Download Efficacy of tyler twist exercise IN REDUCING PAIN

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE, BANGALORE,
KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
1
Name of the candidate
and address
2
Name of the Institution
3
Course of study and subject
4
Date of admission
5
Title of the topic
M.R.ARJUN DEV
FLORENCE COLLEGE OF
PHYSIOTHERAPY
MASTERS OF PHYSIOTHERAPY
(Physiotherapy in musculoskeletal disorders
and sports physiotherapy)
27.06.2011
“EFFICACY OF TYLER TWIST
EXERCISE IN REDUCING PAIN,
IMPROVING GRIP STRENGTH AND
HAND FUNCTION IN PATIENTS WITH
CHRONIC TENNIS ELBOW”
6. Brief resume of the indented work.
6.1 Need of the study:
The term ‘Tennis Elbow’ refers to a painful condition at or around the lateral epicondyle
of the humerus and the common extensor origin(Maffulli.N et al 1990). According to David
J. Magee (2002) this is a chronic overuse injury of the extensor tendons at the elbow resulting
due to repeated micro trauma to the tendon leading to disruption and degeneration of the
tendon’s internal structure. It appears to be a degenerative condition in which the tendon has
failed to heal properly after repetitive micro trauma injury.
It is generally a work related or sport related pain disorder usually caused by excessive
quick, monotonous, repetitive eccentric contractions and gripping activities of the wrist
(Stasinopoulos D et al 2005).
Tennis elbow is one of the most common conditions affecting the upper extremity. The main
complaints being the pain and decreased function, both of which affects the activities of daily
living (ADL), in turn affects their quality of life. In 1980, WHO classified tennis elbow as a
disability as it often limits the work capacity.
Eccentric exercises have been utilized successfully in chronic painful tendinosis like Achilles,
supraspinatus and patellar tendinosis (Ian G Macintyre 2007). Since the different types of
tendinosis show similarities in clinical behavior and in their histological appearance
(Kraushaar B 1999), eccentric training may help in giving pain relief and functional
improvements in patients with tennis elbow.
Theraband Flex bars are inexpensive, portable light equipment used for strengthening. Once
the patient learned this simple exercise, they could easily perform this exercise at home
independently without direct supervision or regular physiotherapy visits. Thus it helps to
maintain the muscle performance and reduce the risk of re-injury and enhance the functional
activities. So there arises the need for the study to assess whether simple and a novel
eccentric training of wrist extensors utilizing ‘Tyler twist’ exercise would reduce pain and
improve grip strength and hand function in tennis elbow patients.
7. REVIEW OF LITERATURE
Norris (1998): Lateral epicondylitis is defined as an overuse injury occurring in the tissue of
the common wrist extensor tendon. The primary structure involved is the tendon of the
extensor carpi radialis brevis muscle.
Bisset L et al (2009): There is an annual incidence of 4-7 cases per 1000 patients in general
practice and 1-3% with in general population. It is a common condition that significantly
impacts on the individual and society. It occurs primarily between the ages of 35 and 54 and
typically affects the dominant arm in men and women alike.
Kraushaar B et al (1999): It is due to the result of multiple micro traumatic events that
cause disruption of internal structure of tendon and degeneration occurs, when it failed to
heal properly.
Maffulli.N et al (1990): ‘Tennis Elbow’ refers to a painful condition at or around the lateral
epicondyle of the humerus and the common extensor origin.
Stasinopoulos D et al (2005): Lateral elbow tendinopathy or tennis elbow is a syndrome of
pain in the area of lateral epicondyle, the main complaints being pain and decreased function,
both of which may affect activities of daily living.
Ian G Macintyre (2007): The cause of pain in the absence of an inflammatory mechanism of
pain production; there are hypothesis that certain byproducts of increased cellular activity or
tendon degeneration such a lactic acid, glutamate and chondroitin sulphate act as biochemical
irritants that activate peritendinous nociceptors. The disruption of collagen in a tendinosis can
also be the cause of pain.
Jane M Fedorczyk (2006): The incidence of upper extremity tendinopathies increases with
age and the amount of exposure to forceful repetitive movements. The prevalence of tennis
elbow ranges from 6-15 % in specific jobs identified in the meat and fish processing
industries.
Kaminsky et al (2003): The incidence of lateral epicondylitis is equal among men and
women. The average peak distribution is 42 years, ranging between 30- 50 years.
Verhaar J. A. R (1994): Epidemiological studies showed an incidence of tennis elbow
between 1 and 2%. The prevalence of tennis elbow in women between 40 and 50 years of age
was 10%.
De Smet L et al (1996): In this study the grip strength in chronic tennis elbow was measured
and mentioned reduced grip strength of the involved arm in several patients.
Tyler T F et al (2010): The objective of their study was to assess the efficacy of a novel
eccentric wrist extensor exercise added to standard treatment for chronic lateral epicondylosis
or tennis elbow. All outcome measures for this condition were markedly improved with the
addition of an eccentric wrist extensor exercise to standard physical therapy. This novel
exercise, using an inexpensive rubber bar, provides a practical means of adding isolated
eccentric training to the treatment of chronic lateral epicondylosis.
Phil page (2010): In this study the clinical suggestion was presented about a novel Flex Bar
exercise sequence, also known as “The Tyler twist”, for tennis elbow. The clinical suggestion
presents an excellent example of clinical practice leading to the creation of an evidencedriven novel exercise technique. The positive effects of eccentric exercise on tendinopathies
used an existing clinical tool (the FlexBar) to develop an “evidence-led” intervention that
could be applied in today’s outpatient physical therapy environment.
Gretchen Reynolds (2009) and Crystal Phend (2009): This study also noted the efficacy of
Tyler twist exercise in the treatment of chronic tennis elbow.
Sheppeard H et al (1985): The visual analogue scale is considered to be robust, sensitive
and reproducible method of expressing pain severity. The VAS is often used to evaluate the
analgesic property of various treatments and accomplishes this by measuring either pain relief
or pain severity.
Croisier J L (2007), Newcomer K L (2005), Svernlov B (2001), Deepak Grover (2006): In
this study the Visual Analogue Scale used as an outcome measure to assess pain in each
subject in their study in tennis elbow.
Jan D Rompe et al (2007):Studies were conducted to determine the reliability, validity and
sensitivity of the Patient Rated Tennis Elbow Evaluation (PRTEE) questionnaire in chronic
tennis elbow patients. Reliability and internal consistency were excellent. (PRTEE pain
subscale=0.94, PRTEE specific activities subscale= 0.93, PRTEE usual activities= 0.85).
Correlations were good between the PRTEE subscales and Visual Analogue Scale (VAS).
The PRTEE was a reliable, reproducible, and sensitive instrument for assessment of chronic
tennis elbow.
Joy C. MacDermid (2007): The PRTEE, formerly known as the Patient-Rated Forearm
Evaluation Questionnaire (PRFEQ), is a 15-item questionnaire designed to measure forearm
pain and disability in patients with tennis elbow. To test the PRTEE’s test-retest reliability,
47 patients with unilateral lateral epicondylitis completed the PRTEE on two consecutive
days. The pain (ICC = 0.89), function (1CC=0.83), and the total (ICC = 0.89) scores all
demonstrated excellent reliability. Concurrent validity was assessed by correlating the
PRTEE scores with the pain-free grip strength. The total PRTEE score (r = -0.36) and the
pain subscale (r = -0.37) had a significant moderate correlation with the pain-free grip
strength but not the function subscale (r = -0.30).
Binder A et al (1985): Reported significantly enhanced recovery in patients with lateral
epicondylitis treated with ultrasound compared to those treated with sham ultrasound.
Ultrasound enhances recovery in most patients with lateral epicondylitis.
Takasaki et al (2007): Stretching exercises is often included in the standard physiotherapy
treatment for TE (tennis elbow). Maximal muscle strain on the ECRB is obtained with the
elbow in extension, forearm in pronation, and wrist in flexion-ulnar deviation.
George. F. Hamilton et al (1992): Their study showed that the sphygmomanometer exhibit
good instrument reliability. Validity of the sphygmomanometer as a grip measurement device
is acceptable. Therefore, it can be utilized with confidence for grip strength measurement.
They performed hand grip strength testing and measurements were taken with a
sphygmomanometer and a Jamar dynamometer while utilizing standardized measurement
procedures. A Spearman Rho correlation coefficient test utilized in measuring withininstrument reliability showed a high correlation for each instrument at 0.85 for the
sphygmomanometer and 0.82 for the Jamar dynamometer. Construct validity testing
performed to determine validity of the measurements by the sphygmomanometer compared
with the Jamar dynamometer produced a 0.75 correlation.
Burton A K (1985): Research study measured grip strengths in twenty seven patients who
presented with tennis elbow using sphygmomanometer.
8 .Objectives of the Study
1. To find out the effectiveness of conventional physiotherapy in reducing pain and
improving grip strength and hand function in patients with tennis elbow.
2. To find out the effectiveness of ‘Tyler twist’ exercise along with conventional
physiotherapy in reducing pain and improving grip strength and hand function in
patients with tennis elbow.
3. To find out the effectiveness of ‘Tyler twist’ exercise along with conventional
physiotherapy over conventional physiotherapy in reducing pain and improving grip
strength and hand function in patients with tennis elbow.
9. HYPOTHESIS
9.1 Null Hypothesis
1. There is no significant reduction of pain and improvement of grip strength and hand
function in patients with tennis elbow, by Tyler twist exercise along with
conventional physiotherapy.
2. There is no significant reduction of pain and improvement of grip strength and hand
function in patients with tennis elbow, by Tyler twist exercise along with
conventional physiotherapy over conventional physiotherapy alone.
9.2Alternative Hypothesis
1. There is significant reduction of pain and improvement of grip strength and hand
function in patients with tennis elbow, by Tyler twist exercise along with
conventional physiotherapy.
2. There is significant reduction of pain and improvement of grip strength and hand
function in patients with tennis elbow, by Tyler twist exercise along with
conventional physiotherapy over conventional physiotherapy alone.
10.MATERIALS AND METHODS:
10.1 SOURCE OF THE STUDY
Florence College of Physiotherapy.
10.2 RESEARCH APPROACH
It is an experimental study approach.
10.3 RESEARCH DESIGN
The research design adopted for the study is pre-test, post-test, Control group,
Experimental group design.
10.4 SETTINGS FOR THE STUDY
The study was conducted at the Department of Physiotherapy in Florence college of
Physiotherapy, Bengaluru, Karnataka.
10.5 POPULATION FOR THE STUDY
Population chosen for the study will include patients with tennis elbow in the
Bengaluru city.
10.6 SAMPLE FOR THE STUDY
The sample consists of 30 patients with unilateral tennis elbow of dominant side, who are
satisfying the inclusion criteria and referred to the Physiotherapy department.
10.7 SAMPLING TECHNIQUE
By using simple random sampling method, 30 patients who are satisfying the inclusion
criteria are assigned to experimental and control group of 15 each.
– Receives conventional physiotherapy
Group A {Control group}
Group
B{Experimental
group}
–
Receives
conventional
physiotherapy
and
‘Tyler Twist’ exercise.
11. SELECTION CRITERIA
11.1 INCLUSION CRITERIA
 Patients who are clinically diagnosed as chronic tennis elbow with duration of symptoms
in between 3 - 6 months.
 Positive Cozen’s test and Mill’s test.
 Unilateral case (dominant extremity).

Sex- both females and males.

Age group 40- 50 years.
11.2 EXCLUSION CRITERIA
 Cases with bilateral symptoms.
 All extraneous cases like shoulder and cervical involvement.
 Recent history of trauma in upper limb.
 Recent history of surgery in upper limb.
 History of immobilization of elbow.
 History of inflammatory arthritis like rheumatoid arthritis.
 Recent steroid injection and anti-inflammatory drugs.
 Fibromyalgia.
 Myositis ossificans.
 Radial and posterior interrosseus nerve entrapment syndrome.
 Joint pathology like elbow arthritis.
 Carpal tunnel syndrome.
 Malignancy.
 Cardiovascular disease.
 Systemic disease such as DM.
11.3 TIME AND DURATION OF THE STUDY
Duration of the study will be 6 months.
Data will be collected for a period of 3 months.
11.4 TOOLS AND MATERIALS
 Assessment chart.
 Data collection sheet.
 Visual Analogue Scale (VAS).
 Patient Rated Tennis Elbow Evaluation Scale (PRTEE).
 Sphygmomanometer.
 Therapeutic Ultrasound Machine.
 Infrared Radiation (IRR).
 Rubber ball or tennis ball.
 Thera-Band Flex Bar.
 Stationary materials.
11.5 OUTCOME MEASUREMENT
1) Pain is measured by VAS.
2) Hand Function is measured by PRTEE.
3) Grip Strength is measured using Sphygmomanometer.
12 INTERVENTIONS TO BE CONDUCTED
12.1 Methodology
30 subjects who are fulfilling the inclusion criteria will be recruited using simple
random sampling and allocated into the groups namely control group (Group A) and
Experimental group (Group B). Each group will contain 15 patients each.
Group A (control group) will receive conventional physiotherapy.
Group B (Experimental group) will receive conventional physiotherapy and ‘Tyler twist’
exercise.
Before starting the study, pre-test will be conducted for both the groups by noting the VAS
scale, PRTEE and grip strength by SPHYGMOMANOMETER.
12.2
MEASUREMENT
OF
GRIP
STRENGTH
USING
SPHYGMOMANOMETER AS DESCRIBED BY AMERICAN SOCIETY
OF HAND THERAPIST.

The sphygmomanometer cuff will be evenly rolled, forming a circumference of
approximately 7 inch to conform to a normal functional hand position for grip.

A rubber band will be placed around each end of the cuff to hold it in position.

The cuff will be pre inflated to 20 mmHg, which was the starting position for
measurement of each subject.

The subject will be positioned in a straight back chair with both feet flat on the floor.

The subject will be instructed to assume a position of adducted and neutrally rotated
shoulders.

The elbow will be flexed to 900, forearm and wrist in neutral position and the fingers
is flexed as needed for maximal contraction.

At the time of measurement a verbal command will be given.

Between each grip strength four to five minutes will be given.

The mean score of three trials will be taken.
13 TREATMENT PROTOCOL
GROUP A (CONTROL GROUP)

Receives conventional physiotherapy.

Conventional Physiotherapy (30 minutes).
Patients will receive conventional physiotherapy on 5 days a week for 3 weeks. Per day one
session will be given and each session lasting for 30 mints.
I. ULTRASOUND THERAPY(7 min)

Patient in a comfortable sitting position and the arm will be supported on a
table with elbow flexed to 90 degree, forearm in pronation and wrist will be
supported by a roll of towel.

Pulsed ultrasound (20 % duty cycle), with 1 MHz frequency will be given with
an intensity of 1- 2 w/cm2 at the point of tenderness around the lateral
epicondyle for 7 minutes.

Given for 3 weeks (5 sessions per week).
II. HEAT APPLICATION (5 min)
Infrared radiation will be given over elbow and forearm region for 5 min.
III. PASSIVE STRETCHING OF WRIST EXTENSORS (6 min)

Patient Position and Procedure: Patient will be sitting in position with forearm
in a pronated position.

Stabilize the forearm against the table and grasp the dorsal aspect of the
patient’s hand.

To elongate the wrist extensors, flex the patient’s wrist and allow the fingers
to extend passively.

To further elongate the wrist extensors, extend the patient’s elbow.

Patient should feel a stretching sensation along the lateral epicondyle or
proximal forearm.

Hold this stretch for 30 sec.

Six repetitions of stretching exercise will be performed in each treatment
session with 30 sec rest interval between each procedure.

It will be given for 5 sessions a week for 3 weeks.
IV. STRENGTHENING EXERCISE (7 min)

Progressive resisted exercise
Progressive resisted isometric contractions with the elbow flexed to 900, apply manual
resistance over the supinated arm of affected side. Pain free isometric contraction of wrist
extensors initiated and held for 6 to 10 seconds. In one session 15 contractions are given.
Progression included forearm pronation as the starting position and increasing resistance.

Ball Squeeze
Place a rubber ball or tennis ball in palm of hand squeeze 25 times repeat 3 times and the
exercise should be pain free, if pain is reproduced squeeze a folded sponge or piece of foam.
V. ICE MASSAGE ( 5 min)
After exercising, massage across the area of tenderness with an ice cube for about 5 minutes.
VI. HOME ADVICE

Active Exercises
Active ROM exercises to the wrist flexors, extensors, radial and ulnar deviators. 10
repetitions for each will be given.

Self-stretching exercise
Teach the patient to stretch the involved muscle. A patient may use a wall and slide his hand
along the wall until a stretch force is experienced, or the opposite hand is used to apply the
stretch force. Hold for 30sec and a total of 6 stretches per session.

Isometrics
Pain free isometrics given to the wrist extensors. The hand of unaffected arm applies manual
resistance over affected arm.
Hold for 6-10sec
Duration 15 repetitions.

Ball squeeze
Place a rubber ball or tennis ball in palm of hand squeeze 25 times repeat 3 times and the
exercise should be pain free, if pain is reproduced squeeze a folded sponge or piece of foam.

Ice massage
After exercising, massage across the area of tenderness with an ice cube for about 5 minutes.
GROUP B (EXPERIMENTAL GROUP)
In addition to the conventional physiotherapy mentioned above, this groupreceived ‘Tyler
twist’ exercise. The patients attended physiotherapy 5 days in a week for 3 weeks. The
duration of each treatment session was 40 minutes including 30 minutes of conventional
Physiotherapy.
TYLER TWIST EXERCISE PROTOCOL (10 min)

Each subject for the Tyler Twist protocol will be given 3 sets of 15 repetitions
of eccentric strengthening provided with a TherabandFlex Bar to perform the
exercise.

The strengthening exercise will be performed in a seated or a standing position.

The elbow will be flexed at 900 and forearm will be neutral (mid prone).

Subject will held one end of rubber bar in involved hand with maximum wrist
extension and grasp the other end of rubber bar by non-involved hand.

Then twist the rubber bar by flexing the non-involved wrist while holding the
involved wrist in extension.

Bring arms in front of the body with elbows in extension while maintaining the
twist in rubber bar by holding with non-involved wrist in full flexion and
involved wrist in full extension.

Slowly allow rubber bar to untwist by allowing involved wrist to move in to
flexion (i.e., eccentric contraction of the involved wrist extensors).

Each eccentric wrist extensor contraction lasted for 4 sec (i.e., slow reversal).

Both upper extremities reset for subsequent repetition.

Subjects in the Tyler Twist exercise group perform 3 sets of 15 repetitions,
with 30 sec rest period between each set.

Intensity will be increase by giving the patient a thicker rubber bar if the patient
reported no longer experiencing discomfort during the exercise.

3sets of 15 repetitions will be given 5 times a week, for 3 weeks.
After 3 weeks of treatment, the pain assessment done through VAS scale, hand function
through PRTEE and grip strength through Sphygmomanometer for both groups will be taken
in to account. Data will be obtained and statistically analyzed.
12.3 Ethical clearance
Ethical clearance will be obtained from the institution.
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WEBSITES
www.dissertations.se
www.orthopedics.about.com/od/tenniselbow/tp/Tennis-Elbow.htm
www.medpagetoday.com
www.spotsperformance.com
www.copperwiki.org index.php/Tennis Elbow
www.linkinghub.elsevier.com
14
Signature of the Candidate
15
Remarks of the Guide
16
Name and Designation of :
16.1 Guide
16.2 Co-Guide (If any)
16.3 Signature
16.4 Head of the Department
16.5 Signature
17
17.1 Remarks of Chairman and Principal
17.2 Signature