Author Names
Peter Hoogvliet,1 Manon S Randsdorp,1,2 Rudi Dingemanse,1,2 Bart W Koes,2 Bionka M A Huisstede1,2
Reviewer Name
Kayla (Sloane) Grace, Duke SPT, B.S Exercise Physiology
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Background: Owing to the change in paradigm of the histological nature of epicondylitis, therapeutic modalities as exercises such as stretching and eccentric loading and mobilisation are considered for its treatment.
Objective: To assess the evidence for effectiveness of exercise therapy and mobilisation techniques for both medial and lateral epicondylitis.
Methods: Searches in PubMed, Embase, Cinahl and Pedro were performed to identify relevant randomised clinical trials (RCTs) and systematic reviews. Two reviewers independently extracted data and assessed the methodological quality.
Results: One review and 12 RCTs, all studying lateral epicondylitis, were included. Different therapeutic regimes were evaluated: stretching, strengthening, concentric/eccentric exercises and manipulation of the cervical or thoracic spine, elbow or wrist. No statistical pooling of the results could be performed owing to heterogeneity of the included studies. Therefore, a best-evidence synthesis was used to summarise the results. Moderate evidence for the short-term effectiveness was found in favour of stretching plus strengthening exercises versus ultrasound plus friction massage. Moderate evidence for short-term and midterm effectiveness was found for the manipulation of the cervical and thoracic spine as add-on therapy to concentric and eccentric stretching plus mobilisation of wrist and forearm. For all other interventions only limited, conflicting or no evidence was found.
Conclusions: Although not yet conclusive, these results support the belief that strength training decreases symptoms in tendinosis. The short-term analgesic effect of manipulation techniques may allow more vigorous stretching and strengthening exercises resulting in a better and faster recovery process of the affected tendon in lateral epicondylitis.
NIH Risk of Bias Tool
Quality Assessment of Systematic Reviews and Meta-Analyses
- Is the review based on a focused question that is adequately formulated and described?
- Yes
- Were eligibility criteria for included and excluded studies predefined and specified?
- Yes
- Did the literature search strategy use a comprehensive, systematic approach?
- Yes
- Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
- Yes
- Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
- Were the included studies listed along with important characteristics and results of each study?
- Yes
- Was publication bias assessed?
- Yes
Key Finding #1
“The short-term analgesic effect of manipulation techniques may allow the patient to do more vigorous stretching and strengthening exercises and, therefore, allow better and faster recovery of the affected tendon in LE resulting in decreased pain and improved function on the midterm” (Hoogvliet et. al).
Key Finding #2
Several works implemented a follow-up period that was relatively short (as short as immediately after treatment), and the question remains as to what the long-term effects (which are clinically more relevant) of these treatments might be.
Key Finding #3
“Moderate evidence for short-term and midterm effectiveness was found for the manipulation of the cervical and thoracic spine as add-on therapy to concentric and eccentric stretching plus mobilization of wrist and forearm” (Hoogvliet et. al).
Please provide your summary of the paper
The aim of this systematic review was to examine the effectiveness of exercise and mobilization techniques in treating medial and lateral epicondylitis. 232 reviews/RCTs were assessed based on five inclusion criteria and one review and 12 RCTs were selected for further investigation. From there, the selected works were divided into three groups (Exercise Therapy, Mobilization Techniques, and Exercise Plus Mobilization Therapy) for thorough review. Four works in the Exercise Therapy category were evaluated and results were as follows: (1) Moderate evidence for effectiveness of stretching and strengthening exercises combined vs ultrasound and stretching relative to short-term follow-up, (2) Limited evidence for (a) long-term results on effectiveness of strengthening and stretching exercises vs. ultrasound therapy, (b) effectiveness of eccentric exercise vs. stretching to decrease symptoms of LE on the midterm; for the short and long term, no evidence was found, (3) No evidence in the short-term for effectiveness of conservative vs. concentric strengthening or a combined stretching and concentric exercise program as add-on therapy to stretching. Eight works in the Mobilization category were evaluation and the results were as follows: (1) Conflicting evidence for effectiveness of C-spine manipulation vs placebo following treatment, (2) Moderate evidence in the short and mid-term for effectiveness of cervical and thoracic manipulation as add-on therapies to concentric and eccentric stretching with mobilization of the wrist and forearm, (3) Limited evidence (a) in the short-term for effectiveness of mobilization of the radial head and nerve vs ultrasound therapy and friction massage, as well as stretching and strengthening exercises for the extensors of the wrist, (b) in the short-term for effectiveness of the Mulligan mobilization accompanying ultrasound and exercise therapy, (c) on utilizing a lateral glide mobilization with movement (MWM) intervention vs a placebo/control, (d) for the effectiveness of MWM at the elbow vs a placebo/control immediately following treatment, (e) for effectiveness in favor of MWM with a force of 2.5 N versus a force of 1.2 or 1.9 N immediately following treatment, (f) the short-term effectiveness of oscillating energy manual therapy of the elbow vs a placebo (g) for the short-term effectiveness of manipulation of the wrist vs ultrasound, friction massage combined with muscle stretching and strengthening exercises. One piece was addressed to evaluate exercise plus mobilization therapy and the results consisted of limited evidence for the short-term effectiveness of ultrasound vs chiropractic therapy used in conjunction with strengthening exercises.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
Based on the findings above, it is clear that utilizing mobilizations in treating Lateral Epicondylitis would benefit from further investigation to extrapolate the long-term effectiveness. It is evident that mobilizations are best used in conjunction with additional therapeutic interventions (i.e stretching and strengthening exercises). The short-term analgesic effects of mobilization/manipulation will benefit additional physical therapy interventions by minimizing patient symptoms and improving time to treat. Although tendinosis may still be ambiguous in nature, minimizing symptoms and capitalizing on efforts to increase analgesic effects will therefore work towards improving patient buy-in and strengthening therapeutic alliance.
