Download 6. Brief resume of the intended work 6.1 Need for the study Lateral

6.
Brief resume of the intended work
6.1
Need for the study
Lateral epicondyltis (also referred to as tennis elbow, lateralis epicondylitis humeri, lawn tennis arm) is by
definition, a tendinopathy of the common extensor-supinator tendon of the elbow characterized by
lateral peri-epicondylar pain1.
The name lateral epicondylitis came into existence when Mr. Runge first distinguished lateral epicondylitis
from writer’s cramp in 1873. it was named lawn tennis arm by Morries shortly there after.2
Many proposed aetiologies for lateral epicondylitis have involved, the inflammatory process of
radiohumeral bursa, the synovium and periosteum.3
Kraushaar and Nirschl’s microscopic study demonstrated the presence of fibroblastic tissue and vascular
invasion of the common extensor tendon described as angiofibroblastic tendonosis, implying a
degenerative tendinopathy.4
However, the recent studies have demonstrated, the presence of
neuropeptides,substance P and
calcitonin related gene peptide (CRG) in sensory nerve fibers supplying ECRB which could imply the
possibility of neurogenic sensitization as an additional source of pain.4
Predisposing factors for this condition could be any repetitive motion of the wrist, including tennis,
overhead arm motion sports5.
Injury can also occur in those who carry out repetitive one sided movements in their jobs, eg;- electrician,
carpenters, knitting, gardening, needle work etc6. Any activity that requires excessive constant gripping or
squeezing can cause lateral epicondylitis.
In the game of tennis, following maneuvers can lead to lateral epicondylitis:
1. One handed backhand with poor form.
2. A late forehand swing resulting in bending the wrist significantly.
3. Snapping and turning the wrist while serving with full power.5
The common age of onset of lateral epicondylitis is 35-50 years with an equal male: female ratio.7
Development of lateral epicondylitis is usually insidious, although the onset may result from strenuous
overuse relating to particular repetitive action.
Clinically, patients present with sharp pain localized to the lateral aspect of the elbow, exacerbated by
activities such as lifting, gripping, forearm, supination or pronation (i.e pouring out tea, turning a stiff door
handle, shaking hands etc.)7 Tenderness is localized to the lateral humeral condyle at the origin of
extensors (extensor carpi radialis bravis). There could be local swelling or warmth8. Elbow ROM is normal.
Patients complain of a weak grasp and dropping of objects particularly with arm pronated. 9
Treatment for lateral epicondylitis can be:
1. Conservative care (chiropractic therapy, electric modalities, soft tissue massage, acupuncture, ice,
patient education, orthotic devices, taping, stretching and strengthening)4
2. Extra-corporeal shock wave therapy
3. Injections and medications
4. Surgical intervention
A trial of conservative therapies is generally advised for lateral epicondylitis patients before more invasive
treatments are attempted.
Large number of conservative treatments including physiotherapy are advised for lateral epicondylitis.
However, there is no review penetrating the best practice in the conservative management of this
condition. Hence this study aims to examine which popular forms of conservative treatment are the most
effective in treating lateral epicondylitis.
Hypothesis :
As this is a narrative review study, hypothesis may not be considered.
6.2
Review of literature:
Leanne Bisset,Elaine Beller,Gwendolen Jull,Peter Brooks,Ross Darnell,Bill Vicenzino 2006, investigated
the efficacy of physiotherapy compared with wait and see approach over 52 weeks. Single blind
randomized controlled trial including 198 participants aged between 18-65 years was done. They
concluded that, physiotherapy combining elbow manipulation and exercise had a superior benefit to wait
and see in the first 6 weeks and to corticosteroid injection after 6 weeks, providing a reasonable
alternative to injections in the mid to long term.10
A. P. D’ Vaz and coworkers 2005, conducted a study on effect of pulsed low intensity ultra sound therapy
for chronic lateral epicondylitis. The study design was randomized controlled trial. In this study, patients
with lateral epicondylitis of at least 6 weeks duration were participated. Participants were given either
ultrasound or placebo treatment. Author concluded that, low intensity ultrasound was no more effective
for a large treatment effect than placebo for recalcitrant lateral epicondylitis.1
P. A. A. Struijs, G. M. M. J Kerkhoffs, W. J. J. Assendelft, C. N. van Dijk 2004, evaluated effectiveness of
brace only treatment, physical therapy and combination of these for tennis elbow. Study design was
randomized clinical trial. Total 180 patients were randomized into 3 groups. Authors concluded that,
brace treatment might be useful as initial therapy. Combination therapy had no additional advantage
compared to physical therapy but it was superior to brace only for the short term.11
Aatit Paungmali, Shaun O’ Leary, Tina Souvlis and Bill Vicenzino 2004, evaluated the effect of naloxone
administration on hypoalgesic effect of movement with mobilization (MWM) in patients with lateral
epicondylitis. A randomized controlled trial evaluated the effect of administering naloxone, saline or no
substance control injection on the MWM induced hypoalgesia in 18 patients with lateral epicondylitis.
Authors found that, naloxone did not significantly antagonize the initial hypoalgesic effect of the MWM
on lateral epicondylitis as compared to a placebo saline injection or no substance injection control.12
Fink M, Wolkenstein E, Karst M, Gehrke A 2002, evaluated the clinical efficacy of acupuncture in
treatment of chronic lateral epicondylitis. In this randomized controlled study, 23 patients were treated
with real acupuncture and 22 patients received sham acupuncture. Authors concluded that, in the
treatment of chronic epicondylopathia lateralis humeri, acupuncture in which real acupuncture points
were stimulated was superior to the nonspecific acupuncture with respect to reduction in pain and
improvement in the functioning of the arm particularly at early follow up.13
Speed C A and coworkers 2002, studied the effectiveness of extracorporeal shock wave therapy (ESWT)
on chronic lateral epicondylitis. adults with lateral epicondylitis received either active treatment (1500
pulses ESWT at 0.12 mJ/ mm2 ) or sham therapy monthly for three months. There was a significant
placebo effect of moderate dose ESWT, but there was no evidence of added benefit of treatment when
compared to sham therapy in chronic lateral epicondylitis patients14.
Basford J R, Sheffield C. G, Cieslak K. R 2000, compared laser and placebo treatment on lateral
epicondylitis patients. Outcome measures used were visual analogue scale, grip strength and pinch
strength. Authors concluded that, laser was not effective for the improvement of the any outcome
measures used in the study15.
Hubert Labelle, Remi Guibert 1997, studied the efficacy of diclofenac in lateral epicondylitis of elbow also
treated with immobilization. One year study with 206 subjects aged 18-60 years was conducted.
Experimental group was treated with daily dose of diclofenac sodium (150 mg) for 28 days while control
group received placebo during same period. Both groups were immobilized in the cast for 14 days.
Authors concluded that it is difficult to recommend the use of diclofenac in the treatment of lateral
epicondylitis at the dosage used in this study.16
6.3
Objective of the study:
To determine which conservative modalities had the best outcomes for the treatment of lateral
epicondylitis in randomized controlled trials.
7.
Materials and Methods
7.1 Source of Data
A literature search will be done from 2010 to 2012 from
1. Padmashree Institute of Physiotherapy, central library.
2. Rajiv Gandhi University of Health Sciences- HELINET.
7.2 Method of collection of data:
Study-Narrative Review
Inclusion criteria:
Randomized controlled trials (RCT’s) and randomized clinical trials including randomized cross
over design studies related to conservative management in lateral epicondylitis.
Exclusion criteria:
1. Case control studies
2. Case series.
3. Case reports
4. Prospective and retrospective cohort studies
7.3 Methodology:
Studies that meet inclusion criteria will be searched from December 2010 to January 2012.
The online searches will be performed in English on the following databases:Medline, Google scholar, CINAHL, Alternative Medicine (AMED), Cochrane Library, MANTIS, PEDRO,
EMBASE, Index of Chiropractic Literature.
Randomized controlled trials or randomized clinical trials will be reviewed using the terms lateral
epicondylitis, elbow pain, conservative treatment, physical therapy, taping, education, acupuncture,
orthotics, ice either individually or in various combinations.
Studies listed in the reference list of the key articles that were retrieved will also be searched.
For this study, only published randomized controlled trials or randomized clinical trials that included one
of the following conservative treatments for lateral epicondylitis will be chosen:1. Conservative care (chiropractic therapy, electrical modalities, patient education, soft tissue
therapy, massage, acupuncture, taping, orthotics, stretching, ice, strengthening)
2. Extracorporeal shock wave therapy.
These forms of treatment will be chosen as these are the choice of treatment chiropractors and
physiotherapists most likely to use when treating patients with lateral epicondylitis.
From this literature search ( from the studies which meet inclusion criteria), the first author of the study,
year of publication, population studied, intervention given, outcome measures, dropout rates and
assessment scales will be extracted for further study review.
On the basis of data that will be retrieved from this review, the best outcomes of different conservative
treatments for lateral epicondylitis will be tabulated and interpreted.
Statistics:
Descriptive Statistics.
7.4 Ethical Clearance :For this study the ethical clearance has been obtained from the ethical committee of Padmashree
Institute of Physiotherapy,Nagarbhavi,Bangalore,as per ethical guidelines research from biomedical
research on human subjects,2000,ICMR,New Delhi.
8.
List of references
1. A. P. D’Vaz et al. Pulsed Low Intensity Ultrasound Therapy for Chronic Lateral Epicondylitis: A
Randomized Controlled Trial. Rheumatology. 2005 Nov 22nd; 45:566-570.
2. David
C.
Reid.
Sports
Injury
Assessment
and
Rehabilitation.
Philadelphia:Churchill
Livingstone;1982.
3. Carrie M. Hall, Lori Thein Body. Therapeutic Exercises. 2nd ed. NewYork:Lippincott Williams and
Wilkins;1999.p.647-48.
4. VAL Jones. Physiotherapy in the management of tennis elbow: a review. Sheffield Shoulder and
Elbow Unit. 2009; 1:108-113.
5. Tennis elbow causes, 2010 Nov 24webMD. Available from:
URL:http//www.emedicinehealth.com/tennis-elbow/page2-em.htm
6. Lars Peterson, Per Renstrom. Sports Injuries Their Prevention and Treatment. 1sted. Kyodo,
Singapore; 2001.
7. Samuel Turek. Orthopedics Principles and Their Application. 6th ed. Philadelphia :Lippincott
Williams and Wilkins;2005.p.412-13.
8. G. S. Kulkarni. Textbook of Orthopedics and Trauma. 2nd ed.New Delhi: JAYPEE;2008. p.2516-17.
9. Samuel Turek. Orthopedic Principles and Their Application. 4th ed. Philadelphia.NewYork:
Lippincott-Raven;1984.p.971-72.
10. Leanne Bisset, Elaine Beller, Gwendolen Jull, Peter Brooks, Ross Darnell, Bill Vicenzino.
Mobilization with Movement and Exercise, Corticosteroid Injection or Wait and See for Tennis
Elbow: Randomized Trial. BMJ. 2006 Nov4;333(7575):939.
11. P.A.A. Struijs, G.M.M.J. Kerkhoffs, W.J.J. Assendelft, C.N. van Dijk. Conservative Treatment of
Lateral Epicondylitis, Brace versus Physical Therapy or A Combination of Both- Randomized
Clinical Trial. American Journal of Sports Medicine. 2004 March; vol. 32:2462-469.
12. Aatit Paungmali, Shaun O’Leary, Tina Souvlis, Bill Vicenzino. Naloxone Fails to Antagonize Initial
Hypoalgesic Effect of Manual Therapy Treatment for Lateral Epicondylalgia. Journal of
Manipulative and Physiological Therapeutics. 2004; 27:180-5.
13. Fink M, Wolkenstein E, Karst M, Gehrke A. Acupuncture in Chronic Lateral Epicondylitis: A
Randomized Controlled Trial. Rheumatology (Oxford). 2002 Feb; 41(2):205-9.
14. Speed CA et al. Extracorporeal Shock Wave Therapy for Lateral Epicondylitis- A Double Blind
Randomized Controlled Trial. J Orthop Res. 2002 Sep; 20(5):895-8.
15. Jeffrey R. Basford B, Charles G. Sheffield, Kathryn R Cieslak. Laser Therapy: A Randomized
Controlled Trial of the Effects of Low Intensity ND: YAG Laser Irradiation on Lateral Epicondylitis.
Arch Phys Med Rehabil. 2000;81:1504-10.
16. Hubert Labelle, Remi Guibert, Efficacy of Diclofenac in Lateral Epicondylitis of Elbow also Treated
with Immobilization. Arch Fam Med.1997 May; 6(3):257-262.