand dynamometer (p<0.05). In our study, three main factors were obtained and MDC and responsiveness sensitivity were found to be moderate (MDC=4.4; SEM=1.61; ES=0.246 p<0.001; SRM=0.538 p<0.001).

Conclusion

Duruöz Hand Index is a reliable, valid, and practical functional assessment scale in patients with lateral epicondylitis.

Direct Effect of Local Cryotherapy on Muscle Stimulation, Pain and Strength in Male Office Workers with Lateral Epicondylitis, Non-Randomized Clinical Trial Study

Background: Local cryotherapy (LC) is one of the physiotherapeutic methods used in the conservative treatment of lateral epicondylitis (LE). The aim of the study was to verify the direct effect of a single LC procedure on the clinical symptoms of lateral epicondylitis enthesopathy (pain, pain free grip, PFG) and its effect on the bioelectrical properties of the wrist extensor muscles at rest, on maximal contraction and isometric contraction during fatigue. Methods: The study group was 28 men (35.4 ± 6.13 years) with confirmed unilateral epicondylitis. The performed procedures included the assessment of pain (visual analogue scale, VAS), PFG and ARMS (root-mean-square amplitude) and mean frequencies (MNF) of the sEMG signal before (T0) and after (T1) LC on the side with enthesopathy (ECRE) and without enthesopathy (ECRN/E). Results: There was an increase in the ARMS values of the signals recorded during rest and MVC from the ECR muscles both with and without enthesopathy (p = 0.0001, p = 0.006), an increased PFG after LC only on the side with LE (p < 0.0001) and decreased pain (p < 0.0001). During isometric fatigue contraction, a higher ARMS on both the ECRE side (p < 0.0001) and the ECRN/E side (p < 0.0001) was observed after LC treatment, and a lower MNF was observed on both the ECRN/E side (p < 0.0001) and the ECRE side (p < 0.0001) after LC. Conclusions: LC reduces the pain and increases PFG and muscle excitation expressed by ARMS and seems to delay muscle fatigue.

Investigating the effects of neuromobilization in lateral epicondylitis

STUDY DESIGN

Randomized controlled study.

INTRODUCTION

Lateral epicondylitis (LE) causes pain and loss of function in the affected limb. Different exercises have been used for the treatment of LE. In recent years, the technique of neuromobilization has been frequently used to treat tendinopathy. However, there is no study that demonstrates the effects of neuromobilization techniques on patients with LE.

PURPOSE OF THE STUDY

The aim of the present study was to determine the effects of neuromobilization techniques on pain, grip strength, and functional status in LE patients and to compare them with conservative rehabilitation treatment.

METHODS

A total of 40 patients (26 females and 14 males; age: 42.80 ± 8.91 years) with a history of LE participated in the study. The patients were randomly assigned to two groups: the neuromobilization group and the control group. The neuromobilization group completed a 6-week conservative rehabilitation and radial nerve mobilization program, whereas the control group received conservative rehabilitation therapy only. Both groups underwent a 7-day weekly conservative home rehabilitation program. Pain severity, grip strength, pinch strength, joint motions, and upper extremity functional level were assessed before treatment, at the third week after treatment, and at the sixth week after treatment.

RESULTS

There was a significant decrease in all pain scores in favor of the neuromobilization group at week 6 after treatment (at rest: P = .001, effect size (ES) = 0.84; at night: P = .001, ES = 0.91 and during activity: P = .004, ES = 1.06). No significant differences were found for grip strength, pinch strength, joint motions, and functional level in the neuromobilization group, although trends toward better improvement were observed.

CONCLUSIONS

Radial nerve mobilization techniques are more effective on pain than conservative rehabilitation therapy in LE patients, and this effect continues after treatment.

Effectiveness of Low Level Laser Therapy (LLLT) in the treatment of Lateral elbow tendinopathy (LET): an umbrella review

PURPOSE

The aim of this umbrella review is to determine the effectiveness of LLLT in the treatment of LET and to provide recommendations based on this evidence.

METHODS

A comprehensive and systematic review was undertaken using Medline, EBSCO and EMBASE. Systematic reviews or meta-analysis were included if they compared Laser with at least one of the following: (i) placebo, (ii) no treatment, (iii) another treatment, conservative (physical therapy intervention or medical) or operative of LET. Principal outcomes included the assessment of short and long-term effect on functional status, pain, grip strength (pain-free or maximum) and a global measure (overall improvement).

RESULTS

Seven papers met the inclusion criteria for the umbrella review, Five papers were of moderate and two of low methodological quality. All reviews reported benefits associated with laser therapy Vs other intervention or placebo, however the significance of the identified benefits differed between studies and reviews. No review reported negative effects of laser therapy or harm to patients. All reviews noted significant variance between included studies with 2 reviews citing statistically significant heterogeneity. It is essential to consider this in the interpretation of these data.

CONCLUSION

This umbrella review found poor results for the effectiveness of LLLT in the management of LET. Therefore, further research with well-designed RCTs is required to provide meaningful evidence on the effectiveness (absolute and relative) of LLLT for the management of LET.

Comparison of effects of eccentric training, eccentric-concentric training, and eccentric-concentric training combined with isometric contraction in the treatment of lateral elbow tendinopathy

STUDY DESIGN

RCT.

INTRODUCTION

Lateral elbow tendinopathy is a common clinical condition. eccentric exercises. eccentric-concentric loading and, isometric exercises are indicated to reduce and manage tendon pain.

PURPOSE OF THE STUDY

To compare the effectiveness of eccentric training, eccentric-concentric training, and eccentric-concentric training combined with isometric contraction in the treatment of lateral elbow tendinopathy.

METHODS

A randomized clinical trial was carried out in a rheumatology and rehabilitation center. A group of 34 patients with later elbow tendinopathy was randomly allocated to Group A (n = 11) who underwent eccentric training, Group B had eccentric-concentric and Group C who had eccentric-concentric and isometric training. All patients received 5 treatments per week for 4 weeks. Pain was evaluated using a visual analog scale and function using a visual analog scale and pain-free grip strength at the end of the 4-week course of treatment (week 4) and 1 month (week 8) after the end of treatment.

RESULTS

The eccentric-concentric training combined with isomentric contractions produced the largest effect in the reduction of pain and improvement of function at the end of the treatment (P < .05) and at any of the follow-up time points (P < .05).

CONCLUSION

The eccentric-concentric training combined with isomentric contractions was the most effective treatment. Future well-designed studies are needed to confirm the results of the present trial.

LEVEL OF EVIDENCE

III.

Comparison of effects of Cyriax physiotherapy, a supervised exercise programme and polarized polychromatic non-coherent light (Bioptron light) for the treatment of lateral epicondylitis

Objective: To compare the effectiveness of Cyriax physiotherapy, a supervised exercise programme, and polarized polychromatic non-coherent light (Bioptron light) in the treatment of lateral epicondylitis.

Design: Controlled clinical trial.

Setting: Rheumatology and rehabilitation centre.

Subjects: This study was carried out with 75 patients who had lateral epicondylitis. They were allocated to three groups by sequential allocation.

Interventions: Group A ( n=25) was treated with Cyriax physiotherapy. A supervised exercise programme was given to group B ( n=25). Group C ( n=25) received polarized polychromatic non-coherent light (Bioptron light). All patients received three treatments per week for four weeks.

Outcomes: Pain was evaluated using a visual analogue scale and function using a visual analogue scale and pain-free grip strength at the end of the four-week course of treatment (week 4), one month (week 8), three months (week 16) and six months (week 28) after the end of treatment.

Results: The supervised exercise programme produced the largest effect in the reduction of pain and in the improvement of function at the end of the treatment ( P<0.05) and at any of the follow-up time points ( P<0.05).

Conclusion: The supervised exercise programme should be the first treatment option for therapists when they manage lateral epicondylitis patients. If this is not possible, Cyriax physiotherapy and polarized polychromatic non-coherent light (Bioptron light) may be suitable.

Greek adaptation and validation of the Patient-Rated Tennis Elbow Evaluation (PRTEE)

PURPOSE OF THE STUDY

To cross-culturally adapt and validate the Greek version of the Patient-Rated Tennis Elbow Evaluation (PRTEE-G) Questionnaire.

METHODS

Four bi-lingual translators were involved in the translation and cultural adaptation procedures. Eighty-two patients (61 women and 21 men) with Lateral Elbow Tendinopathy (LET) participated in the study. To establish test - retest reliability, the patients were asked to complete the PRTEE-G Questionnaire before and after the first physiotherapy treatment. Internal consistency of the translated instrument was measured using Cronbach 'alpha'. An intraclass correlation coefficient was used to assess the test - retest reliability of the PRTEE-G Questionnaire. Concurrent validity was measured by correlating the PRTEE-G Questionnaire scores with the Greek version of the Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) scores using Pearson's correlation coefficient.

RESULTS

The Greek PRTEE questionnaire has acceptable internal consistency (Cronbach 'alpha' = 0.95), excellent test - retest reliability (ICC = 0.94) and demonstrates expected concurrent validity (r > 0.72).

CONCLUSION

The Greek version of PRTEE Questionnaire is a reliable and valid measure when administered to patients with LET.

The diagnostic test accuracy of ultrasound for the detection of lateral epicondylitis: a systematic review and meta-analysis

BACKGROUND

The purpose of this study was to determine the diagnostic test accuracy of ultrasound for the detection of lateral epicondylitis.

METHODS

An electronic search of databases registering published (MEDLINE, EMBASE, CINAHL, AMED, Cochrane Library, ScienceDirect) and unpublished literature was conducted to January 2013. All diagnostic accuracy studies that compared the accuracy of ultrasound (index test) with a reference standard for lateral epicondylitis were included. The methodological quality of each of the studies was appraised using the QUADAS tool. When appropriate, the pooled sensitivity and specificity analysis was conducted.

RESULTS

Ten studies investigating 711 participants and 1077 elbows were included in this review. Ultrasound had variable sensitivity and specificity (sensitivity: 64%-100%; specificity: 36%-100%). The available literature had modest methodological quality, and was limited in terms of sample sizes and blinding between index and reference test results.

CONCLUSIONS

There is evidence to support the use of ultrasound in the detection of lateral epicondylitis. However, its accuracy appears to be highly dependent on numerous variables, such as operator experience, equipment and stage of pathology. Judgement should be used when considering the benefit of ultrasound for use in clinical practice. Further research assessing variables such a transducer frequency independently is specifically warranted.

LEVEL OF EVIDENCE

Level II.

Comparison of effectiveness of supervised exercise program and Cyriax physiotherapy in patients with tennis elbow (lateral epicondylitis): a randomized clinical trial

OBJECTIVE

To compare the effectiveness of supervised exercise program and Cyriax physiotherapy in the treatment of tennis elbow (lateral epicondylitis).

DESIGN

Randomized clinical trial.

SETTING

Physiotherapy and rehabilitation centre.

SUBJECTS

This study was carried out with 20 patients, who had tennis elbow (lateral epicondylitis).

INTERVENTION

Group A (n = 10) had received supervised exercise program. Group B (n = 10) was treated with Cyriax physiotherapy. All patients received three treatment sessions per week for four weeks (12 treatment sessions).

OUTCOME MEASURES

Pain was evaluated using a visual analogue scale (VAS), and functional status was evaluated by completion of the Tennis Elbow Function Scale (TEFS) which were recorded at base line and at the end of fourth week.

RESULTS

Both the supervised exercise program and Cyriax physiotherapy were found to be significantly effective in reduction of pain and in the improvement of functional status. The supervised exercise programme resulted in greater improvement in comparison to those who received Cyriax physiotherapy.

CONCLUSION

The results of this clinical trial demonstrate that the supervised exercise program may be the first treatment choice for therapist in managing tennis elbow.

Joint manipulation in the management of lateral epicondylalgia: a clinical commentary

Lateral epicondylalgia or tennis elbow is a prevalent musculoskeletal disorder that is characterized by lateral elbow pain often associated with gripping tasks. The underlying pathology remains to be fully elucidated; however, evidence indicates that the disorder does not involve an inflammatory process but rather impairments of the pain and motor systems as well as morphological changes in the structure of both the extensor carpi radialis brevis muscle and tendon. Although the most efficient management approach remains controversial, there is a growing body of literature reporting the effects and underlying mechanisms of joint manipulation in the management of lateral epicondylalgia. Evidence exists demonstrating that joint manipulation directed at the elbow and wrist as well as at the cervical and thoracic spinal regions results in clinical alterations in pain and the motor system. In addition to presenting this evidence, this paper describes proposed underlying physiological mechanisms of joint manipulation associated with the observed clinical effects. We propose that this information will be useful for the physical therapist in making clinical decisions regarding the selection of treatment technique for the management of patients with lateral epicondylalgia.

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

Lateral epicondylalgia is a commonly encountered musculoskeletal complaint. Currently, there is no agreement regarding the exact underlying pathoanatomical cause or the most effective management strategy. Various forms of joint manipulation have been recommended as treatment. The purpose of this study was to systematically review available literature regarding the effectiveness of manipulation in treating lateral epicondylalgia. A comprehensive search of Medline, CINAHL, Health Source, SPORTDiscus, and the Physiotherapy Evidence Database ending in November 2007 was conducted. Thirteen studies, both randomized and non-randomized clinical trials, met inclusion criteria. Articles were assessed for quality by one reviewer using the 10-point PEDro scale. Quality scores ranged from 1-8 with a mean score of 5.15 +/- 1.85. This score represented fair quality overall; however, trends indicated the presence of consistent methodological flaws. Specifically, no study achieved successful blinding of the patient or treating therapist, and less than 50% used a blinded outcome assessor. Additionally, studies varied significantly in terms of outcome measures, follow-up, and comparison treatments, thus making comparing results across studies difficult. Results of this review support the use of Mulligan's mobilization with movement in providing immediate, short-, and long-term benefits. In addition, positive results were demonstrated with manipulative therapy directed at the cervical spine, although data regarding long-term effects were limited. Currently, limited evidence exists to support a synthesis of any particular technique whether directed at the elbow or cervical spine. Overall, this review identified the need for further high-quality studies using larger sample sizes, valid functional outcome measures, and longer follow-up periods.

Interactive effects of acute experimental pain in trapezius and sored wrist extensor on the electromyography of the forearm muscles during computer work

We investigated the interactive effects of shoulder pain and wrist extensor muscle soreness on surface electromyography (EMG) during computer mouse work. On day one, subjects (N = 12) performed computer work with/without acute muscle pain induced in the trapezius muscle. Subsequently, eccentric exercise was performed to induce delayed onset muscle soreness (DOMS) in wrist extensor muscles. In presence of DOMS on day two, computer work recordings with/without pain were repeated. EMG signals were recorded from the descending part of trapezius bilaterally, flexor carpi ulnaris and extensor carpi radialis brevis. Experimental muscle pain in trapezius led to a decrease in the muscular activity of the wrist extensor (P < 0.02) and decreased the relative rest time in the wrist flexor even in presence of DOMS (P < 0.01). The present result suggests that shoulder pain plays a role in the coordination of wrist flexors and extensors during computer work.

Autologous blood versus corticosteroid local injection in the short-term treatment of lateral elbow tendinopathy: a randomized clinical trial of efficacy

OBJECTIVE

To compare local corticosteroid with autologous blood injections for the short-term treatment of lateral elbow tendinopathy.

DESIGN

A single blind, randomized clinical trial was performed in an outpatient clinic at a university hospital. Sixty patients aged 27-64 yrs with a new episode of tennis elbow were recruited. Thirty patients were randomized to methylprednisolone and 30 to autologous blood group over 1 yr. Severity of pain within last 24 hrs; limb function; pain and strength in maximum grip; disabilities of the arm, shoulder, and hand quick questionnaire (Quick DASH) scores; modified Nirschl scores; and pressure pain threshold were evaluated before injection and at 4 and 8 wks after injection. We analyzed our data with the chi and t test.

RESULTS

Within-group analyses showed better results for autologous blood (all P values <0.001 except for grip strength, P = 0.005). In the corticosteroid group, differences in severity of pain (P = 0.008) and grip strength (P = 0.001) were significant. At 4 wks, between-group analyses showed superiority of autologous blood for severity of pain (P = 0.001), pain in grip (P = 0.002), pressure pain threshold (P = 0.031), and Quick DASH questionnaire score (P = 0.004). There were no significant differences in modified Nirschl score, grip strength, and limb function. At 8 wks, autologous blood was more effective in all the outcomes (all P values <0.001).

CONCLUSIONS

Autologous blood was more effective in short term than the corticosteroid injection.

Measurement issues in the sonographic assessment of tennis elbow

Sonography is increasingly being used for assessment in tennis elbow research and clinical practice, but there are a lack of data regarding its validity, reliability, and responsiveness to change for this application. Studies using the modality were reviewed to establish current levels of evidence for these measurement properties. There is reasonable evidence regarding its validity for identifying tennis elbow tendinopathy, but a lack of data addressing its reliability and responsiveness. Practical issues affecting image quality are discussed, and recommendations for further investigation are suggested, to enhance the credible use of sonography with this debilitating condition.

Management of Tennis Elbow with sodium hyaluronate periarticular injections

Objectives

To determine the efficacy and safety of peri-articular hyaluronic acid injections in chronic lateral epicondylosis (tennis elbow).

Design

Prospective randomized clinical trial in primary care sport medicine.

Patients

Three hundred and thirty one consecutive competitive racquette sport athletes with chronic (>3 months) lateral epicondylosis were administered 2 injections (first injection at baseline) into the subcutaneous tissue and muscle 1 cm. from the lateral epicondyle toward the primary point of pain using a two-dimensional fanning technique. A second injection was administered 1 week later.

Outcomes measures

Assessments were done at baseline, days 7, 14, 30, 90 and 356. Efficacy measures included patient's visual analogue scale (VAS) of pain at rest (0-100 mm) and following assessment of grip strength (0-100 mm). Grip strength was determined using a jamar hydraulic hand dynamometer. Other assessments included patients' global assessment of elbow injury (5 point categorical scale; 1 = no disability, 5 = maximal disability), patients' assessment of normal function/activity (5 point categorical scale), patients/physician satisfaction assessment (10 point categorical scale), time to return to pain-free and disability-free sport and adverse events as per WHO definition. Differences between groups were determined using an intent-to-treat ANOVA.

Results

Average age of the study population was 49 years (± 12 years). One hundred and sixty-five patients were randomized to the HA and 166 were randomized to the control groups. The change in VAS pain was -6.7 (± 2.0) for HA vs -1.3 (± 1.5) for control (p < 0.001). The VAS post handgrip was -7.8 (± 1.3) vs +0.3 (± 2.0) (p < 0.001) which corresponded to a significant improvement in grip of 2.6 kg in the HA vs control groups (p < 0.01). Statistically significant improvement in patients' global assessment of elbow injury (p < 0.02), patients' assessment of normal function/activity (p < 0.05) and patients/physician satisfaction assessment (p < 0.05) were also observed favoring the HA group. Time to return to pain-free and disability-free sport was 18 (± 11) days in the HA group but was not achieved in the control group. VAS changes were maintained in the HA group at each followup while those in the control significantly declined from baseline. Assessment of patient and physician satisfaction continued to favor the HA group at subsequent followup.

Conclusion

Peri-articular HA treatment for tennis elbow was significantly better than control in improving pain at rest and after maximal grip testing. Further, HA treatment was highly satisfactory by patients and physicians and resulted in better return to pain free sport compared to control.

Autologous blood and corticosteroid injection and extracoporeal shock wave therapy in the treatment of lateral epicondylitis

Lateral epicondylitis is a common disorder characterized by pain and tenderness over the lateral epicondyle. It occurs most frequently as a result of minor, unrecognized trauma during sports activities and occupation-related physical activities. The goal of this study was to evaluate the short-, medium-, and long-term effects of corticosteroid injection, autologous blood injection, and extracorporeal shock wave therapy in the treatment of lateral epicondylitis.Sixty patients (32 women, 28 men) with lateral epicondylitis were randomly divided into 3 groups: group 1 received a corticosteroid injection; group 2, an autologous blood injection, and group 3, extracorporeal shock wave therapy. Thomsen provocative testing, upper extremity functional scores, and maximal grip strength were used for evaluation. Outcomes were assessed at 4, 12, 26, and 52 weeks. Corticosteroid injection gave significantly better results for all outcome measures at 4 weeks; success rates in the 3 groups were 90%, 16.6%, and 42.1%, respectively. Autologous blood injection and extracorporeal shock wave therapy gave significantly better Thomsen provocative test results and upper extremity functional scores at 52 weeks; the success rate of corticosteroid injection was 50%, which was significantly lower than the success rates for autologous blood injection (83.3%) and extracorporeal shock wave therapy (89.9%). Corticosteroid injection provided a high success rate in the short term. However, autologous blood injection and extracorporeal shock wave therapy gave better long-term results, especially considering the high recurrence rate with corticosteroid injection. We suggest that the treatment of choice for lateral epicondylitis be autologous blood injection.

Cyriax physiotherapy versus phonophoresis with supervised exercise in subjects with lateral epicondylalgia: a randomized clinical trial

Cyriax and Cyriax advocated the use of deep transverse friction massage in combination with Mill's manipulation in treating lateral epicondylalgia. Evidence comparing this approach with other physical therapies is lacking. The purpose of this randomized clinical trial was to compare the effectiveness of deep transverse friction massage with Mill's manipulation versus phonophoresis with supervised exercise in managing lateral epicondylalgia. Sixty patients age 30-60, presenting with the teno-periosteal variety of lateral epicondylalgia with symptom duration greater than one month, were randomized into two groups. The control group received phonophoresis with diclofenac gel over the area of the lateral epicondyle for 5 minutes combined with supervised exercise. The experimental group received 10 minutes of deep transverse friction massage followed by a single application of Mill's manipulation. Both groups received treatment 3 times per week for 4 weeks. Outcomes of interest included pain via visual analog scale (VAS), pain-free grip strength, and functional status measured with the Tennis Elbow Function Scale. Data were analyzed using a one-way ANOVA. Whereas both groups improved significantly from the initiation of treatment, a between-group comparison revealed significantly greater (p<0.05) improvements regarding pain, pain-free grip, and functional status for the experimental group compared to the control group. The results of this study demonstrate that Cyriax physiotherapy is a superior treatment approach compared to phonophoresis and exercise in managing lateral epicondylalgia.

Effects of low-level laser and plyometric exercises in the treatment of lateral epicondylitis

OBJECTIVE

This study was undertaken to compare the effectiveness of a protocol of combination of laser with plyometric exercises and a protocol of placebo laser with the same program, in the treatment of tennis elbow.

BACKGROUND DATA

The use of low-level laser has been recommended for the management of tennis elbow with contradictory results. Also, plyometric exercises was recommended for the treatment of the tendinopathy.

METHODS

Fifty patients who had tennis elbow participated in the study and were randomised into two groups. Group A (n = 25) was treated with a 904 Ga-As laser CW, frequency 50 Hz, intensity 40 mW and energy density 2.4 J/cm(2), plus plyometric exercises and group B (n = 25) that received placebo laser plus the same plyometric exercises. During eight weeks of treatment, the patients of the two groups received 12 sessions of laser or placebo, two sessions per week (weeks 1-4) and one session per week (weeks 5-8). Pain at rest, at palpation on the lateral epicondyle, during resisted wrist extension, middle finger test, and strength testing was evaluated using Visual Analogue Scales. Also it was evaluated the grip strength, the range of motion and weight test. Parameters were determined before the treatment, at the end of the eighth week course of treatment (week 8), and eighth (week 8) after the end of treatment.

RESULTS

Relative to the group B, the group A had (1) a significant decrease of pain at rest at the end of 8 weeks of the treatment (p < 0.005) and at the end of following up period (p < 0.05), (2) a significant decrease in pain at palpation and pain on isometric testing at 8 weeks of treatment (p < 0.05), and at 8 weeks follow-up (p < 0.001), (3) a significant decrease in pain during middle finger test at the end of 8 weeks of treatment (p < 0.01), and at the end of the follow-up period (p < 0.05), (4) a significant decrease of pain during grip strength testing at 8 weeks of treatment (p < 0.05), and at 8 weeks follow-up (p < 0.001), (5) a significant increase in the wrist range of motion at 8 weeks follow-up (p < 0.01), (6) an increase in grip strength at 8 weeks of treatment (p < 0.05) and at 8 weeks follow-up (p < 0.01), and (7) a significant increase in weight-test at 8 weeks of treatment (p < 0.05) and at 8 weeks follow-up (p < 0.005).

CONCLUSION

The results suggested that the combination of laser with plyometric exercises was more effective treatment than placebo laser with the same plyometric exercises at the end of the treatment as well as at the follow-up. Future studies are needed to establish the relative and absolute effectiveness of the above protocol.

Steroid injection therapy is the best conservative treatment for lateral epicondylitis: a prospective randomised controlled trial

The relative merits of a watch and wait policy, physiotherapy alone, steroid injection therapy alone, and physiotherapy and steroid injection therapy combined, for the treatment of tennis elbow, were assessed using a prospective randomised controlled trial (RCT) of factorial design. Although RCTs comparing different treatment strategies for tennis elbow have previously been published, to our knowledge none of the previous studies have combined the modalities of physiotherapy and steroid injection as one of the treatment groups, as we have done in this study. Patients who received steroid injection were statistically significantly better for all outcome measures at follow up. No statistically significant effect of physiotherapy nor interaction between physiotherapy and injection was found. On the basis of the results of this study, the authors advocate steroid injection alone as the first line of treatment for patients presenting with tennis elbow demanding a quick return to daily activities.

Effectiveness of low-level laser therapy for lateral elbow tendinopathy

OBJECTIVE

Our aim was to determine the effectiveness of low-lever laser therapy (LLLT) in the management of lateral elbow tendinopathy (LET) and to provide recommendations based on this evidence.

BACKGROUND DATA

LET is a common clinical condition, and a wide array of physiotherapy treatments is used for treating LET.

METHODS

Randomized controlled trials (RCTs) identified by a search strategy in six databases were used in combination with reference checking. RCTs that included LLLT, patients with LET, and at least one of the clinically relevant outcome measure were selected. Aqualitative analysis of the selected studies was conducted using the Chalmers' technique.

RESULTS

Nine RCTs fulfilled the criteria and were included in the review. Although these studies had satisfactory methodology, shortcomings were not absent; poor results were revealed as to the effectiveness of LLLT for LET management.

CONCLUSIONS

LLLT need not be ruled out for LET as it is a dose-response modality, and the optimal treatment dose has obviously not yet have been discovered. Further research with well-designed RCTs is needed to establish the absolute and relative effectiveness of this intervention for LET.

Treatment of lateral epicondylitis: where is the evidence?

Lateral epicondylitis is the most commonly diagnosed elbow condition and affects about 1-3% of the population at large. It produces a heavy burden of workdays lost and residual impairments. Although many treatment modalities are used, few of them rest on scientific evidence and none has been proven more effective than the others. This paucity of evidence on treatments for lateral epicondylitis may stem from several sources, including the possible self-limiting nature of the condition, the lack of pathophysiological data, the methodological shortcomings of available studies, and the existence of numerous factors influencing the outcome.

Exploring the Evidence for Occupational Therapists' Interventions with Clients with Lateral Epicondylitis

Lateral epicondylitis is known to be a major problem in work absenteeism and permanent partial disability. Although occupational therapists are often asked to treat clients with this disorder, its management remains controversial since there is insufficient research evidence to favour any particular intervention. This study gathered information on the current interventions used by occupational therapists with clients with lateral epicondylitis according to three phases: acute, subacute and chronic. A self-administered questionnaire was sent to a convenience sample of 219 occupational therapists working in the province of Québec in Canada.

After two reminders, a participation rate of 81% was obtained. Over 20 interventions were identified and sorted into five categories: education, activities/exercises, assistive devices, environment and pain management modalities. Overall, education about risk factors was the most frequently used intervention by occupational therapists in all phases. Activities/exercises formed the second most frequently used intervention group, but were more preferred in the subacute and chronic phases.

Although many interventions are currently used in health care facilities, few studies on their effectiveness have been conducted. This study explored the gap between research and practice by surveying clinicians on their management of clients with lateral epicondylitis, allowing the targeting of areas considered useful for future studies in occupational therapy.

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.

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.

The initial effects of an elbow mobilization with movement technique on grip strength in subjects with lateral epicondylalgia

This preliminary study indicates the proportion of patients with lateral epicondylalgia that demonstrate a favourable initial response to a manual therapy technique - the mobilization with movement (MWM) for tennis elbow. Twenty-five subjects with lateral epicondylalgia participated. In a one-group pretest - post-test design, we measured (1) pain with active motion, (2) pain-free grip strength and, (3) maximum grip strength before and after a single intervention of MWM. Results of the study indicate that MWM was effective in allowing 92% of subjects to perform previously painful movements pain-free, and improving grip strength immediately afterwards. Significant differences were found between the grip strength of the affected and unaffected limbs prior to the intervention. Both pain-free grip strength and maximum grip strength of the affected limb increased significantly following the intervention. Pain-free grip strength increased by a greater magnitude than maximum grip strength. It can be concluded that MWM is a promising intervention modality for the treatment of patients with Lateral Epicondylalgia. Pain-free grip strength is a more responsive measure of outcome than maximum grip strength for patients with Lateral Epicondylalgia. Further research is warranted to investigate the long-term effectiveness of MWM in the treatment of impairment and disability resulting from Lateral Epicondylalgia.

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.

A new technique for the selective recording of extensor carpi radialis longus and brevis EMG

Tennis Elbow or Lateral Epicondylalgia is manifested by pain over the region of the lateral epicondyle of the humerus, related to use of the wrist extensor muscles. Extensor carpi radialis longus (ECRL) and brevis (ECRB) have been implicated in the dysfunction associated with Lateral Epicondylalgia. For muscles in the human forearm, particularly those in close proximity, selective recordings are nearly impossible without the use of fine wire, indwelling electrodes. These can be inserted in precise locations and have small recording areas. Standard electromyography texts indicate, however, that the activity of ECRL and ECRB cannot be distinguished, even with intramuscular electrodes. We present a new technique for determining the most appropriate sites at which to insert intramuscular electrodes for selective recordings of ECRB and ECRL. The location of ECRB and ECRL was measured on 10 cadaver specimens, 5 right arms and 5 left arms. The distance from the muscle origin to (1) insertion, (2) largest portion of the muscle belly, (3) most proximal fibres and (4) most distal fibres were measured and expressed relative to forearm length. The mean distance and 95% confidence interval was calculated for each of the four measures. These data indicated a significant separation of the belly of each muscle along the length of the forearm. These relative distances were used to mark electrode insertion points on three volunteers. Fine wire electrodes were used to record the electromyogram in three participants. Each participant was required to perform isometric contractions to produce (1) wrist extension torque, (2) radial deviation torque, (3) elbow flexion torque and (4) finger extension. The electromyographic recordings show clear differentiation of ECRB and ECRL with the relative activation patterns reflecting the underlying anatomical organisation of the two muscles. This technique provides an important objective method that can be used in conjunction with manual muscle testing to provide a means of ensuring accurate intramuscular electromyographic recording from these two muscles.