IJCRR - 4(2), January, 2012
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PHYSIOTHERAPY MANAGEMENT OF LATERAL EPICONDYLALGIA: A CRITICAL REVIEW OF TREATMENT METHODS
Author: Jagatheesan Alagesan Sanjeev Saxena, Anandbabu Ramadass
Abstract:Objective: Lateral epicondylalgia (LE) is a commonly encountered musculo skeletal complaint. Currently, there is no agreement regarding the exact underlying patho-anatomical cause or the most effective management strategy. The aim of this systematic review was to identify and summarize the existing evidence on physiotherapy management in patients with Lateral Epicondylalgia through published studies to establish an evidence for decision making in clinical practice and research. Methods: The therapeutic modalities reported in Medline, EBSCO and Google Scholar were searched independently and 27 suitable trials were identified and qualitatively reviewed. The selected studies were grouped under each treatment method and were described under manual therapy, exercise therapy, brace, electrotherapy and actinotherapy in the review. Results: The physiotherapy management of LE patients includes Manual therapy, taping, electrotherapy, Actinotherapy, Exercises therapy, Brace, Low-Level Laser Therapy, Ultrasound Therapy and Extracorporeal Shock Wave Therapy and no specific therapy has emerged as a 'gold standard' with demonstrably superior long-term efficacy. Conclusion: This review finding would facilitate clinicians and researchers to understand the
physiotherapy treatment options available for the management of patients with LE. There is a lack of evidence for the long term benefit of physical therapy interventions in general and an effective treatment strategy that provides rapid alleviation of LE and that is maintained in the long term is needed.
Keywords: Physiotherapy, Rehabilitation, Lateral Epicondylalgia
Lateral Epicondylalgia (LE), lateral epicondylitis or tennis elbow is a musculo skeletal disorder often encountered by healthcare practitioners, such as physical therapists, and is characterized by pain over the lateral elbow that is typically aggravated by gripping activities.1 The syndrome is most prevalent (35-64% of all cases) in jobs requiring repetitive manual tasks, it results in restricted function, and it is one of the more costly of all work-related illnesses.2-4 The peak incidence of this condition occurs between the ages of 35 and 50 and usually affects the dominant arm.5 Formerly called lateral epicondylitis, lateral epicondylalgia or epicondylar tendinopathy are more appropriate terms considering that numerous studies6-9 have shown the absence of inflammatory cells in this disorder. It has therefore, been suggested that the term epicondylitis be abandoned in favor of 'epicondylalgia’.
1,10,11 The exact underlying pathological process contributing to LE has been the topic of much debate, and there still exists no consensus.11 Current evidence following surgical intervention indicates that LE is a chronic disorder demonstrated by the presence of degenerative changes, such as increased fibroblasts and disorganized collagen, as opposed to inflammatory cells.1,8,12,13 Repetitive wrist dorsiflexion with supination and pronation causes overuse of the extensor tendons of the forearm and subsequent micro tears, collagen degeneration, and angio fibroblastic proliferation. If untreated, lateral epicondylitis persists for an average of six to 24 months.14 Lateral epicondylitis presents as a history of occupation or activity related pain at the lateral elbow. Symptoms are usually reproduced with resisted supination or wrist dorsiflexion, particularly with the elbow in full extension. The pain is typically located just distal to the lateral epicondyle over the extensor tendon mass. Imaging studies are rarely required for diagnosis. Recent review articles have addressed the use of patient history, differential diagnosis, and physical examination in the diagnosis of lateral epicondylitis.15,16 A significant number of treatments are offered for LE, ranging from medical interventions such as surgery and medication to physical therapy including modalities, exercise, and manual therapy.12,17-19 Given the complexity surrounding the identification of an underlying cause, it is not surprising that no agreement exists as to which method is most effective in treating this disorder.5,17,19 In addition, evidence regarding treatment effectiveness for LE is also lacking. World Confederation for Physical Therapy (WCPT) defines Physiotherapy as, "….providing services to individuals and populations to develop, maintain and restore maximum movement and functional ability throughout the lifespan. Physiotherapy includes providing services in circumstances where movement and function are threatened by ageing, injury, diseases, disorders, conditions or environmental factors. Functional movement is central to what it means to be healthy. Physiotherapy is concerned with identifying and maximising quality of life and movement potential within the spheres of promotion, prevention, treatment or intervention, habilitation and rehabilitation. This encompasses physical, psychological, emotional, and social wellbeing. Physiotherapy involves the interaction between the physiotherapist, patients or clients, other health professionals, families, care givers and communities in a process where movement potential is assessed and goals are agreed upon, using knowledge and skills unique to physiotherapists.?20 Physiotherapy for LE include; friction massage, manipulative therapy, ultrasound, phonophoresis, iontophoresis, shock wave therapy, orthotic therapy, elbow braces and supports, taping, low level laser therapy, and plyometric exercises.21-27 The aim of this systematic review was to identify and summarize the existing evidence on physiotherapy management in patients with Lateral Epicondylalgia through published studies to establish an evidence for decision making in clinical practice and research.
Search Strategy and Selection Criteria Independent search was carried out by testers using a well-defined search strategy in following databases; Medline, EBSCO and Google Scholar published from 1996 to 2011 using the key terms lateral epicondylalgia, lateral epicondylitis, tennis elbow, lateral elbow pain, physiotherapy, rehabilitation, management, treatment. The Boolean operator AND was used to link terms describing diagnosis (lateral epicondylalgia, lateral epicondylitis, etc.) with terms describing intervention (physiotherapy, rehabilitation, etc.). Relevant studies were included regardless of methodological quality so as to include those articles that may have been excluded from past reviews. A total of 168 studies were potentially identified by the authors. Studies published in English language on effectiveness, efficacy, effects of physiotherapy treatment methods Main findings of the review The 27 included studies were grouped under twelve treatment methods studied for their effectiveness in LE patient population which are descriptively reported below using a qualitative approach.was included in the review; and studies on surgery (45 Studies), pharmacotherapy (29 studies), comparison of drugs (32 studies) or combined drug therapy (23 studies) with other treatments (12 studies) were excluded. A total of 27 studies were finally identified and then considered for review. To avoid search bias, the testers performed independent searches and then disagreements were solved by consensus at various stages of the study.
Main findings of the review The 27 included studies were grouped under twelve treatment methods studied for their effectiveness in LE patient population which are descriptively reported below using a qualitative approach. Manual therapy Vicenzino et al28 investigated effect of spinal manipulative therapy in a group of 15 patients by randomised, double blind, placebo controlled, repeated measures design with treatment, placebo or control condition. The treatment condition produced significant improvement in pressure pain threshold, pain-free grip strength, neurodynamics and pain scores relative to placebo and control conditions. One-group pre-test post-test research by Abbott et al29 and placebo, control, repeated-measures research by Paungmali et al30 investigated the effect of elbow mobilization with movement and they prove it to be effective. Nourbakhsh and Fearon31 assessed effect of Oscillating-energy Manual Therapy in a randomized, placebo-control, doubleblinded study on pain, grip strength, and functional abilities of subjects with chronic LE and found as an efficient treatment for LE. Ahuja32 in a narrative review from 1992 to 2010 on efficacy of mobilization with movement (MWM) in LE concluded that there is a significant immediate hypoalgesic effect of MWM in LE.
Manual therapy and exercises Blanchette and Normand33 in a pilot randomized clinical study assessed 27 subjects for the effect of augmented soft tissue mobilization and control group with stretching exercises and life style modification, showed improvements in pain-free grip strength, visual analog scale in both groups.
Manual therapy and taping Vicenzino12 in a master class presented that the manipulative therapy and taping warrant consideration in the clinical best practice management of LE.
Manual therapy and electrotherapy One case report by Radpasand34 presented a 57-year-old woman with LE who was treated successfully by high-velocity and low-amplitude manipulation, high-voltage pulsed galvanic stimulation, a hardpadded elbow brace, ice, and exercise, along with restricted use of the affected elbow in a 10 week protocol and proved effect of the specific sequential multimodal treatment.
Manual therapy and Actinotherapy Stasinopoulos and Stasinopoulos35 compared the effectiveness of Cyriax physiotherapy, a supervised exercise programme, and polarized polychromatic non-coherent light (Bioptron light) in the treatment of LE in a controlled clinical trial with 75 patients sequentially allocated in to three groups. Intervention given for four weeks three treatments per week, pain and pain-free grip strength were assessed at baseline, and of intervention and 28 week follow up. The authors concluded that supervised exercise programme should be the first treatment option for therapists when they manage LE patients. If this is not possible, Cyriax physiotherapy and polarized polychromatic non-coherent light (Bioptron light) may be suitable.
Exercises therapy Stasinopoulos et al36 studied the use and effects of strengthening and stretching exercise programmes in the treatment of LE and concluded a well designed trial is needed to study the effectiveness of a supervised exercise programme for LET consisting of eccentric and static stretching exercises. Martinez-Silvestrini et al37 evaluated effect of home exercises on Ninety-four subjects with chronic LE in a randomised trial with three groups: stretching, concentric strengthening with stretching, and eccentric strengthening with stretching for six weeks. The authors found no significant differences among the three groups in painfree grip strength, Patient-rated Forearm Evaluation Questionnaire, Disabilities of the Arm, Shoulder, and Hand questionnaire, Short Form 36, and visual analog pain scale.
Exercises therapy and brace Svernlov and Adolfsson38 performed a Pilot Randomized Clinical Trial on 38 patients with LE to compare stretching and eccentric exercise along with forearm bands and wrist support nightly for 12 weeks and found that eccentric training considerably reduce symptoms than conventional stretching. Luginbuhl et al39 analysed the effect of forearm support band and of strengthening exercises for the treatment of LE in a prospective randomised study with 3 groups of treatment: (I) forearm support band, (II) strengthening exercises and (III) both methods on 29 patients. No differences in the scores were found between the 3 groups of treatment (p=0.27), indicating that no beneficial influence was found either for the strengthening exercises or for the forearm support band. Improvement seems to occur with time, independent of the method of treatment used.
Brace Struijs et al40 evaluated the effectiveness of brace-only treatment, physical therapy, and the combination of these for patients with LE in a randomized trial of 180 patients over 3 groups for 1 year follow-up. Conflicting results were found. Brace treatment might be useful as initial therapy. Combination therapy has no additional advantage compared to physical therapy but is superior to brace only for the short term. Faes et al41 investigated the effect of an external wrist extension force on extensor muscle activity during hand gripping in patients with LE in a semi experimental study and concluded that the dynamic extensor brace could be a promising intervention for LE.
Low-Level Laser Therapy (LLLT) Papadopoulos et al42 studied the effect of low-level laser therapy in a randomized, double-blind, placebo controlled study on patients with LE (n = 29) using a gallium aluminium arsenide laser. No significant differences were found between the treatment and placebo groups. Bjordal et al43 in a systematic review with meta-analysis, with primary outcome measures of pain relief and/or global improvement and subgroup analyses of methodological quality, wavelengths and treatment procedures identified 18 randomised placebo-controlled trials were LLLT administered with optimal doses of 904 nm and possibly 632 nm wavelengths directly to the lateral elbow tendon insertions, seem to offer short-term pain relief and less disability in LE, both alone and in conjunction with an exercise regimen.
Oken et al44 evaluated the effects of LLLT and compared these with the effects of brace or ultrasound (US) treatment in tennis elbow in a prospective and randomized, controlled, single-blind trial on 58 patients over 6 weeks intervetion. The results show that, in patients with lateral epicondylitis, a brace has a shorter beneficial effect than US and laser therapy in reducing pain, and that laser therapy is more effective than the brace and US treatment in improving grip strength. Stergioulas45 compared 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 LE. Fifty patients 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 for 8 weeks. Pain at rest, grip strength and range of motion were analyzed at baseline, 8 week course of treatment and 8 weeks after the end of treatment. 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.
Ultrasound Therapy D'Vaz et al46 in a randomized, doubleblind, placebo controlled trial assessed the effectiveness of low-intensity ultrasound therapy (LIUS) vs placebo therapy daily for 12 weeks in 55 patients with chronic LE. No significant difference found between LIUS and placebo in elbow pain at baseline and 12 weeks.
Smidt et al47 evaluate the available evidence of the effectiveness of physiotherapy for LE. 23 RCTs were included in the review evaluating the effects of laser therapy, ultrasound treatment, electrotherapy, and exercises and mobilisation techniques. The pooled estimate of the treatment effects of two studies on ultrasound compared to placebo ultrasound, showed statistically significant and clinically relevant differences in favour of ultrasound. There is insufficient evidence either to demonstrate benefit or lack of effect of laser therapy, electrotherapy, exercises and mobilisation techniques for LE.
Manual therapy and Ultrasound Therapy
Nagrale et al48 in a RCT compared the effectiveness of deep transverse friction massage with Mill's manipulation versus phonophoresis with supervised exercise in managing LE with sixty patients. The control group received phonophoresis with diclofenac gel over the area of the lateral epicondyle for 5 minutes combined with supervised exercises and the experimental group received 10 minutes of deep transverse friction massage followed by a single application of Mill's manipulation for 4 weeks. Pain, pain-free grip strength and functional status were measured. This study demonstrates that Cyriax physiotherapy is a superior treatment approach compared to phonopboresis and exercise in managing lateral epicondylalgia. Kochar and Dogra49 compared the effect of a combination of Mulligan mobilisation (a manual therapy approach) and ultrasound therapy with that of ultrasound therapy alone in a RCT with 66 patients for 3 weeks. In follow up of 12 weeks of therapy pain and grip strength were analysed. The authors conclude that addition of Mulligan mobilisation to a regimen comprising ultrasound therapy and progressive exercises brings about increased and faster recovery in patients with LE.
Extracorporeal Shock Wave Therapy Bisset et al50 in a systematic review of the literature on the effectiveness of physical interventions for LE identified 76 RCT of which 28 satisfied the minimum criteria for meta-analysis. The evidence suggests that extracorporeal shock wave therapy is not beneficial in the treatment of LE and there is a lack of evidence for the long term benefit of physical interventions in general. Rompe and Maffulli51 in a qualitative study-by-study assessment included 10 trials that randomized 948 participants to shock wave therapy (SWT) or placebo or treatment control and evidence was found for effectiveness of SWT for LE under well-defined, restrictive conditions only. Kohia et al 52 analyzed research literatures that has examined the effectiveness of various physical therapy interventions on LE evidence databases from 1994 to 2006 using the key words lateral epicondylitis, tennis elbow, modalities, intervention, management of, treatment for, radio humeral bursitis, and experiment. Shockwave therapy and Cyriax therapy protocol are effective physical therapy interventions and no single intervention has been proven to be the most efficient. Wright et al19 reviewed a range of physical therapies, drug therapies and surgical interventions and concluded no specific therapy has emerged as a 'gold standard' with demonstrably superior long-term efficacy.
This review was a clinically and scientifically applicable for use both by clinicians and researchers involved with patients of Lateral Epicondylalgia. Some of the potential limitations of this review were the lack of meta-analysis and quality scoring of the included studies. This review included studies of all designs leading to heterogeneity not only in interventions, outcome assessment and follow-up, but also in analysis and effect size. Only studies in English were reviewed and this might have missed some other important studies. Finally, no attempt was made to locate and obtain unpublished data, which introduces the potential for publication bias. These sources can prove to be difficult to identify and obtain when not indexed in databases such as Medline.53 Lack of indexing is a significant barrier to successfully incorporating unpublished data into the search methodology, and for this reason it was not included in this review. The increased variability regarding different physiotherapy modalities, comparison interventions, follow-up, and outcome measures also made it very difficult to compare results across studies and draw relevant conclusions. Though a large volume of literature on management of LE patients is on pharmacotherapy and surgical intervention,54-56 future research could be on developing a comprehensive management involving physiotherapy treatment methods in patients with LE. Further good quality controlled clinical trials on comparison between the physiotherapy modalities and lifestyle modification are necessary to derive valid conclusions.
This review has presented evidence to prove physiotherapy intervention methods for management of lateral epicondylalgia. It is clear that lateral epicondylalgia is a complex condition, which is more than a simple soft-tissue injury of the extensor tendons. An effective treatment strategy that provides rapid alleviation of LE and that is maintained in the long term is needed. There is a lack of evidence for the long term benefit of physical therapy interventions in general.
ACKNOWLEDGMENTS Authors acknowledge the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles and journals from where the literature for this article has been reviewed and discussed. Disclosures This review was performed as part of review of literature for Doctoral thesis (PhD Thesis) of the first author.
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