No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
The effect of cryotherapy and exercise on lateral epicondylitis: A controlled randomised study
Abstract
Aims: The purposes of this randomised clinical trial were to determine the effect that exercise, cryotherapy, and exercise with cryotherapy have on treating lateral epicondylitis. The therapeutic efficacy of a newly designed controlled release cold pack was also investigated.
Methods: Grip strength and pain were measured, and the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) was given before and after a home programme consisting of either exercise only, exercise with a conventional cold pack, exercise with a Cryo-MAX®, and Cryo-MAX® without exercise. Cryo-Max® is the commercial name given to the cold pack that remains consistently cold for an extended time.
Findings: ANCOVA showed significant improvements between pre and post-treatment values for DASH, pain level, and grip strength for all subject groups receiving treatment. No treatment group was superior to the other, indicating that exercise and cryotherapy alone was as effective as the combination of exercise and cryotherapy. In addition, the type of cold pack used (conventional or Cryo-Max®) also showed no significant difference.
Conclusions: Exercise and cryotherapy used in isolation or in combination reduces the symptoms of lateral epicondylitis. Cryo-MAX® was preferred over conventional cold packs but it did not have any additional therapeutic benefit.
... 26 28-31 33-55 Ten studies (33%) included pain provoked by gripping or decreased PFGS. [27][28][29] 32 33 35 42 45 52 55 Eleven studies (37%) used stretching of forearm extensor muscles for inclusion. 28 29 32 35 40-42 45 48 52 53 Exercise as an intervention was used alone, in combination with physiotherapy, and as a home exercise programme (HEP). ...
... 28 29 32 35 40-42 45 48 52 53 Exercise as an intervention was used alone, in combination with physiotherapy, and as a home exercise programme (HEP). Nine of the included trials compared exercise with invasive treatment, 26 28 43 50 53 three trials with forearm support band (FSB), 31 44 47 four trials with physiotherapy with or without modalities, 32 35 52 54 two trials with ultrasound, 40 41 four trials made a direct or indirect comparison of eccentric and concentric exercises, 33 39 45 51 one trial with cryotherapy, 27 one trial with the addition of Pilates-based exercises, 29 one trial with the addition of scapular strengthening exercises, 42 one trial with delayed exercise initiation and use of nonsteroidal anti-inflammatory drugs (NSAIDs), 37 one study with propioceptive neuromuscular facilitation (PNF) stretching, 48 one trial with neural tension techniques of the radial nerve 30 and one with manipulation techniques of the wrist. 46 ...
... Three studies with high risk of bias were excluded from further analyses mainly due to inability to retrieve data from the publications. 27 48 54 There were non-significant differences between exercises and cryotherapy, 27 Pilates-based exercises, 29 a delayed programme of isometric exercises after 1 month of oral NSAIDs, 37 PNF stretching, 48 wrist manipulation, 46 physiotherapy programme 54 and neural tension techniques 30 in all comparators and follow-up occassions (online supplemental material 5). There were statistically significant differences in favour of exercises (physiotherapy ±HEP) compared with prolotherapy in mean change in pain rating and PFGS at short-term follow-up 55 and in favour of the Table 3 Pain intensity, pain-free grip strength and elbow disability (DASH) for eccentric exercise compared with concentric (±eccentric) exercises with or without physiotherapy or home exercise programme Review addition of scapular strengthening compared with standard care in all comparisons at very short-term follow-up 42 (online supplemental material 5). ...
Objective:
To evaluate the effectiveness of exercise compared with other conservative interventions in the management of lateral elbow tendinopathy (LET) on pain and function.
Design:
Systematic review and meta-analysis.
Methods:
We used the Cochrane risk-of-bias tool 2 for randomised controlled trials (RCTs) to assess risk of bias and the Grading of Recommendations Assessment, Development and Evaluation methodology to grade the certainty of evidence. Self-perceived improvement, pain intensity, pain-free grip strength (PFGS) and elbow disability were used as primary outcome measures.
Eligibility criteria:
RCTs assessing the effectiveness of exercise alone or as an additive intervention compared with passive interventions, wait-and-see or injections in patients with LET.
Results:
30 RCTs (2123 participants, 5 comparator interventions) were identified. Exercise outperformed (low certainty) corticosteroid injections in all outcomes at all time points except short-term pain reduction. Clinically significant differences were found in PFGS at short-term (mean difference (MD): 12.15, (95% CI) 1.69 to 22.6), mid-term (MD: 22.45, 95% CI 3.63 to 41.3) and long-term follow-up (MD: 18, 95% CI 11.17 to 24.84). Statistically significant differences (very low certainty) for exercise compared with wait-and-see were found only in self-perceived improvement at short-term, pain reduction and elbow disability at short-term and long-term follow-up. Substantial heterogeneity in descriptions of equipment, load, duration and frequency of exercise programmes were evident.
Conclusions:
Low and very low certainty evidence suggests exercise is effective compared with passive interventions with or without invasive treatment in LET, but the effect is small.
Prospero registration number:
CRD42018082703.
... Four studies had a placebo or sham control 171,186,187,189 and the remainder (n = 32) were head-to-head studies. 18,[167][168][169][170][172][173][174][175][176][177][178][179][180][181][182][183][184][185][188][189][190][191][192][193][194][195][196][197][198] The majority of studies had small sample sizes (≤ 50 participants, n = 18; 51-100 participants, n = 15; > 100 participants, n = 3). ...
... Given the paucity of the available data (one RCT with moderate-quality evidence for pain relief in the intermediate term 112 ), the overall low level of evidence as determined using the GRADE principles (see Table 24) and the subsequent publication of four relevant RCTs, 18,164,166,172 we conclude that there is insufficient evidence at present to demonstrate either benefit or lack of effect of exercises for LET. All of the subsequent RCTs identified are recent publications 18,164,166,172 In addition, seven RCTs were identified that were included in an intermediate-/low-quality systematic review. ...
... Given the paucity of the available data (one RCT with moderate-quality evidence for pain relief in the intermediate term 112 ), the overall low level of evidence as determined using the GRADE principles (see Table 24) and the subsequent publication of four relevant RCTs, 18,164,166,172 we conclude that there is insufficient evidence at present to demonstrate either benefit or lack of effect of exercises for LET. All of the subsequent RCTs identified are recent publications 18,164,166,172 In addition, seven RCTs were identified that were included in an intermediate-/low-quality systematic review. 137,141,149,151,157,162,163 An updated, good-quality systematic review of exercises for LET is needed before stronger recommendations can be made; however, we suggest that some consideration should also be given to conducting large-scale, good-quality RCTs of clearly defined exercise modalities with sufficient follow-up periods (to 1 year). ...
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.
This systematic review aims to summarise the evidence concerning the clinical effectiveness and cost-effectiveness of conservative interventions for LET.
A comprehensive search was conducted from database inception to 2012 in a range of databases including MEDLINE, EMBASE and Cochrane Databases.
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.
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.
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.
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.
This study is registered as PROSPERO CRD42013003593.
The National Institute for Health Research Health Technology Assessment programme.
... It can also cause vasoconstriction of superficial blood thereby reducing any chemical pain if present 39 . The authors (study itself) want to suggest to the clinicians that ice massage should be there first choice (until otherwise contradicted) as it is well known to be an integral part of any multimodal program meant for treating tendinopathies 40 . But involvement of ice as a direct massage tool and its direct skin contact may not be readily acceptable for all individuals. ...
... Another alternative way is to do ice therapy at the elbow region, 3-4 times daily for 10 minutes each time. It will help in pain reduction 40,41 . According to ' Achilles and Patellar Tendinopathies 12 Eccentric exercises are the gold standard to recupurate from tendon overuse injuries and in prevention of further re-injuries 42 . ...
This literature review article has drawn attention to the current available physical therapies which can be applied in managing Tennis Elbow or lateral epicondylitis (LET) whose prevalence is about 3% in general population and about 20% in elderly population. This condition is characterised by lesions in Extensor Carpi Radialis Brevis muscle leading to painful and debilitating musculoskeletal condition and affecting the overall quality of life of a patient. The review has also discussed the updated pathophysiological findings in this condition. The study has discussed that tennis elbow is degenerative disorder and initially caused by inflammation. The typical pathology found is presence of disorderly arrangement of immature collagen fibers consisting of fibroblastic and vascular components. Finally, the review has discussed several methods of physical therapies to manage tennis elbow. This includes counterforce bracing, Soft tissue techniques, various modalities , various exercises including Wrist extensor eccentric exercise, stabilization exercise, Stretching exercises, Eccentric strengthening exercise and. Overall, the review brings updated guidelines of the exercises and physical rehabilitation therapy points for managing LET or Tennis Elbow. Keywords tennis elbow, musculoskeletal condition, elbow pain, physical therapy
... There is insufficient number of studies reporting on analgesic use to evaluate the certainty of evidence, only one and of high risk of bias (Meng et al., 2018). No adverse events were found in the study reporting on the occurrence of adverse events (Agostinucci et al., 2012). ...
... The modality of cryotherapy may be of importance (Agostinucci et al., 2012;Barca et al., 2016;Bech et al., 2015;Modabber et al., 2013;Moro et al., 2011;Rana et al., 2011Rana et al., , 2013Ruffilli et al., 2015;Schinsky et al., 2016;Thienpont, 2014). However, there was a large variation in terms of temperature, timing and dose in the included studies. ...
... One of the most troublesome symptoms of LE is pain in the area of the lateral epicondyle, which occurs during the activity of wrist extensors. Therefore, to evaluate the clinical effect of LC, we assessed pain on the VAS scale during resisted wrist extension before and immediately after the treatment [18,38,57]. Pain was measured on a visual analogue scale (VAS), where 0 (cm) was "least pain imaginable" and 10 (cm) was "worst pain imaginable" [58]. ...
... A similar effect of increased grip strength (pain-free grip or handgrip strength) and reduced pain was demonstrated after an exercise programme with ice therapy [18], after manual therapy and local cryostimulation (high-pressure refrigerated carbon dioxide microcrystals at −78 • C) [38], after exercise with a conventional cold pack [57], and after cryoultrasound therapy sessions (a new technology that combines the therapeutic ultrasound 1.8 W/cm 2 with cryotherapy at a temperature of −2 • C) [69]. Although cryotherapy is one of the therapies that make up a comprehensive rehabilitation program for treating lateral elbow tendinopathy [70], no evidence was found evaluating only the effect of LC on this enthesopathy symptoms. ...
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.
... 95 In the inflammatory stage of healing, cryotherapy may be safe and effective as a supplementary intervention. 96 Although there are no known adverse effects of cryotherapy treatment, there is no evidence for its effectiveness after 6 weeks of the initial onset of symptoms. 96 As a whole, physical agents do not appear to be consistently effective as a primary intervention in the management of LET. ...
... 96 Although there are no known adverse effects of cryotherapy treatment, there is no evidence for its effectiveness after 6 weeks of the initial onset of symptoms. 96 As a whole, physical agents do not appear to be consistently effective as a primary intervention in the management of LET. There is some evidence for the use of physical agents to resolve pain associated with LET in the short term, but most studies recommend incorporating physical agents with patient education and exercise into the plan of care. ...
... There is insufficient number of studies reporting on analgesic use to evaluate the certainty of evidence, only one and of high risk of bias (Meng et al., 2018). No adverse events were found in the study reporting on the occurrence of adverse events (Agostinucci et al., 2012). ...
... The modality of cryotherapy may be of importance (Agostinucci et al., 2012;Barca et al., 2016;Bech et al., 2015;Modabber et al., 2013;Moro et al., 2011;Rana et al., 2011Rana et al., , 2013Ruffilli et al., 2015;Schinsky et al., 2016;Thienpont, 2014). However, there was a large variation in terms of temperature, timing and dose in the included studies. ...
Purpose
This review aimed to evaluate the certainty of evidence for the use of cryotherapy in patients with musculoskeletal disorders.
Methods
PubMed, Embase, Cochrane Library and AMED were searched from January 2000 to January 2018 (update June 2019) for systematic reviews (SRs) and randomized controlled trials (RCTs) reporting outcomes on pain, swelling, range of motion (ROM), function, blood loss, analgesic use, patient satisfaction and adverse advents. The papers were categorised into: after surgical procedures, acute pain or injury and long-term pain or dysfunction. Methodological quality and risk of bias were assessed using the AMSTAR and the Swedish Health Technology Assessment instruments. Level of certainty of evidence was synthesized using GRADE.
Study selection
Eight SRs and 50 RCTs from a total of 6027 (+ 839) were included. In total 34 studies evaluated cryotherapy in surgical procedures, twelve evaluated cryotherapy use in acute pain or injury and twelve studies evaluated cryotherapy in long-term pain and dysfunction.
Results
The certainty of evidence is moderate (GRADE III) after surgical procedures to reduce pain, improve ROM, for patient satisfaction and few adverse events are reported. Cryotherapy in acute pain and injury or long-term pain and dysfunction show positive effects but have a higher number of outcomes with low certainty of evidence (GRADE II)
Conclusion
Cryotherapy may safely be used in musculoskeletal injuries and dysfunctions. It is well tolerated by patients. More advanced forms of cryotherapy may accentuate the effect. Future research is needed where timing, temperature for cooling, dose (time) and frequency are evaluated.
... Age and sex were commonly reported across the review, with a mean (SD) participant age of 46 (7.7) years (median 48 years). The sex of the included participants was not reported in 6/45 studies (Cherry et al., 2012;Engebretsen et al., 2009;Koch et al., 2015;Nagrale et al., 2009;Tonks et al., 2007;Yelland et al., 2019) with the majority of studies using a mixed sample, with an almost even breakdown in male:female ratio (Males 1618; Females 2014). Height and weight were reported in only 14/45 and 13/45 studies respectively, with a mean of 173 cm and 78 kg for height and weight respectively. ...
... One study by Nejati et al. (Nejati et al., 2017) outlined a minimum age of 40 years, while another study by Visnes et al. (Visnes et al., 2005) included participants between 18 and 35 years old. Ten studies in the review specified a minimum severity of symptoms and/or disability for inclusion (Yelland et al., 2019) (Cherry et al., 2012) (Visnes et al., 2005) (Yelland et al., 2011) (Vuvan et al., 2019) (Bennell et al., 2010) (Rompe et al., 2010) (Lombardi et al., 2008) (Roos et al., 2004). The minimum level of severity specified for inclusion varied across tendons and was based on both (Roos et al., 2004 ...
Objective
To evaluate the reporting of eligibility criteria and baseline participant characteristics in randomised controlled trials investigating the effects of exercise interventions in tendinopathy.
Methods
Randomised controlled trials investigating the effects of exercise therapy compared to a non-exercising intervention in upper and lower limb tendinopathy were included. Data extraction was categorised into the following domains: participant demographics, tendinopathy descriptors, general health, participant recruitment and eligibility criteria.
Results
The review included the following tendinopathies: Achilles (n = 9), gluteal (n = 2), lateral elbow tendinopathy (n = 15), patellar (n = 3) plantar (n = 3), and rotator cuff (n = 13). Age, sex, duration of symptoms and symptom severity were commonly reported across the review, while prior history of tendinopathy was poorly reported (6/45). Variables such as physical activity level (17/45), sleep (0/45), psychological factors (2/45), medication at baseline (8/45), co morbid health complaints (10/45) and sociodemographic factors (11/45) were poorly reported across the included studies. Substantial variation existed between studies in the specific eligibility criteria used.
Conclusion
The findings of this systematic review demonstrate that participant characteristics are poorly reported in exercise trials in tendinopathy. To improve effectiveness of exercise interventions in tendinopathy, improved reporting of participant characteristics may allow better comparisons and targeted interventions for specific subgroups.
... Another study showed that friction massage combined with therapeutic ultrasound reduces pain in individuals with lateral epicondylitis [26]. Moreover, a study showed that cryotherapy is effective in reducing pain in patients with lateral epicondylitis [27]. ...
This study was conducted to investigate the effect of extracorporeal shock-wave therapy (ESWT) on pain, grip strength, and upper-extremity function in lateral epicondylitis. A sample of 40 patients with LE (21 males) was randomly allocated to either the ESWT experimental (n = 20) or the conventional-physiotherapy control group (n = 20). All patients received five sessions during the treatment program. The outcome measures used were the Visual Analog Scale (VAS), the Taiwan version of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, and a dynamometer (maximal grip strength). Forty participants completed the study. Participants in both groups improved significantly after treatment in terms of VAS (pain reduced), maximal grip strength, and DASH scores. However, the pain was reduced and upper-extremity function and maximal grip strength were more significantly improved after ESWT in the experimental group. ESWT has a superior effect in reducing pain and improving upper-extremity function and grip strength in people with lateral epicondylitis. It seems that five sessions of ESWT are optimal to produce a significant difference. Further studies are strongly needed to verify our findings.
... Par ailleurs, l'étude de Agostinucci et al. [14] ne montre ni de supériorité de traitement ni d'amé-lioration significative entre les groupes ayant reçu différents protocoles de froid et le groupe contrôle ayant bénéficié uniquement de rééducation. ...
Iterative lateral epicondylitis develop after an incomplete treat- ment, early resumption of a sport or work causing excessive stress on the tendons.
To avoid recurrence and chronicity, establishing a self-rehabilita- tion protocol that takes little time in the patient's day requires little equipment and containing the most effective means described in the literature, seems to guarantee maximum results.
... In this case, the clinician has the option of providing a homemade or commercial ice pack with one thin layer (typically a pillow case) to the lateral elbow after treatment in the clinic. 54 Patients should also be instructed to perform cryotherapy at home and to apply the ice massage over the painful area for 3-5 minutes, especially after an aggravating activity. As an alternative, the patient is given the option to apply an ice pack to the elbow for 10 minutes up to 3-4 times a day to reduce pain. ...
Scapular muscle weakness in patients with lateral elbow tendinopathy is an identified impairment and is part of a multimodal rehabilitation approach. The published literature provides little information regarding specific rehabilitation guidelines that address both the proximal scapular muscle weakness and local elbow/wrist dysfunctions common in patients with lateral elbow tendinopathy. The purpose of this clinical commentary is to describe a comprehensive rehabilitation strategy for individuals with lateral elbow tendinopathy. This program emphasizes a phased therapeutic strategy that addresses proximal and local dysfunction along the kinetic chain. This clinical protocol is currently being tested for efficacy as part of a randomized controlled trial. The information in this commentary is intended to provide clinicians with sufficient detail to comprehensively guide the rehabilitation of a patient with lateral elbow tendinopathy.
Level of evidence:
5.
... 15 Similarly, the use of ice alone has been estimated to be as effective as physical therapy in decreasing disability scores; and no additional benefit was found with combination of interventions. 19 During the late tendon disrepair/degenerative tendinopathy stage, management should focus on interventions that stimulate cell activity, increase protein production, and restructure the matrix. Main attention should be brought on eccentric exercises that have been shown to be beneficial for function, return to activity, and pain reduction in 4 to 6 weeks. ...
The aim of this case report is to differentiate the recovery timeline expected for patients with simple lateral epicondylitis from an abnormal recovery period, in which case an underlying condition should be suspected.
A 49-year-old woman presented to a chiropractic clinic with posterolateral right elbow pain. The history included chronic recurrent lateral elbow pain, followed by a traumatic event leading to sustained pain and disability.
Following a trial of conservative therapy including activity restrictions, soft tissue therapy, joint mobilizations, and therapeutic ultrasonography that led to no significant improvement, the patient was referred for diagnostic imaging that revealed hydroxyapatite dihydrite deposition disease.
This report describes a case for which lateral epicondylitis symptoms failed to resolve because of an underlying condition (hydroxyapatite dihydrite deposition disease). This case emphasizes that primary care practitioners treating lateral epicondylitis should consider referral for further investigations when positive results are not achieved.
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.
Context:
There is a lack of consensus on the best management approach for lateral elbow tendinopathy (LET). Recently, scapular stabilizer strength impairments have been found in individuals with LET.
Objective:
The purpose of this study was to compare the effectiveness of local therapy (LT) treatment to LT treatment plus a scapular muscle-strengthening (LT + SMS) program in patients diagnosed with LET.
Design:
Prospective randomized clinical trial.
Setting:
Multisite outpatient physical therapy.
Patients:
Thirty-two individuals with LET who met the criteria were randomized to LT or LT + SMS.
Interventions:
Both groups received education, a nonarticulating forearm orthosis, therapeutic exercise, manual therapy, and thermal modalities as needed. Additionally, the LT + SMS group received SMS exercises.
Main outcome measure:
The primary outcome measure was the patient-rated tennis elbow evaluation; secondary outcomes included global rating of change (GROC), grip strength, and periscapular muscle strength. Outcomes were reassessed at discharge, 6, and 12 months from discharge. Linear mixed-effect models were used to analyze the differences between groups over time for each outcome measure.
Results:
The average duration of symptoms was 10.2 (16.1) months, and the average total number of visits was 8.0 (2.2) for both groups. There were no significant differences in gender, age, average visits, weight, or height between groups at baseline (P > .05). No statistical between-group differences were found for any of the outcome measures. There were significant within-group improvements in all outcome measures from baseline to all follow-up points (P < .05).
Conclusion:
The results of this pilot study suggest that both treatment approaches were equally effective in reducing pain, improving function, and increasing grip strength at discharge as well as the 6- and 12-month follow-ups. Our multimodal treatment programs were effective at reducing pain and improving function up to 1 year after treatment in a general population of individuals with LET.
Purpose: The aim of this study was to develop evidence-based nursing practice guidelines for cold application in adult care. Methods: The study procedure was based on the Scottish Intercollegiate Guidelines Network and Korean Hospital Nurses Association's guideline development methods. The evidence review procedures included targeted searches from databases including the Cochrane Library, PubMed, CINAHL, Embase, KoreaMed, KERIS and NDSL. The initial search yielded 6,426 articles published from 2006 to 2016. Based on the screening process, 147 articles were selected and systematically reviewed. From evidence summaries of 20 clinical questions, recommendations were formulated and graded. Draft recommendation were evaluated through external review. Results: The guidelines consisted of 10 domains and 27 recommendations. The content validity index of the recommendations was above .80. Major recommendations include 1) applying external cooling to reduce acute pain, edema, and hemorrhage, 2) selecting cooling instruments based on the purpose, patient's condition, and preference, 3) preparing and maintaining cooling instruments at an adequate temperature, and 4) intermittent cold application for appropriate durations with sufficient recovery time. Conclusion: These guidelines can be utilized in both clinical and community settings to help narrow the gaps between nursing practices.
Background:
Core stability and flexibility, features of Pilates exercise, can reduce loads to the upper extremities. Reducing loads is essential to improve symptoms for individuals with lateral epicondylosis. Although Pilates exercise has gained popularity in healthy populations, it has not been studied for individuals with lateral epicondylosis.
Objective:
The purpose of this study was to determine if adding Pilates-based intervention to standard occupational therapy intervention improved outcomes as measured by the Patient-Rated Tennis Elbow Evaluation (PRTEE) more than standard intervention for individuals with lateral epicondylosis.
Methods:
Participants (N= 17) were randomized to the standard intervention group or Pilates-based intervention group. All participants received standard intervention. The Pilates-based intervention group additionally completed abdominal strengthening, postural correction, and flexibility.
Results:
For both groups, paired t-tests showed significantly improved PRTEE scores, 38.1 for the Pilates-based intervention group, and 22.9 for the standard intervention group. Paired t-test showed significantly improved provocative grip strength and pain for both groups. Independent t-tests showed no significant difference between groups in improved scores of PRTEE, pain, and provocative grip.
Conclusions:
Although the Pilates-based intervention group showed greater improvement in PRTEE outcome, provocative grip, and pain, scores were not significantly better than those of the standard intervention group, warranting further research.
Cryotherapy is a widely used modality following acute joint injury. It is considered helpful in reducing pain and swelling, and there is a growing body of evidence to suggest that it may have additional benefits in muscle function. Following joint injury, it is common for patients to experience persistent muscle weakness that is resistant to traditional strengthening exercises. This may be due to a reflex inhibition of musculature surrounding the injured joint. The underlying cause of this reflex inhibition may arise from aberrant sensory information from the joints' neural receptors, which result in a neural inhibition of motor neurons. This inhibition is beyond conscious control, is ongoing, and impedes normal joint function via a disruption of normal muscle function. Cryotherapy treatments targeted at peripheral joints have been shown to result in transient resolution of reflex inhibition, which thereby provide an environment where injured patients can benefit from a more thorough motorneuron pool during controlled rehabilitation exercises. This article presents current evidence-based recommendations regarding the use of joint cryotherapy for maximizing the effectiveness of commonly used rehabilitation exercises in patients recovering from joint injury.
Home and supervised exercise programmes consisting of stretching and eccentric exercises have been recommended for the management of lateral elbow tendinopathy (LET). No studies have examined their comparative efficacy effectiveness.
In this study, whether a home exercise programme is more successful than a supervised exercise programme in treating patients with LET was investigated.
Patients with unilateral LET for at least 4 weeks were included in this trial. They were sequentially allocated to receive either a home exercise programme or a supervised exercise programme five times a week for 12 weeks. The exercise programme consisted of slow progressive eccentric exercises of wrist extensors and static stretching of the extensor carpi radialis brevis tendon. Outcome measures were pain, using a visual analogue scale, and function, using a visual analogue scale and the pain-free grip strength. Patients were evaluated at baseline, at the end of treatment (week 12), and 3 months (week 24) after the end of treatment.
70 patients met the inclusion criteria. At the end of treatment, there was a decline in pain and a rise in function in both groups compared with baseline (p<0.0005, paired t test). There were significant differences in the reduction of pain and the improvement of function between the groups at the end of treatment and at the 3-month follow up; the supervised exercise programme produced the largest effect (p<0.0005, independent t test).
Supervised exercise programme is superior to home exercise programme to reduce pain and improve function in patients with LET at the end of the treatment and at the follow-up. Further research is needed to confirm our results.
We prospectively studied the effect of heavy-load eccentric calf muscle training in 15 recreational athletes (12 men and 3 women; mean age, 44.3 +/- 7.0 years) who had the diagnosis of chronic Achilles tendinosis (degenerative changes) with a long duration of symptoms despite conventional nonsurgical treatment. Calf muscle strength and the amount of pain during activity (recorded on a visual analog scale) were measured before onset of training and after 12 weeks of eccentric training. At week 0, all patients had Achilles tendon pain not allowing running activity, and there was significantly lower eccentric and concentric calf muscle strength on the injured compared with the noninjured side. After the 12-week training period, all 15 patients were back at their preinjury levels with full running activity. There was a significant decrease in pain during activity, and the calf muscle strength on the injured side had increased significantly and did not differ significantly from that of the noninjured side. A comparison group of 15 recreational athletes with the same diagnosis and a long duration of symptoms had been treated conventionally, i.e., rest, nonsteroidal antiinflammatory drugs, changes of shoes or orthoses, physical therapy, and in all cases also with ordinary training programs. In no case was the conventional treatment successful, and all patients were ultimately treated surgically. Our treatment model with heavy-load eccentric calf muscle training has a very good short-term effect on athletes in their early forties.
This paper reviews the relative strengths and weaknesses of outcome and process measures as performance indicators in health care. Differences in outcome may be due to case mix, how the data were collected, chance, or quality of care. Health care is only one determinant of health and other factors have important effects on health outcomes, such as nutrition, environment, lifestyle and poverty. The advantages of process measures are that they are more sensitive to differences in the quality of care and they are direct measures of quality. However, outcome measures are of greater intrinsic interest and can reflect all aspects of care, including those that are otherwise difficult to measure such as technical expertise and operator skill. Outcome indicators can be improved if efforts are made to standardize data collection and case mix adjustment systems are developed and validated. It is argued that this is worth doing only where it is likely that variations in health care might lead to significant variations in health outcome and where the occurrence of the outcome is sufficiently common that the outcome indicator will have the power to detect real differences in quality. If these conditions are not met, then alternative strategies such as process measurement and risk management techniques may be more effective at protecting the public from poor quality care.
As consumers, payers, and regulatory agencies require evidence regarding health care qualities the demand for process of care measures will grow. Although outcome measures of quality represent the desired end results of health care, validated process of care measures provide an important additional element to quality improvement efforts, as they illuminate exactly which provider actions could be changed to improve patient outcomes. In this essay, we discuss the advantages and disadvantages of process measures of quality, and outline some practical strategies and issues in implementing them.
Lateral epicondylitis is generally treated with corticosteroid injections or physiotherapy. Dutch clinical guidelines recommend a wait-and-see policy. We compared the efficacy of these approaches.
Patients with lateral epicondylitis of at least 6 weeks' duration were recruited by family doctors. We randomly allocated eligible patients to 6 weeks of treatment with corticosteroid injections, physiotherapy, or a wait-and-see policy. Outcome measures included general improvement, severity of the main complaint, pain, elbow disability, and patient satisfaction. Severity of elbow complaints, grip strength, and pressure pain threshold were assessed by a research physiotherapist who was unaware of treatment allocation. We assessed all outcomes at 3, 6, 12, 26, and 52 weeks. The principal analysis was done on an intention-to-treat basis.
We randomly assigned 185 patients. At 6 weeks, corticosteroid injections were significantly better than all other therapy options for all outcome measures. Success rates were 92% (57) compared with 47% (30) for physiotherapy and 32% (19) for wait-and-see policy. However, recurrence rate in the injection group was high. Long-term differences between injections and physiotherapy were significantly in favour of physiotherapy. Success rates at 52 weeks were 69% (43) for injections, 91% (58) for physiotherapy, and 83% (49) for a wait-and-see policy. Physiotherapy had better results than a wait-and-see policy, but differences were not significant.
Patients should be properly informed about the advantages and disadvantages of the treatment options for lateral epicondylitis. The decision to treat with physiotherapy or to adopt a wait-and-see policy might depend on available resources, since the relative gain of physiotherapy is small.
The disabilities of the arm, shoulder and hand (DASH) questionnaire is a self-administered region-specific outcome instrument developed as a measure of self-rated upper-extremity disability and symptoms. The DASH consists mainly of a 30-item disability/symptom scale, scored 0 (no disability) to 100. The main purpose of this study was to assess the longitudinal construct validity of the DASH among patients undergoing surgery. The second purpose was to quantify self-rated treatment effectiveness after surgery.
The longitudinal construct validity of the DASH was evaluated in 109 patients having surgical treatment for a variety of upper-extremity conditions, by assessing preoperative-to-postoperative (6-21 months) change in DASH score and calculating the effect size and standardized response mean. The magnitude of score change was also analyzed in relation to patients' responses to an item regarding self-perceived change in the status of the arm after surgery. Performance of the DASH as a measure of treatment effectiveness was assessed after surgery for subacromial impingement and carpal tunnel syndrome by calculating the effect size and standardized response mean.
Among the 109 patients, the mean (SD) DASH score preoperatively was 35 (22) and postoperatively 24 (23) and the mean score change was 15 (13). The effect size was 0.7 and the standardized response mean 1.2.The mean change (95% confidence interval) in DASH score for the patients reporting the status of the arm as "much better" or "much worse" after surgery was 19 (15-23) and for those reporting it as "somewhat better" or "somewhat worse" was 10 (7-14) (p = 0.01). In measuring effectiveness of arthroscopic acromioplasty the effect size was 0.9 and standardized response mean 0.5; for carpal tunnel surgery the effect size was 0.7 and standardized response mean 1.0.
The DASH can detect and differentiate small and large changes of disability over time after surgery in patients with upper-extremity musculoskeletal disorders. A 10-point difference in mean DASH score may be considered as a minimal important change. The DASH can show treatment effectiveness after surgery for subacromial impingement and carpal tunnel syndrome. The effect size and standardized response mean may yield substantially differing results.
There are wide variations in the clinical use of cryotherapy, and guidelines continue to be made on an empirical basis.
Systematic review assessing the evidence base for cryotherapy in the treatment of acute soft-tissue injuries.
A computerized literature search, citation tracking, and hand searching were carried out up to April 2002. Eligible studies were randomized-controlled trials describing human subjects recovering from acute soft-tissue injuries and employing a cryotherapy treatment in isolation or in combination with other therapies. Two reviewers independently assessed the validity of included trials using the Physiotherapy Evidence Database (PEDro) scale.
Twenty-two trials met the inclusion criteria. There was a mean PEDro score of 3.4 out of of 10. There was marginal evidence that ice plus exercise is most effective, after ankle sprain and postsurgery. There was little evidence to suggest that the addition of ice to compression had any significant effect, but this was restricted to treatment of hospital inpatients. Few studies assessed the effectiveness of ice on closed soft-tissue injury, and there was no evidence of an optimal mode or duration of treatment.
Many more high-quality trials are needed to provide evidence-based guidelines in the treatment of acute soft-tissue injuries.
The use of ice as a supplement to an exercise programme has been recommended for the management of lateral elbow tendinopathy (LET). No studies have examined its effectiveness.
To investigate whether an exercise programme supplemented with ice is more successful than the exercise programme alone in treating patients with LET.
Patients with unilateral LET for at least four weeks were included in this pilot study. They were sequentially allocated to receive five times a week for four weeks either an exercise programme with ice or the exercise programme alone. The exercise programme consisted of slow progressive eccentric exercises of wrist extensors and static stretching of the extensor carpi radialis brevis tendon. In the exercise programme/ice group, the ice was applied after the exercise programme for 10 minutes in the form of an ice bag to the facet of the lateral epicondyle. Patients were evaluated at baseline, at the end of treatment, and three months after the end of treatment. Outcome measures used were the pain visual analogue scale and the dropout rate.
Forty patients met the inclusion criteria. At the end of treatment there was a decline in visual analogue scale of about 7 units in both groups compared with baseline (p<0.0005, paired t test). There were no significant differences in the magnitude of reduction between the groups at the end of treatment and at the three month follow up (p<0.0005, independent t test). There were no dropouts.
An exercise programme consisting of eccentric and static stretching exercises had reduced the pain in patients with LET at the end of the treatment and at the follow up whether or not ice was included. Further research to establish the relative, absolute, and cost effectiveness as well as the mechanism of action of the exercise programme is needed.
Cryotherapy and thermotherapy are useful adjuncts for the treatment of musculoskeletal injuries. Clinicians treating these conditions should be aware of current research findings regarding these modalities, because their choice of modality may affect the ultimate outcome of the patient being treated. Through a better understanding of these modalities, clinicians can optimize their present treatment strategies. Although cold and hot treatment modalities both decrease pain and muscle spasm, they have opposite effects on tissue metabolism, blood flow, inflammation, edema, and connective tissue extensibility. Cryotherapy decreases these effects while thermotherapy increases them. Continuous low-level cryotherapy and thermotherapy are newer concepts in therapeutic modalities. Both modalities provide significant pain relief with a low side-effect profile. Contrast therapy, which alternates between hot and cold treatment modalities, provides no additional therapeutic benefits compared with cryotherapy or thermotherapy alone. Complications of cryotherapy include nerve damage, frostbite, Raynaud's phenomenon, cold-induced urticaria, and slowed wound healing. With thermotherapy, skin burns may occur, especially in patients with diabetes mellitus, multiple sclerosis, poor circulation, and spinal cord injuries. In individuals with rheumatoid arthritis, deep-heating modalities should be used with caution because increased inflammation may occur. Whirlpool and other types of hydrotherapy have caused infections of the skin, urogenital, and pulmonary systems. Additionally, ultrasound should not be used in patients with joint prostheses.
Lateral epicondylitis represents a frequent overuse injury. In spite of many conservative treatment procedures, prolonged symptoms and relapse are frequently observed.
To compare the outcome of patients performing an isokinetic eccentric training with that of age-, gender-, activity-matched patients receiving a non-strengthening classical rehabilitation.
Ninety-two patients with unilateral chronic lateral epicondylar tendinopathy (mean duration of symptoms 8+/-3 months) were assigned either to a control group (n = 46) or to an eccentrically trained group (n = 46). The control group underwent a passive standardised rehabilitation programme that excluded strengthening exercises. In addition to this programme, the trained group also performed eccentric exercises based on the repetitive lengthening of the active musculo-tendinous unit. The latter exercises started with submaximal contraction intensity and slow speed movement. Modalities were progressively intensified (increase in intensity contraction and speed movement) over a long period of treatment. Programme effectiveness was assessed through pain score evaluation, a disability questionnaire, muscle strength measurement and ultrasonographic examination.
Compared to the non-strengthening control group, the following observations were made in the eccentrically trained group: (1) a significantly more marked reduction of pain intensity, mainly after one month of treatment; (2) an absence of strength deficit on the involved side through bilateral comparison for the forearm supinator and wrist extensor muscles; (3) an improvement of the tendon image as demonstrated by decreasing thickness and a recovered homogenous tendon structure; and (4) a more marked improvement in disability status during occupational, spare time and sports activities.
These results highlight the relevance of implementing isokinetic adapted eccentric training in the management of chronic lateral epicondylar tendinopathy.
Lateral epicondylosis is a degenerative overuse tendinopathy involving the extensor tendons of the forearm, predominantly the extensor carpi radialis brevis, in the region of the lateral epicondyle of the elbow. The Orthopaedic Research Institute-Tennis Elbow Testing System (ORI-TETS) is designed to record objective measurements of force generated with a simulated chair pick-up test. Interrater reliability of the ORI-TETS was excellent, with high intraclass correlation coefficients (ICCs) for right arm mean peak force of 0.93, left arm mean peak force of 0.84, right arm mean total force of 0.93, and left arm mean total force of 0.86. The ORI-TETS also demonstrated excellent intrarater reliability with ICCs ranging from 0.9 to 0.97. The relative technical error of the ORI-TETS for all measurements ranged from 5.8% to 7.2%. Testing patients with lateral epicondylosis (N = 16) and comparing analog pain scores with ORI-TETS testing demonstrated a strong negative relationship between the two parameters (Spearman rho, -0.87 to -1.0). Thus, the ORI-TETS is a reliable and reproducible testing system for the forearm extensors. The testing system is inexpensive, takes 5 minutes to perform, and demonstrates good predictive value for objectively assessing patients with lateral epicondylosis. This system could be used for routine clinical monitoring of patients with lateral epicondylosis.
SummaryChronic lateral epicondylitis has been identified as one of the most common lesions of the upper limb (Thurston 1999). However, a literature search of Medline, Embase (Exerpta Medica) and CINAHL revealed limited published evidence regarding treatment protocols used by physiotherapists in the management of this condition. A survey of opinions of outpatient physiotherapists regarding their current practice of chronic lateral epicondylitis was therefore carried out in a random sample of National Health Service outpatient departments in Scotland.The questionnaire was completed by 120 physiotherapists, giving a response rate of 80%. According to 77.3% of respondents, lateral epicondylitis patients always or frequently present with chronic symptoms. A sizeable proportion of respondents (67.5%) indicated that their chronic lateral epicondylitis patients have a poor understanding of their condition. The importance of joint protection techniques was highlighted with 83.3% of the respondents reporting that they demonstrated protection techniques to patients. Only 1.7%, however, provided written information about these techniques for future reference.Respondents identified pain upon resisted wrist extension (88.3%) and palpation of the wrist extensor origin (63.3%) as diagnostic tests for chronic lateral epicondylitis. Differential diagnosis tests were identified as cervical spine examination and radial nerve tension test by 67.5% and 66.7% of respondents, respectively.Range of motion was the most commonly used outcome measure with 83.3% of respondents using it always or frequently.Only one respondent indicated a defined departmental protocol regarding the management of chronic lateral epicondylitis, although much agreement was found regarding treatment. Progressive stretching (88%) and strengthening exercises (75.8%) were always or frequently used by respondents.This study has provided information regarding current physiotherapeutic approaches to chronic lateral epicondylitis and identified the latest published evidence. However, this condition will continue to be a therapeutic challenge until more evidence regarding best practice is available and physiotherapists acknowledge that it is a multi-factorial condition.
Rubin's multiple imputation is a three-step method for handling complex missing data, or more generally, incomplete-data problems, which arise frequently in medical studies. At the first step, m (> 1) completed-data sets are created by imputing the unobserved data m times using m independent draws from an imputation model, which is constructed to reasonably approximate the true distributional relationship between the unobserved data and the available information, and thus reduce potentially very serious nonresponse bias due to systematic difference between the observed data and the unobserved ones. At the second step, m complete-data analyses are performed by treating each completed-data set as a real complete-data set, and thus standard complete-data procedures and software can be utilized directly. At the third step, the results from the m complete-data analyses are combined in a simple, appropriate way to obtain the so-called repeated-imputation inference, which properly takes into account the uncertainty in the imputed values. This paper reviews three applications of Rubin's method that are directly relevant for medical studies. The first is about estimating the reporting delay in acquired immune deficiency syndrome (AIDS) surveillance systems for the purpose of estimating survival time after AIDS diagnosis. The second focuses on the issue of missing data and noncompliance in randomized experiments, where a school choice experiment is used as an illustration. The third looks at handling nonresponse in United States National Health and Nutrition Examination Surveys (NHANES). The emphasis of our review is on the building of imputation models (i.e. the first step), which is the most fundamental aspect of the method.
Satisfactory treatment of lateral epicondylitis results from correct diagnosis followed by a well-controlled operative or nonoperative treatment program. Many options for nonoperative and operative treatment exist for lateral epicondylitis. More study is needed on outcomes of both nonoperative treatment and operative treatment so that each patient can attain maximal improvement. Balanced assessments of specific patient populations, along with definitions of the optimal treatment for each group, are required. This will allow physicians to integrate the available information and improve patient care.
In a pilot study 38 patients with lateral humeral epicondylalgia were randomly allocated to two treatment groups. Group S (stretching) was treated with a contract-relax-stretching program while group E (eccentric exercise) underwent an eccentric exercise program. Both groups also received forearm bands and wrist support nightly. The programs were carried out daily at home during 12 weeks. Evaluation before and 3, 6 and 12 months after treatment, included subjective assessment of symptoms using visual analogue scales and grip strength measurements. Thirty-five patients were available for follow-up. Five patients, three in group S and two in group E, did not complete the programs due to increased pain while 30 (86%) reported complete recovery or improvement. Reduced pain and increased grip strength were seen in both treatment groups but 12 out of 17 patients (71%) in group E rated themselves as completely recovered as compared to 7 out of 18 (39%) in group S (P=0.09), and in group E the increase in grip strength after 6 months was statistically significantly larger than in group S. In a second study the eccentric training regime was used in a consecutive series of 129 patients with lateral epicondylalgia. The patients were divided into two groups with one group consisting of patients with less than one year duration of symptoms and the other comprised patients with a duration of symptoms for more than one year. The results of treatment were evaluated in the same way as in the pilot study, and also after 3.4 years using the scoring system by Verhaar et al. At the end of the treatment period statistically significant improvements were seen in all VAS recordings and in grip strength. After 3.4 years 38% had excellent, 28% good, 25% fair and 9% poor results according to the score. In the self-rated outcome 54% regarded themselves as completely recovered, 43% improved, 2% unchanged and 2% worse. No significant differences were seen between patients with a duration of symptoms for more than one year compared to patients with symptoms for less than one year. The eccentric training regime can considerably reduce symptoms in a majority of patients with lateral humeral epicondylalgia, regardless of duration, and is possibly superior to conventional stretching.
Missing data occur frequently in survey and longitudinal research. Incomplete data are problematic, particularly in the presence of substantial absent information or systematic nonresponse patterns. Listwise deletion and mean imputation are the most common techniques to reconcile missing data. However, more recent techniques may improve parameter estimates, standard errors, and test statistics. The purpose of this article is to review the problems associated with missing data, options for handling missing data, and recent multiple imputation methods. It informs researchers' decisions about whether to delete or impute missing responses and the method best suited to doing so. An empirical investigation of AIDS care data outcomes illustrates the process of multiple imputation.
Lateral epicondylosis is a degenerative overuse tendinopathy involving the extensor tendons of the forearm, predominantly the extensor carpi radialis brevis, in the region of the lateral epicondyle of the elbow. The Orthopaedic Research Institute-Tennis Elbow Testing System (ORI-TETS) is designed to record objective measurements of force generated with a simulated chair pick-up test. Interrater reliability of the ORI-TETS was excellent, with high intraclass correlation coefficients (ICCs) for right arm mean peak force of 0.93, left arm mean peak force of 0.84, right arm mean total force of 0.93, and left arm mean total force of 0.86. The ORI-TETS also demonstrated excellent intrarater reliability, with ICCs ranging from 0.9 to 0.97. The relative technical error of the ORI-TETS for all measurements ranged from 5.8% to 7.2%. Testing patients with lateral epicondylosis (N = 16) and comparing analog pain scores with ORI-TETS testing demonstrated a strong negative relationship between the two parameters (Spearman rho, -0.87 to -1.0). Thus, the ORI-TETS is a reliable and reproducible testing system for the forearm extensors. The testing system is inexpensive, takes 5 minutes to perform, and demonstrates good predictive value for objectively assessing patients with lateral epicondylosis. This system could be used for routine clinical monitoring of patients with lateral epicondylosis.
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.
The objective of this study was to evaluate the effectiveness of eccentric strengthening. Ninety-four subjects (50 men) with chronic lateral epicondylitis were allocated randomly into three groups: stretching, concentric strengthening with stretching, and eccentric strengthening with stretching. Subjects performed an exercise program for six weeks. All three groups received instruction on icing, stretching, and avoidance of aggravating activities. The strengthening groups received instruction on isolated concentric and eccentric wrist extensor strengthening, respectively. At six weeks, significant gains were made in all three groups as assessed with pain-free grip strength, Patient-rated Forearm Evaluation Questionnaire, Disabilities of the Arm, Shoulder, and Hand questionnaire, Short Form 36, and visual analog pain scale. No significant differences in outcome measures were noted among the three groups. Although there were no significant differences in outcome among the groups, eccentric strengthening did not cause subjects to worsen. Further studies are needed to assess the unique effects of a more intense or longer eccentric strengthening program for patients with lateral epicondylitis.
Physical therapy is commonly used postoperatively in humans to decrease pain, inflammation and recovery time. The same goals can be achieved in our veterinary patients using similar modalities such as; cryotherapy, passive range of motion, massage, transcutaneous electrical stimulation and low-level light laser therapy. When used in the first 48 hours following surgery, the reduction in pain, increased mobility, and decreased inflammation will aid in early return to normal function. Applied appropriately these treatments have both immediate and long term benefits.