Elbow

Mobilisation with Movement and Exercise, Corticosteroid Injection, or Wait and See for Tennis Elbow: Randomised Trial

Author Names: Bisset L., Beller E., Jull G., Brooks P., Darnell R., Vicenzino B.

Reviewer Name: Kendall Bietsch, SPT

Reviewer Affiliation(s): Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract: Objective: To investigate the efficacy of physiotherapy compared with a wait and see approach or corticosteroid injections over 52 weeks in tennis elbow. Design: Single blind randomized controlled trial. Setting: Community setting, Brisbane, Australia. Participants: 198 participants aged 18 to 65 years with a clinical diagnosis of tennis elbow of a minimum six weeks’ duration, who had not received any other active treatment by a health practitioner in the previous six months. Interventions: Eight sessions of physiotherapy; corticosteroid injections; or wait and see. Main outcome measures: Global improvement, grip force, and assessor’s rating of severity measured at baseline, six weeks, and 52 weeks. Results: Corticosteroid injection showed significantly better effects at six weeks but with high recurrence rates thereafter (47/65 of successes subsequently regressed) and significantly poorer outcomes in the long term compared with physiotherapy. Physiotherapy was superior to wait and see in the short term; no difference was seen at 52 weeks, when most participants in both groups reported a successful outcome. Participants who had physiotherapy sought less additional treatment, such as non-steroidal anti-inflammatory drugs, than did participants who had wait and see or injections. Conclusion: Physiotherapy combining elbow manipulation and exercise has a superior benefit to wait and see in the first six weeks and to corticosteroid injections after six weeks, providing a reasonable alternative to injections in the mid to long term. The significant short term benefits of corticosteroid injection are paradoxically reversed after six weeks, with high recurrence rates, implying that this treatment should be used with caution in the management of tennis elbow.

NIH Risk of Bias Tool: Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT: Yes
Was the method of randomization adequate (i.e., use of randomly generated assignment)?: Yes
Was the treatment allocation concealed (so that assignments could not be predicted)?: No
Were study participants and providers blinded to treatment group assignment?: No
Were the people assessing the outcomes blinded to the participants’ group assignments?: Yes
Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?: Cannot Determine, Not Reported, or Not Applicable
Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?: Yes
Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?: Yes
Was there high adherence to the intervention protocols for each treatment group?: Yes
Were other interventions avoided or similar in the groups (e.g., similar background treatments)?: Yes
Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?: Yes
Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?: No
Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?: Cannot Determine, Not Reported, or Not Applicable
Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?: Yes

Key Finding #1: When comparing 3 different types of management of lateral elbow pain, corticosteroid injection was the most effective intervention within the first 6 weeks of treatment, over the physiotherapy (joint mobilization with movement and exercise) and the control (“wait and see”) groups. However, in the mid- to long-term stages of treatment (i.e.: 6-52 weeks), the corticosteroid group had higher lateral elbow pain recurrence rates and experienced delayed recovery compared to the other groups.

Key Finding #2: After the first 6 weeks of treatment, the effects of physiotherapy (mobilization and exercise) were superior to both the corticosteroid injection and the “wait and see” groups. However, at 52 weeks, there was no significant difference between the physiotherapy and “wait and see” groups.

Key Finding #3: In most cases, lateral elbow pain (i.e.: tennis elbow) is a self-limiting condition at 52-weeks post-onset.

Key Finding #4: The physiotherapy group had significantly less use of analgesics or non-steroidal anti-inflammatory drugs compared to the corticosteroid and “wait and see” groups.

Reviewer Paper Summary: This randomized controlled trial compared the effectiveness between corticosteroid injection, physiotherapy (joint mobilizations with movement + exercise), and the “wait and see” approach to treating lateral elbow pain (i.e.: tennis elbow). Effectiveness was measured by analyzing each participant’s severity rating, pain-free grip ratio (comparing involved versus non-involved sides), and global improvement on a 6-point Likert scale, ranging from “completely recovered” to “much worse.” The corticosteroid injections consisted of a 1 mL local injection of 1% lidocaine and 10 mg of triamcinolone, administered at painful points in the elbow (maximum number of injections: 2). The physiotherapy group consisted of elbow manipulation and therapeutic exercise in 8, 30-minute sessions throughout the course of 6 weeks. The “wait and see” group was instructed not to seek additional treatment during the study. Results showed that short-term outcomes favored corticosteroid injection over physiotherapy or “wait and see” interventions for improving tennis elbow symptoms. However, after the initial 6 weeks of treatment, physiotherapy outcomes showed significant improvements compared to the other management approaches. By 52 weeks, there were no differences in outcomes between the physiotherapy or “wait and see” groups. The authors therefore suggested that combining elbow manipulation and exercise is the most effective form of treatment in the first 6 weeks of lateral elbow pain onset, but that most cases will be self-limiting (i.e.: not require intervention) in the long-term (i.e.: 52 weeks). Of note, the physiotherapy group had significantly less use of analgesics or non-steroidal anti-inflammatory drugs compared to the corticosteroid and “wait and see” groups, and this should be considered when managing patients with lateral elbow pain with regard to adverse side-effects.

Reviewer Clinical Interpretation of this paper: This study highlights the timeline of effectiveness in the following approaches for treating lateral elbow pain (tennis elbow): corticosteroid injections, physiotherapy (joint manipulation + therapeutic exercise), and “wait and see.” Because corticosteroid injections produce the quickest symptom relief (i.e.: within the first 6 weeks), they may be more heavily considered in patients whose contextual situation requires a prompt recovery. For example, corticosteroid injections may be more ideal treatment options in athletes who are competing in his/her final season of sport and require a quick recovery to complete the season. However, if the patient’s contextual situation allows for a more gradual progression of recovery (>6 weeks), it may be more optimal to utilize the physiotherapy approach (with joint manipulation + therapeutic exercise) in order to achieve better long-term outcomes (e.g.: decreased likelihood of recurrence/overall improved recovery). Using this physiotherapy approach could decrease the risk for adverse side-effects of corticosteroid injections and/or other drugs such as analgesics or non-steroidal anti-inflammatory drugs that were more prevalent in the “wait and see” group. Regardless of the treatment approach, providers should educate patients about the natural progression of tennis elbow by highlighting the fact that it is typically a self-limiting condition within one year. Sharing this information could assist in facilitating shared decision making between the patient and provider to utilize a treatment approach that is most optimal for the patient’s activities, participation, and overall contextual requirements.

The Effect of Manual Therapy to the Thoracic Spine on Pain-Free Grip and Sympathetic Activity in Patients with Lateral Epicondylalgia Humeri: A Randomized, Sample-Sized Planned, Placebo-Controlled, Patient-Blinded Monocentric Trial

Author Names

Philipp Zunke, Alexander Auffarth, Wolfgang Hitzl, and Mohamed Moursy

Reviewer Name

Jordan Burnett, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: The treatment of first choice for lateral epicondylalgia humeri is conservative therapy. Recent findings indicate that spinal manual therapy is effective in the treatment of lateral epicondylalgia. We hypothesized that thoracic spinal mobilization in patients with epicondylalgia would have a positive short–term effect on pain and sympathetic activity. Methods: Thirty patients (all analyzed) with clinically diagnosed (physical examination) lateral epicondylalgia were enrolled in this randomized, sample size planned, placebo-controlled, patient-blinded, monocentric trial. Pain-free grip, skin conductance and peripheral skin temperature were measured before and after the intervention. The treatment group (15 patients) received a one-time 2-min T5 costovertebral mobilization (2 Hz), and the placebo group (15 patients) received a 2-min one-time sham ultrasound therapy. Results: Mobilization at the thoracic spine resulted in significantly increased strength of pain-free grip + 4.6 kg ± 6.10 (p = 0.008) and skin conductance + 0.76 μS ± 0.73 (p = 0.000004) as well as a decrease in peripheral skin temperature by − 0.80 °C ± 0.35 (p < 0.0000001) within the treatment group. Conclusion: A thoracic costovertebral T5 mobilization at a frequency of 2 Hz shows an immediate positive effect on painfree grip and sympathetic activity in patients with lateral epicondylalgia. Clinical trial registration: German clinical trial register DRKS00013964, retrospectively registered on 2.2.2018. Keywords: Lateral epicondylalgia, Tennis elbow, Thoracic spine, Manual therapy, Sympathetic activity, musculoskeletal pain

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

Cannot Determine, Not Reported, or Not Applicable

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Cannot Determine, Not Reported, or Not Applicable

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

Mobilization of costovertebral junction at T5, at 2 Hz, has instant, positive effects on symptoms of lateral epicondylitis.

Key Finding #2

Immediate effects of thoracic mobilization include increased pain-free grip strength and activation of descending pain inhibitory mechanisms through the sympathetic nervous system, as measured by an increase in skin conductance and decrease in skin temperature.

Key Finding #3

While lateral epicondyle pain decreased and grip strength increased directly after the thoracic mobilization, there was no measurement of long-term effect of the treatment, which is a direction of further study.

Please provide your summary of the paper

Lateral epicondylalgia/tennis elbow is often treated well with conservative management, including eccentric exercises for wrist flexors and extensors, stretching of the wrist flexors and extensors, and manual therapy (MT) to the elbow and wrist. Prior research showed cervical spine mobilizations to be effective in increasing pain-free grip (PFG) and pain threshold at lateral epicondyle. Other research also shows spinal manipulation to be effective in sympathetic nervous system (SNS) activation, as demonstrated through increased skin conductance and decreased skin temperature, though most research has been conducted on asymptomatic patients. The immediate hypoalgesia effects in the symptomatic population tested are thought to be due to this sympathetic response and as the sympathetic trunk is at the thoracic spine, authors hypothesized that mobilization to the mid-thoracic spine would contribute to pain reduction and sympathetic activation for lateral epicondylalgia treatment. The thoracic mobilizations were applied to the costovertebral junction at T5 on the affected side at 2 Hz and pain-free grip, skin conductance, and skin temperature were measured immediately after treatment to determine effect on pain and sympathetic activation. The mobilization treatment group was compared to a control group that received gentle ultrasound therapy at the lateral epicondyle. Immediately after treatment and sham interventions, significant changes were observed in the treatment group of increased pain-free grip strength, increased skin conductance, and decreased skin temperature. No long-term outcomes were assessed in this study, though the authors mentioned that as a future direction.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

This study highlights how manual therapy applied to body regions outside the area with pain can contribute to statistically significant and positive changes. While the mobilization was performed at the thoracic spine and not at the lateral epicondyle, symptoms related to lateral epicondylalgia were decreased. Also, this study encourages continued research into sympathetic activation in the treatment of musculoskeletal conditions.

Chronic Lateral Epicondylitis of the Elbow: A Prospective Study of Low-Energy Shockwave Therapy and Low-Energy Shockwave Therapy Plus Manual Therapy of the Cervical Spine

Author Names

Rompe, J. D., Riedel, C., Betz, U., & Fink, C.

Reviewer Name

Juan Carlos Chavez Casiano

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Rompe JD, Riedel C, Betz U, Fink C. Chronic lateral epicondylitis of the elbow: a prospective study of low-energy shockwave therapy and low-energy shockwave therapy plus manual therapy of the cervical spine. Arch Phys Med Rehabil 2001;82:578-82. Objective: To compare the effects of extracorporeal shockwave therapy (ESWT) alone with a combination of ESWT and manual therapy of the cervical spine in treating chronic tennis elbow. Design: Prospective, matched single-blind control trial. Setting: University hospital clinic. Patients: Thirty patients with unilateral chronic tennis elbow, an unsuccessful conservative therapy during the 6 months before referral, and clinical signs of cervical dysfunction (eg, pressure pain at the C4-5 and/or C5-6 level, protraction of the head). Interventions: Three times at weekly intervals all patients received 1000 shockwave impulses of an energy flux density of.16mJ/mm2 at the lateral elbow. Additionally, they underwent manual therapy of the cervical spine and the cervicothoracic junction 10 times (group I). For each patient, a control matched by age (3-yr range) and gender at first conservative treatment was drawn at random from 127 patients who had undergone low-energy shockwave therapy in the same unit in the past 3 years (group II). Follow-up examinations took place at 12 weeks and at 12 months. Main Outcome Measures: The Roles and Maudsley outcome score at 12 months, defining an excellent or good result with no or only occasional discomfort without limitation of activity and range of motion. Results: Neither group differed statistically before the study, with a poor rating for all patients (p>.05). At 12 months, there was still no significant difference, with the outcome being excellent or good in 56% in group I, and in 60% in group II (p >.05). Each group showed significant improvement compared with the respective prestudy evaluation (p <.0001). Conclusion: ESWT may be an effective conservative treatment method for unilateral chronic tennis elbow. The efficacy of additional cervical manual therapy for lateral epicondylitis remains questionable.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Cannot Determine, Not Reported, or Not Applicable

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Cannot Determine, Not Reported, or Not Applicable

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Cannot Determine, Not Reported, or Not Applicable

Was there high adherence to the intervention protocols for each treatment group?

Cannot Determine, Not Reported, or Not Applicable

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Cannot Determine, Not Reported, or Not Applicable

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Cannot Determine, Not Reported, or Not Applicable

Key Finding #1

There was no statistically significant difference between group I and group II in the Roles and Maudsley scores (extended Fisher test) and the VAS rating (Wilcoxon test for independent samples).

Key Finding #2

There was a highly significant improvement within both groups for the VAS and on the Roles and Maudsley outcome score upon follow ups.

Key Finding #3

This study shows the values of low-energy ESWT in patients with chronic lateral epicondylalgia but it also questions the usefulness of additional cervical spine manual treatment in these patients.

Please provide your summary of the paper

This study compared the effects of extracorporeal shockwave therapy (ESWT) alone with a combination of ESWT and manual therapy of the cervical spine un treating chronic tennis elbow. Group I received shockwave therapy and manual therapy to the cervical spine ang group II underwent a monotherapy with low-energy shockwaves. Both group were treated under the same condition and the patients were treated singly to avoid influencing one another. One this this study failed to do was to compare the effects of only manual therapy. There was a significant improvement for both groups with the respective pre study evaluation. In conclusion further studies are needed to establish the optimum treatment regime with ESWT for patients with a recalcitrant tennis elbow and to clarify the effects of manual therapy.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

The study looked at the benefits of using extracorporeal shockwave therapy (ESWT) and ESWT plus manual therapy on patients with tennis elbow. According to the study both groups showed significant improvement. In clinical I could use a combination of both depending on how sever the patients pain is. I think another study could be done but with a third group that only gets manual therapy, to see how just manual therapy affects the patients.

Manual Therapy Reduces the Frequency of Clinical Hemarthrosis and Improves Range of Motion and Perceived Disability in Patients with Hemophilic Elbow Arthropathy: A Randomized, Single-Blind, Clinical Trial

Author Names

Cuestra-Barriuso R, Pérez-Llanes R, López-Pina J A, Donoso-Úbeda E, Meroño-Gallut

Reviewer Name

Razan Mazin Fayyad, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Purpose: To evaluate the effectiveness of manual therapy in reducing the frequency of clinical hemarthrosis, increasing range of motion and improving the perception of disability in the upper limbs in patients with hemophilic elbow arthropathy. Materials and methods: Sixty-nine patients were randomized into experimental (N1⁄435) and control group (N1⁄434). The outcome measures were: frequency of clinical hemarthrosis, the elbow range of motion and the perception of disability in the upper limbs (DASH questionnaire). The intervention included one 50 min weekly session, for three weeks, of upper limb fascial therapy according to our treatment protocol. Results: There were differences (p < 0.001) in the repeated measures analysis for frequency of elbow clinical hemarthrosis (F1⁄420.64) and range of motion in flexion (F1⁄417.37) and extension (F1⁄421.71). No differences were found in the overall perceived disability (F1⁄40.91; p 1⁄4 .37). We found group interaction with the (p<0.001) in the frequency of elbow clinical hemarthrosis, range of motion and overall perceived disability. Conclusions: Manual therapy is safe in patients with hemophilia and elbow arthropathy. Fascial therapy reduces the frequency of hemarthrosis, increases the range of motion and improves the perceived disability in the upper limbs.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

Manual therapy can significantly reduce the frequency of clinical hemarthrosis in patients with hemophilic elbow arthropathy

Key Finding #2

Patients who received manual therapy also showed significant improvements in range of motion and perceived disability compared to the control group

Key Finding #3

The study suggests that manual therapy can be an effective non-pharmacological intervention to reduce the frequency of hemarthrosis and improve joint function and quality of life in patients with hemophilic elbow arthropathy

Please provide your summary of the paper

Hemophilic elbow arthropathy causes specific functional alternations that with time lead to ROM restrictions in elbow flexion, extension, periarticular muscle hypotrophy, and chronic pain. Recurring hemarthrosis and its long-term effects on joints cause chronic pain, severe joint damage, disability, and a decrease in quality of life. There are a limited number of treatments. Of those, manual therapy using joint traction achieved improvements in range of motion and perceived pain in patients with hemophilic elbow arthropathy. With that, this study aims to evaluate the effectiveness of a manual therapy intervention in reducing the frequency of hemarthrosis, increasing range of motion and improving the perceived disability in the upper limbs in adult patients with hemophilia and elbow arthropathy. Sixty-nine patients were randomized into either the experimental or control group. The experimental group received a fascial therapy-based manual therapy intervention while the patients in the control group did not receive any treatment and were asked to continue with their usual routines. The frequency of clinical hemarthrosis, the elbow range of motion and the perception of disability in the upper limbs were the outcomes measured. The results showed that manual therapy was effective in reducing the frequency of clinical hemarthrosis and improving the range of motion and perceived disability in patients with this condition.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

This study showed how the addition of fascial therapy-based manual therapy significantly reduced the frequency of clinical hemarthrosis and improved the range of motion and perceived disability in these patients. This study recruited a significant number of patients with hemophilic elbow arthropathy. The evaluation of the effects of manual therapy on upper limb functionality was crucial in better understanding the relationship between the intervention and upper limb functionality. The paper discusses several limitations of the study, including the use of goniometric evaluation to measure elbow ROM and the hemarthrosis evaluation method. Other instruments such as the isokinetic dynamometer could provide more exact values. Although the study did not have any events of clinical hemarthrosis, subclinical hemarthrosis should be considered and identified through an ultrasound evaluation, something that should be incorporated into the study design. With that, further research is needed to confirm the findings and determine the long-term effects of manual therapy on hemophilic elbow arthropathy.

Effectiveness of Mobilization with Movement of Elbow Compared with Manipulation of Wrist in Patients of Lateral Epicondylitis

Author Names

Patel, Namrata

Reviewer Name

Jasmin Flores, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Purpose: To evaluate the effectiveness of mobilization with movement of elbow compared with manipulation of wrist on pain, strength and activities of daily living in patients of lateral epicondylitis. Methodology: An interventional comparative study was conducted on 30 patients having symptomatic lateral epicondylitis. They were randomly assigned to one of the three groups. Group A (n=10) control group, Group B (n=10) Mobilization with movement group and Group C (n=10) wrist manipulation. All the 3 groups were received conventional treatment of ultrasound, stretching and strengthening of wrist extensors. Baseline measurements of pain (VAS score), functional status (PRTEE questionnaire) and strength (maximal isometric grip strength) were taken on day 1 and after 10th treatment session. Results: The data analysis was performed with Graph Pad Instat trial version 3 software. All three groups showed improvement in VAS, maximal isometrics grip strength and PRTEE questionnaire. There is statistically significant difference between groups B (Mobilization with movement) and Group C (Manipulation of wrist) for VAS and PRTEE questionnaire score. But No statistically significant difference is found in maximal isometric grip strength. Mobilization with movement of elbow along with conventional therapy showed significant improvement in Pain and functional status as compared to wrist manipulation. Conclusion: It can be concluded that mobilization with movement of elbow along with conventional therapy program is effective in treating chronic lateral epicondylitis. KEYWORDS: Lateral epicondylitis; Mobilization with movement; Wrist manipulation.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Cannot Determine, Not Reported, or Not Applicable

Was the treatment allocation concealed (so that assignments could not be predicted)?

Cannot Determine, Not Reported, or Not Applicable

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Cannot Determine, Not Reported, or Not Applicable

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

When comparing the group that received conventional treatment and mobilization with movement of elbow (Group B) and the group that received conventional treatment and wrist manipulation (Group C), there was significant improvement in pain and functional status for Group B.

Key Finding #2

Mobilization with movement of the elbow was beneficial for patients to maintain their daily activities and it is effective within short periods.

Key Finding #3

All three groups, Group A was a control group, did not show statistically significant differences in grip strength throughout the testing period.

Please provide your summary of the paper

This paper focuses on the most effective treatment for patients with symptomatic lateral epicondylitis though three 3 randomized groups of 10 individuals in each group. Group A was the control group, Group B were given conventional treatment and mobilization with movement of elbow, and Group C were given conventional treatment and wrist manipulation. Conventional treatment was defined as ultrasound, static stretching of forearm extensors, and strengthening exercises of the wrist extensors. The baseline measurements that were used were pain (VAS score), functional status (PRTEE questionnaire), and strength (maximal isometrics grip strength). After 10 treatment sessions they found that the study showed improvement in VAS, maximal isometric grip strength, and PRTEE scores in all 3 groups, however there was significantly better outcomes for group B. There was a significant difference between groups B and C, and between group A and group B for VAS and PRTEE questionnaire score. There was no significant difference found between the groups for grip strength. Overall, there is a significant improvement in pain and functional status when given conventional treatment and mobilization with movement of elbow.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

Even though this paper did have limitations like having a small sample size, there was no long term follow up on the patients, and it was a short study, I believe it gives a good insight on different ways we can treat lateral epicondylitis (tennis elbow). Since there was no long term follow up, it is difficult to determine if these treatments are effective for patients with chronic lateral epicondylitis. However, a combination of ultrasound, wrist extension stretching, wrist extensor strengthening, and mobilization with movement of the elbow may be the most effective way to treat this condition according to the article.

Deep Transverse Friction Massage for Treating Lateral Elbow or Lateral Knee Tendinitis

Author Names

Laurianne M Loew, Lucie Brosseau,corresponding author Peter Tugwell, George A Wells, Vivian Welch, Beverley Shea, Stephane Poitras, Gino De Angelis, Prinon Rahman, and Cochrane Musculoskeletal Group

Reviewer Name

Jessica Fritson, SPT, ATC

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Deep transverse friction massage, one of several physical therapy interventions suggested for the management of tendinitis pain, was first demonstrated in the 1930s by Dr James Cyriax, a renowned orthopedic surgeon in England. Its goal is to prevent abnormal fibrous adhesions and abnormal scarring. This is an update of a Cochrane review first published in 2001. Objectives: To assess the benefits and harms of deep transverse friction massage for treating lateral elbow or lateral knee tendinitis. Search methods: We searched the following electronic databases: the specialized central registry of the Cochrane Field of Physical and Related Therapies, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Clinicaltrials.gov, and the Physiotherapy Evidence Database (PEDro), up until July 2014. The reference lists of these trials were consulted for additional studies. Selection criteria: All randomized controlled trials (RCTs) and controlled clinical trials (CCTs) comparing deep transverse friction massage with control or other active interventions for study participants with two eligible types of tendinitis (ie, extensor carpi radialis tendinitis (lateral elbow tendinitis, tennis elbow or lateral epicondylitis or lateralis epicondylitis humeri) and iliotibial band friction syndrome (lateral knee tendinitis)) were selected. Only studies published in English and French languages were included. Data collection and analysis: Two review authors independently assessed the studies on the basis of inclusion and exclusion criteria. Results of individual trials were extracted from the included study using extraction forms prepared by two independent review authors before the review was begun. Data were cross‐checked by a third review author. Risk of bias of the included studies was assessed using the “Risk of bias” tool of The Cochrane Collaboration. A pooled analysis was performed using mean difference (MD) for continuous outcomes and risk ratio (RR) for dichotomous outcomes with 95% confidence intervals (CIs). Main results: Two RCTs (no new additional studies in this update) with 57 participants met the inclusion criteria. These studies demonstrated high risk of performance and detection bias, and the risk of selection, attrition, and reporting bias was unclear. The first study included 40 participants with lateral elbow tendinitis and compared (1) deep transverse friction massage combined with therapeutic ultrasound and placebo ointment (n = 11) versus therapeutic ultrasound and placebo ointment only (n = 9) and (2) deep transverse friction massage combined with phonophoresis (n = 10) versus phonophoresis only (n = 10). No statistically significant differences were reported within five weeks for mean change in pain on a 0 to 100 visual analog scale (VAS) (MD ‐6.60, 95% CI ‐28.60 to 15.40; 7% absolute improvement), grip strength measured in kilograms of force (MD 0.10, 95% CI ‐0.16 to 0.36) and function on a 0 to 100 VAS (MD ‐1.80, 95% CI ‐0.18.64 to 15.04; 2% improvement), pain‐free function index measured as the number of pain‐free items (MD 1.10, 95% CI ‐1.00 to 3.20) and functional status (RR 3.3, 95% CI 0.4 to 24.3) for deep transverse friction massage, and therapeutic ultrasound and placebo ointment compared with therapeutic ultrasound and placebo ointment only. Likewise for deep transverse friction massage and phonophoresis compared with phonophoresis alone, no statistically significant differences were found for pain (MD ‐1.2, 95% CI ‐20.24 to 17.84; 1% improvement), grip strength (MD ‐0.20, 95% CI ‐0.46 to 0.06) and function (MD 3.70, 95% CI ‐14.13 to 21.53; 4% improvement). In addition, the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach was used to evaluate the quality of evidence for the pain outcome, which received a score of “very low”. Pain relief of 30% or greater, quality of life, patient global assessment, adverse events, and withdrawals due to adverse events were not assessed or reported. The second study included 17 participants with iliotibial band friction syndrome (knee tendinitis) and compared deep transverse friction massage with physical therapy intervention versus physical therapy intervention alone, at two weeks. Deep transverse friction massage with physical therapy intervention showed no statistically significant differences in the three measures of pain relief on a 0 to 10 VAS when compared with physical therapy alone: daily pain (MD ‐0.40, 95% CI ‐0.80 to ‐0.00; absolute improvement 4%), pain while running (scale from 0 to 150) (MD ‐3.00, 95% CI ‐11.08 to 5.08), and percentage of maximum pain while running (MD ‐0.10, 95% CI ‐3.97 to 3.77). For the pain outcome, absolute improvement showed a 4% reduction in pain. However, the quality of the body of evidence received a grade of “very low.” Pain relief of 30% or greater, function, quality of life, patient global assessment of success, adverse events, and withdrawals due to adverse events were not assessed or reported. Authors’ conclusions: We do not have sufficient evidence to determine the effects of deep transverse friction on pain, improvement in grip strength, and functional status for patients with lateral elbow tendinitis or knee tendinitis, as no evidence of clinically important benefits was found. The confidence intervals of the estimate of effects overlapped the null value for deep transverse friction massage in combination with physical therapy compared with physical therapy alone in the treatment of lateral elbow tendinitis and knee tendinitis. These conclusions are limited by the small sample size of the included randomized controlled trials. Future trials, utilizing specific methods and adequate sample sizes, are needed before conclusions can be drawn regarding the specific effects of deep transverse friction massage on lateral elbow tendinitis.

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?

Were eligibility criteria for included and excluded studies predefined and specified?

Did the literature search strategy use a comprehensive, systematic approach?

Cannot Determine, Not Reported, Not Applicable

Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

Cannot Determine, Not Reported, Not Applicable

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?

Was publication bias assessed?

Was heterogeneity assessed? (This question applies only to meta-analyses.)

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

Clear and better designed RCT need to be conducted to support or deny efficacy of deep transverse friction massage for tendinitis.

Key Finding #2

No studies that met the systematic review criteria showed significant pain relief, increase in quality of life, or a successful pain global assessment regarding treatment.

Key Finding #3

More research needs to be conducted to determine the side effects and complications associated with deep transverse friction massage for patients with lateral elbow tendinitis.

Key Finding #4

There was not enough evidence or support to determine deep transverse friction massage influences pain, grip strength, and functional status for lateral elbow tendinitis in patients.

Please provide your summary of the paper

Deep transverse friction massage (DTFM) has been considered for tendonitis pain since the 1930s with the goal of reducing scaring, increasing blood flow, and facilitate healing. This systematic review looks at random control trials and controlled clinical trials that compare DTFM to other active interventions for patients with lateral elbow tendonitis. Two RCT fit the selection criteria. The research study focusing on DTFM on the elbow consisted of 40 participants and looked at DTFM in combination to ultrasound with a placebo ointment in comparison to just ultrasound treatment with the same placebo ointment over a five-week span. The study also looked at DTFM in combination with phonophoresis compared to just phonophoresis for the same duration of the study. The evidence was insufficient for DTFM to demonstrate a clinically significant benefit for patients with lateral elbow tendinitis. There is not sufficient evidence to determine how pain, grip strength, and function status are affected in patients with lateral elbow tendinitis when DTFM is implemented as part of the plan of care. Some limitations of the study include not being able to generalize the results due to the specific study population. Along with this, the two RCTs had difficulty blinding participants and personnel increasing bias risk as it may impact patient-reported outcomes. There were also small sample sizes and a 15% dropout rate within one of the studies. Moving forward, it is necessary for high-quality research with larger randomized samples are conducted to access the effects of deep transverse friction massage to treat tendinitis.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

It is important to consider the research and how we can implement evidence-based practice in our treatment as clinicians. This article gives information that given the RCT referenced in the studies that met the criteria for the systematic review, the research and evidence is poor that deep transverse friction massage is an effective form of treatment for lateral elbow tendinitis. When considering which interventions, specifically manual techniques, it is important to consider what the literature says to have the most informed care. It also reminds clinicians not all studies are conducted in a manner that allows the conclusions to be beneficial to clinical practice. Finally, in healthcare, it is not only important to take into consideration research evidence as a component of evidence-based practice but also clinical expertise and patient values. Given this, the patient values and clinician experience need to be taken into consideration which does not completely negate deep transverse friction massage in lateral elbow tendinitis. Further, better quality research must be explored to gain more understanding of the potential effects and risks.

Effectiveness of Nerve Gliding Exercises on Carpal Tunnel Syndrome: A Systematic Review

Author Names

Ballestero-Pérez, R. et. al.

Reviewer Name

Miranda Frohlich, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective: The objective of this study was to review the literature regarding the effectiveness of neural gliding exercises for the management of carpal tunnel syndrome (CTS).

Methods: A computer-based search was completed through May 2014 in PubMed, Physiotherapy Evidence Database (PEDro), Web of Knowledge, Cochrane Plus, and CINAHL. The following key words were included: nerve tissue, gliding, exercises, carpal tunnel syndrome, neural mobilization, and neurodynamic mobilization. Thirteen clinical trials met the inclusion/exclusion criteria, which were: nerve gliding exercise management of participants aged 18 years or older; clinical or electrophysiological diagnostics of CTS; no prior surgical treatment; and absence of systemic diseases, degenerative joint diseases, musculoskeletal affectations in upper limbs or spine, or pregnancy. All studies were independently appraised using the PEDro scale. Results: The majority of studies reported improvements in pain, pressure pain threshold, and function of CTS patients after nerve gliding, combined or not with additional therapies. When comparing nerve gliding with other therapies, 2 studies reported better results from standard care and 1 from use of a wrist splint, whereas 3 studies reported greater and earlier pain relief and function after nerve gliding in comparison with conservative techniques, such as ultrasound and wrist splint. However, 6 of the 13 studies had a quality of 5 of 11 or less according to the PEDro scale. Conclusions: Limited evidence is available on the effectiveness of neural gliding. Standard conservative care seems to be the most appropriate option for pain relief, although neural gliding might be a complementary option to accelerate recovery of function. More high-quality research is still necessary to determine its effectiveness and the subgroups of patients who may respond better to this treatment. (J Manipulative Physiol Ther 2017;40:50-59)

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?

Were eligibility criteria for included and excluded studies predefined and specified?

Did the literature search strategy use a comprehensive, systematic approach?

Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

Cannot Determine, Not Reported, Not Applicable

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?

Was publication bias assessed?

Was heterogeneity assessed? (This question applies only to meta-analyses.)

Key Finding #1

The majority of the studies found that nerve gliding, combined with or not combined with additional therapies, improved pain, pressure pain threshold, and function of CTS.

Key Finding #2

The results show that use of standard conservative care (splint or tendon/carpal mobilization) continues to be the best option to improve pain and function of individuals with CTS; and nerve gliding exercise can be utilized as an additional modality to decrease recovery time of CTS.

Key Finding #3

More than half the studies reviewed had a quality of 5/11 or less, according to the PEDro scale, impacting results.

Key Finding #4

There has been studies conducted that show patients to have a significant decrease in symptoms after tendon and nerve gliding exercises, post surgical intervention.

Please provide your summary of the paper

This research study was performed to assess literature regarding the effectiveness of neural gliding exercises for the management of carpal tunnel syndrome (CTS). The study was conducted as a systematic review for which 13 of the 118 articles considered met the inclusion/exclusion criteria. All studies applied neural mobilization by nerve gliding with the exception of 1 study which compared neural mobilization with increasing stress on the nerve to neural mobilization with decreasing stress on the nerve. The majority of the articles (8) compared nerve gliding with standard care consisting of volar wrist splint and medication. The remaining (5) articles either compared nerve gliding with carpal or tendon mobilization, nerve gliding with ultrasound therapy, or no additional intervention to nerve gliding. Reliable outcome measures were utilized to compare changes in pain and/ or function including the numerical pain rating scale (NPRS), visual analog scale (VAS), pain relief scale, Disabilities of the Arm, Shoulder, and Hand questionnaire, Functional Status scale, Functional status box, pinch and grip strength, Symptom Severity Scale, 24-hour symptom diary, Carpal Tunnel Specific Questionnaire, and Symptom Total Point Score. It can be strongly suggested from the results of this systematic review that standard conservative care is the best treatment option for patients with CTS. However, patients may demonstrate improved outcomes and a faster recovery with the addition of nerve gliding as a compliment to treatment. The PEDro scale was utilized to assess the quality of the articles. It was found that all articles had some form of limitation. Some of these limitations include a strict inclusion criteria, lack of blinding treatment, concealed allocation, and lack of comparison with a controled intervention. With the lack of high-quality research on neural mobilization, further research should be conducted to distinguish neural mobilization with the glissade and/or tension parameter to form a better understanding on the effects of both neural techniques.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

I believe this systematic review provided a great insight to the lack of evidence on neural gliding exercises and it’s different techniques. I appreciate that specifics were given with regards to the research and computer-based strategy. The study has a variance of low to high quality literature which make findings difficult to tract and implement in practice. Personally, I feel neural gliding exercises are a great tool to have in ones tool box as a physical therapist, but I continue to feel that they are best utilized as a compliment to other therapy treatment.

Effects of Myofascial Release with Tennis Ball on Spasticity and Motor Functions of the Upper Limb in Patients with Chronic Stroke: A Randomized Controlled Trial

Author Names

Parikh RJ, Sutaria JM, Ahsan M, Nuhmani S, Alghadir AH, Khan M

Reviewer Name

Megan Hayden, SPT

Reviewer Affiliation(s)

Duke University Doctor of Physical Therapy

Paper Abstract

Background: Impaired motor function and upper extremity spasticity are common concerns in patients after stroke. It is essential to plan therapeutic techniques to recover from the stroke. The objective of this study was to investigate the effects of myofascial release with the tennis ball on spasticity and motor functions of the upper extremity in patients with chronic stroke. Methods: Twenty-two chronic stroke patients (male-16, female-6) were selected to conduct this study. Two groups were formed: the control group (n=11) which included conventional physiotherapy only and the experimental group (n=11) which included conventional physiotherapy along with tennis ball myofascial release – in both groups interventions were performed for 6 sessions (35 minutes/session) per week for a total of 4 weeks. The conventional physiotherapy program consisted of active and passive ROM exercises, positional stretch exercises, resistance strength training, postural control exercises, and exercises to improve lower limb functions. All patients were evaluated with a modified Ashworth scale for spasticity of upper limb muscles (biceps brachii, pronator teres, and the long finger flexors) and a Fugl-Meyer assessment scale for upper limb motor functions before and after 4 weeks. Nonparametric (Mann–Whitney U test and Wilcoxon signed-rank test) tests were used to analyze data statistically. This study has been registered on clinicaltrial.gov (ID: NCT05242679). Results: A significant improvement (P < .05) was observed in the spasticity of all 3 muscles in both groups. For upper limb motor functions, significant improvement (P < .05) was observed in the experimental group only. When both groups were compared, greater improvement (P < .05) was observed in the experimental group in comparison to the control group for both spasticity of muscles and upper limb motor functions. Conclusion: Myofascial release performed with a tennis ball in conjunction with conventional physiotherapy has more beneficial effects on spasticity and motor functions of the upper extremity in patients with chronic stroke compared to conventional therapy alone. Keywords: chronic stroke, Fugl–Meyer assessment scale, modified Ashworth scale, motor functions, myofascial release, spasticity

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

Spasticity and increased tone secondary to stroke can be major contributors to chronic pain and reduced functional capacity, but myofascial release may be an easy supplement to therapeutic exercise to address these deficits.

Key Finding #2

Myofascial release may take a role in altering afferent signals by inhibiting motor neuron excitability as well as having a musculoskeletal effect of breaking down the fibrous adhesive tissues in the muscle.

Key Finding #3

The study sample was very small so further research would be needed before applying these findings to a larger stroke population.

Please provide your summary of the paper

The study was a double-blinded randomized control trial that observed the effects of using a myofascial release to address spasticity where the control group consisted of active and passive ROM exercises, positional stretch exercises, resistance strength training, and postural control exercises, and the experimental group performed these same therapeutic exercises as well as incorporated myofascial release with a tennis ball in the UE. The Modified Ashworth Scale was used to examine spasticity and a Fugl-Meyer Assessment Scale was used to examine upper limb motor function. Patients in the experimental group were taught to perform myofascial release with a tennis ball to the biceps brachii, pronator teres, and long finger flexors. Research has been conducted on myofascial release in the lower extremity as well that found that myofascial release reduces spasticity by inhibiting motor neuron excitability through prolonged stretch and compression on muscle spindles, Golgi tendon organ, joint and cutaneous receptors. other research also suggests a neuro-reflexive component when manual forces are applied to skeletal tissue. The results of this study were that both groups showed statistically significant changes in spasticity as well as upper limb motor function; however, the experimental group displayed an even greater change in the outcome measures.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

While further research needs to be conducted on larger sample sizes, this paper is very supportive of the use of myofascial release for a reduction in spasticity. It can be a great supplement to already prescribed exercises given to a patient to perform at home. The technique can be easily taught to the patient and/or their caregiver and is not time-consuming; the study prescribed only 2 minutes for each muscle (a total of 6 minutes) every day and resources already found in the home like a tennis or lacrosse ball can be used. Because of its potential to reduce spasticity in the UE, it may be useful to perform first, before other prescribed exercises that may be limited due to higher levels of spasticity.

Muscle Energy Technique Versus Corticosteroid Injection for Management of Chronic Lateral Epicondylitis: Randomized Controlled Trial With 1-Year Follow-up

Author Names

Küçükşen, S., Yilmaz, H., Salli, A., Uğurlu, H.

Reviewer Name

Jake Isaac, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective To determine the short- and long-term effectiveness of the muscle energy technique (MET) compared with corticosteroid injections (CSIs) for chronic lateral epicondylitis (LE). Design Randomized controlled trial with 1 year of follow-up. Setting Outpatient clinic of a university’s department of physical medicine and rehabilitation. Participants Patients with chronic LE (N=82; 45 women, 37 men). Interventions Eight sessions of MET, or a single CSI was applied. Main Outcome Measures Grip strength, pain intensity, and functional status were assessed using the pain-free grip strength (PFGS), a visual analog scale (VAS), and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, respectively. Measurements were performed before beginning treatment and at 6, 26, and 52 weeks afterward. Results When the baseline PFGS, VAS, and DASH scores were compared with the scores at the 52-week follow-up, statistically significant improvements were observed in both groups over time. The patients who received a CSI showed significantly better effects at 6 weeks according to the PFGS and VAS scores, but declined thereafter. At the 26- and 52-week follow-ups, the patients who received the MET were statistically significantly better in terms of grip strength and pain scores. At 52 weeks, the mean PFGS score in the MET group was significantly higher (75.08±26.19 vs 62.24±21.83; P=.007) and the mean VAS score was significantly lower (3.28±2.86 vs 4.95±2.36; P=.001) than those of the CSI group. Although improvements in the DASH scores were more pronounced in the MET group, the differences in DASH scores between the groups were not statistically significant. Conclusions This study showed that while both MET and CSI improved measures of strength, pain, and function compared with baseline, subjects receiving MET had better scores at 52 weeks for PFGS and the VAS for pain. We conclude that MET appears to be an effective intervention in the treatment of LE.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Cannot Determine, Not Reported, or Not Applicable

Were study participants and providers blinded to treatment group assignment?

Cannot Determine, Not Reported, or Not Applicable

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

Compared with subjects receiving corticosteroid injections, those receiving the muscle energy technique had better scores at 52 weeks for pain free grip strength (PFGS) and pain measured by the VAS.

Key Finding #2

No significant differences were found between the two groups in DASH scores at 52 weeks, however, significant differences in DASH scores were found over time in both groups.

Please provide your summary of the paper

This randomized controlled trial examined the long- and short-term effectiveness of a muscle energy technique (MET) compared with corticosteroid injections (CSIs) for the treatment of lateral epicondylitis (LE). 82 patients with chronic LE (duration>3 months) were eligible for the study and were randomly selected into the MET or CSI group. The main outcomes assessed in the study were pain free grip strength (PFGS), pain intensity via the visual analog scale (VAS), and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Outcomes were assessed at baseline, 6, 26, and 52 weeks after treatment. The CSI group received a singular injection given 1 cm distal to the lateral epicondyle aimed towards the area of maximal tenderness. The MET was applied 2 sessions per week for 4 weeks. For the MET, the distal humerus was stabilized by the operator and then the forearm was supinated until pain or resistance was detected. After holding the position, the patient was asked to pronate the forearm against resistance for 5 seconds followed by a relaxation period and supination was increased until resistance was met again. This process was repeated 5 times in each treatment session. Compared to baseline measures, both groups improved significantly in all outcome measures. Patients in the CSI group demonstrated significantly better PFGS and VAS scores at week 6, but declined in these measures at 26 and 52 weeks. At 26 and 52 weeks, patients in the MET group showed significantly better improvements in grip strength and pain intensity compared to the CSI group. Both groups showed statistically significant improvements in DASH scores at 52 weeks compared to baseline, however, no significant difference In DASH scores was found between the two groups.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

This study indicates that both MET and CSIs can be effective at improving grip strength, decreasing pain, and increasing function for those with chronic lateral epicondylitis. The results demonstrate that CSIs may be effective as a short-term intervention, however, their effectiveness may dissipate after 6 weeks. Although the MET group scored lower at the 6 week period, their PFGS and VAS scores were significantly better in the long-term compared to the CSI group indicating that this may be a more beneficial intervention to generate long-term effects. The aforementioned results demonstrate that CSIs could be a short-term solution resulting in pain reduction but should not be the sole approach to treating chronic LE. Similarly, MET can be an effective approach to improve grip strength and decrease pain, however, it may require more time compared to CSIs for the benefits to be seen. These two interventions used in conjunction with one another would likely result in greater improvements in grip strength, pain, and function in those with chronic LE compared with the results seen by using the interventions independently.

The Analgesic Effect of Joint Mobilization and Manipulation in Tendinopathy: A Narrative Review

Author Names

Savva, C, Karagiannis, C, Korakakis, V, and Efstathiou, M

Reviewer Name

Annemarie Jacob

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective: To summarize the available literature with regards to the potential analgesic effect and mechanism of joint mobilization and manipulation in tendinopathy. Results: The effect of these techniques in rotator cuff tendinopathy and lateral elbow tendinopathy, applied alone, compared to a placebo intervention or along with other interventions has been reported in some randomized controlled trials which have been scrutinized in systematic reviews. Due to the small randomized controlled trials and other methodological limitations of the evidence base, including short-term follow-ups, small sample size and lack of homogenous samples further studies are needed. Literature in other tendinopathies such as medial elbow tendinopathy, de Quervain’s disease and Achilles tendinopathy is limited since the analgesic effect of these techniques has been identified in few case series and reports. Therefore, the low methodological quality renders caution in the generalization of findings in clinical practice. Studies on the analgesic mechanism of these techniques highlight the activation of the descending inhibitory pain mechanism and sympathoexcitation although this area needs further investigation. Conclusion: Study suggests that joint mobilization and manipulation may be a potential contributor in the management of tendinopathy as a pre-conditioning process prior to formal exercise loading rehabilitation or other proven effective treatment approaches.

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?

Cannot Determine, Not Reported, Not Applicable

Were eligibility criteria for included and excluded studies predefined and specified?

Did the literature search strategy use a comprehensive, systematic approach?

Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

Cannot Determine, Not Reported, Not Applicable

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?

Was publication bias assessed?

Was heterogeneity assessed? (This question applies only to meta-analyses.)

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

Manual therapy in combination with exercise is suggested to reduce rotator cuff tendon pain and improve short term function moreso than just exercise therapy on it’s own.

Key Finding #2

Joint mobilizations and manipulations that are directed at the cervical and thoracic spine (or the elbow and the wrist) have been shown to be effective on both pain and function in patients with lateral elbow tendinopathy.

Please provide your summary of the paper

There is still, overall, limited research out there that can firmly support the effectiveness of manual therapy in numerous tendinopathies. However, in rotator cuff tendinopathies and lateral elbow tendinopathies, there is more evidence. These techniques when used with both of these conditions could be utilized as a pre-conditioning treatment in order to prepare the individual for formal exercise that can further help their condition.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

The findings of this review support the idea that joint mobilizations and manipulations, whether applied alone or in combination with other interventions, could be effective in reducting tendon pain both in the rotator cuff and the lateral elbow. Moreover, these techniques can be used as an analgesic modality in many sessions that can provide an outlet to manage the patient’s pain so that they can work through other, more intensive interventions as well.

The Initial Effects of an Elbow Mobilization with Movement Technique on Grip Strength in Subjects with Lateral Epicondylalgia

Author Names

Abbott, J., Patla, C., Jensen, R.

Reviewer Name

Mallory Martlock SPT

Reviewer Affiliation(s)

Duke University, School of Medicine Doctor of Physical Therapy Division

Paper Abstract

This preliminary study indicates the proportion of patients with lateral epicondylalgia that demonstrate a favourable initial response to a manual therapy technique – the mobilization with movement (MWM) for tennis elbow. Twenty-five subjects with lateral epicondylalgia participated. In a one-group pretest –post-test design, we measured (1) pain with active motion, (2) pain-free grip strength and, (3) maximum grip strength before and after a single intervention of MWM. Results of the study indicate that MWM was effective in allowing 92% of subjects to perform previously painful movements pain-free, and improving grip strength immediately afterwards. Significant differences were found between the grip strength of the affected and unaffected limbs prior to the intervention. Both pain-free grip strength and maximum grip strength of the affected limb increased significantly following the intervention. Pain-free grip strength increased by a greater magnitude than maximum grip strength. It can be concluded that MWM is a promising intervention modality for the treatment of patients with Lateral Epicondylalgia. Pain-free grip strength is a more responsive measure of outcome than maximum grip strength for patients with Lateral Epicondylalgia. Further research is warranted to investigate the long-term effectiveness of MWM in the treatment of impairment and disability resulting from Lateral Epicondylalgia. # 2001 Harcourt Publishers Ltd.

NIH Risk of Bias Tool

Quality Assessment Tool for Before-After (Pre-Post) Studies With No Control Group

Was the study question or objective clearly stated?

Were eligibility/selection criteria for the study population prespecified and clearly described?

Were the participants in the study representative of those who would be eligible for the test/service/intervention in the general or clinical population of interest?

Were all eligible participants that met the prespecified entry criteria enrolled?

Was the sample size sufficiently large to provide confidence in the findings?

Was the test/service/intervention clearly described and delivered consistently across the study population?

Were the outcome measures prespecified, clearly defined, valid, reliable, and assessed consistently across all study participants?

Were the people assessing the outcomes blinded to the participants’ exposures/interventions?

Was the loss to follow-up after baseline 20% or less? Were those lost to follow-up accounted for in the analysis?

Did the statistical methods examine changes in outcome measures from before to after the intervention? Were statistical tests done that provided p values for the pre-to-post changes?

Were outcome measures of interest taken multiple times before the intervention and multiple times after the intervention (i.e., did they use an interrupted time-series design)?

If the intervention was conducted at a group level (e.g., a whole hospital, a community, etc.) did the statistical analysis take into account the use of individual-level data to determine effects at the group level?

Key Finding #1

The Mulligan mobilization with movement (MWM) is an effective technique in decreasing the pain of a previously painful movement.

Key Finding #2

MWM resulted in decreased pain during grip strength as well as an increase in grip strength from pre to post test of grip strength with a hand dynamometer.

Please provide your summary of the paper

This paper investigated the effects that a mobilization with movement had on patients with lateral epicondylalgia. The investigators measured pain with active motion, pain free grip strength, and maximum grip strength before and after a single intervention of MWM. The mobilization technique that was performed involved a laterally directed manual pressure applied at the proximal medial forearm while the patient performed a motion that they had previously identified as painful (this included making a fist, gripping a rolled elastic bandage, wrist extension unresisted, wrist extension resisted, third finger extension unresisted or third finger extension resisted). The patient’s were then split into two groups depending on if the mobilization technique did or did not eliminate their pain. The results showed that 23 out of 25 subjects responded positively to the MWM technique. Grip strength measurements were performed on all 25 participants but the 23 participants were further tested with the three criteria listed above. The conclusion stated that the mobilization technique was effective in allowing a previously painful active movement to be performed pain free while the mobilization was being applied.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

This paper provides evidence in favor of manual therapy in the treatment of patients with lateral epicondylalgia. To be used clinically, it should be noted that each patient identified a specific motion that caused the pain on their lateral elbow. Each motion presented differently for each patient which emphasizes the variability in treatment that exists. The clinician should focus on a symptoms based approach for each patient and take time to identify what specific movements are irritable for each patient. This will help the mobilization technique be as effective as it possibly can be.

Effectiveness of a Specific Physiotherapy Regimen on Patients with Tennis Elbow

Author Names

Kochar, M., Dogra, Ankit.

Reviewer Name

Haley Mills, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

The effect of a combination of Mulligan mobilisation (a manual therapy approach) and ultrasound therapy is compared with that of ultrasound therapy alone. In both cases, a progressive exercise programme followed ten sessions of therapy to improve strength and facilitate return to work. Sixty-six patients (male:female ratio 6:5, mean age 41 years) were recruited. Of these patients, 46 were randomised into two treatment groups by a random draw of chits. The remaining 20, who could not be randomised, comprised the control group.The first (MM) group was treated with a combination of ultrasound therapy and Mulligan mobilisation while the second group was treated with ultrasound therapy alone for ten sessions (completed within three weeks). Both groups then followed a progressive exercise regime for a further nine weeks. They were evaluated at weekly intervals from the time of selection until the third week and finally at the 12th week with four outcome measures: visual analogue scale (VAS), isometric grip strength, weight test and patient assessment test. In the follow-up visit after 12 weeks of therapy, there was improvement in VAS, weight test and grip strength in both the MM (p < 0.01, 0.01, 0.01) and ultrasound groups (p < 0.01, 0.05, 0.05). The MM group showed a greater improvement than both the ultrasound group and the control group on VAS (p < 0.05, 0.05); weight test (p < 0.01, 0.001) and grip strength (NS, p < 0.05). The ultrasound group was superior to the control group on VAS (p < 0.05); weight test (p < 0.01), but the difference from the control group in grip strength was not significant. The MM group showed improvement on most parameters from the first week onwards whereas the ultrasound group improved only from the second week. Also the patient assessment score improved for the MM group (p < 0.05) and for the ultrasound group improvement was significant at three weeks of therapy (p < 0.05), but the difference was not statistically significant at 12 weeks.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT?

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Cannot Determine, Not Reported, or Not Applicable

Were study participants and providers blinded to treatment group assignment?

Cannot Determine, Not Reported, or Not Applicable

Were the people assessing the outcomes blinded to the participants’ group assignments?

Cannot Determine, Not Reported, or Not Applicable

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Cannot Determine, Not Reported, or Not Applicable

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Cannot Determine, Not Reported, or Not Applicable

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Cannot Determine, Not Reported, or Not Applicable

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

The Mulligan mobilization group showed significantly better subjective and objective short- and medium-term outcomes than the ultrasound and control groups.

Key Finding #2

Using ultrasound and Mulligan mobilization greatly reduced pain, improved grip strength, and the amount of weight lifted.

Key Finding #3

The ultrasound group demonstrated greater improvement than the control group in most parameters.

Key Finding #4

The Mulligan mobilization group had lower pain levels than the ultrasound group at discharge, when they began their exercise regime, likely explaining why their recovery was more strikingly improved than the ultrasound group.

Please provide your summary of the paper

The researchers aimed to evaluate whether the addition of manual therapy to the typical treatment plan, including ultrasound and exercise, would change outcomes. To study this they took 66 patients with elbow lateral epicondyle pain and randomly divided them into a Mulligan mobilization (manual therapy) and ultrasound group, an ultrasound group, and a control group. The researchers describe Mulligan mobilization as “mobilization with movement”, where a patient lifts a weight that would usually produce their symptoms while the therapist provides a lateral glide. The control group was compiled of people who could not make it to the clinic. Both groups receiving interventions received a graduated exercise therapy program in addition to the treatments being assessed. The outcome measures used for the study were the VAS, a weight test, grip strength, and a self-reported pain question about pain in the last 24 hours. Outcomes were assessed before the interventions, once a week for 3 weeks, and then once after 4 months. After gathering the data and processing it, the researchers found that the Mulligan mobilization group showed the greatest out of the groups in all of the short- and medium-term outcomes. They also found that though the ultrasound group did not improve more than the Mulligan mobilization group, they did improve more than the control group. With this information, the researchers suggest that the addition of Mulligan mobilization to a regimen comprising ultrasound therapy and progressive exercises will enhance the recovery of patients with tennis elbow.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

This paper, though slightly dated, provides some information that could be used to help develop a plan of care for patients with tennis elbow. The design of this study does, however, have a limitation that they do not address entirely and that I believe to be an important distinction to make. They seem to rationalize the use of ultrasound as the standard treatment regime by listing that the group had greater improvements than the control. What they fail to appropriately highlight, when discussing results, is that the control group did not receive the same graduated exercise regime that the other two treatment groups received. This oversight could contribute to drawing incorrect conclusions about the strength of ultrasound as a stand-alone treatment, when in fact it was used in conjunction with exercise in the context of this study. Having said that, it does highlight the impact that manual therapy had on the participant’s success with their at-home exercise regime which I believe translates well into clinical practice. This finding can allow clinicians to understand manual therapy as an adjunct to exercise which sets patients up to perform their exercises with little to no pain, rather than a passive modality that may or may not be as good as exercise therapy.

Do Joint Mobilizations Assist in the Recovery of Lateral Elbow Tendinopathy? A Systematic Review and Meta-Analysis

Author Names

Lucado, A., Dale, R., Vincent, J., Day, J.

Reviewer Name

Rose O’Donoghue, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Study design: Systematic review. Introduction: No consensus exists as to which are the most effective methods to treat the symptoms associated with lateral elbow tendinopathy (LET). Research has suggested that joint mobilizations may assist in the recovery of patients with LET. Purpose of the study: To determine if joint mobilizations are effective in improving pain, grip strength, and disability in adults with LET. Methods: Searches in 3 databases were performed to identify relevant clinical trials. Reviewers independently extracted data and assessed the methodological quality. Summary measures of quantitative data were extracted or calculated where possible. Appropriate data were pooled for meta-analysis using a random-effects model. Results: A total of 20 studies met the inclusion criteria; 7 were included in the meta-analysis. Studies were broadly classified into 3 groups: mobilization with movement (MWM), Mill’s manipulation, and regional mobilization techniques. Pooled data across all time periods demonstrated a mean effect size of 0.43 (95% confidence interval [CI]: 0.15-0.71) for MWM on improving pain rating, and 0.31 (95% CI: 0.11-0.51) for MWM on improving grip strength, 0.47 (95% CI: 0.11-0.82) for Mill’s manipulation on improving pain rating. A mean effect size of -0.01 (95% CI: -0.27 to -0.26) shows Mill’s manipulation did not improve pain free grip strength. Functional outcomes varied considerably among studies. Pain, grip strength, and functional outcomes were improved with regional mobilizations. Conclusion: There is compelling evidence that joint mobilizations have a positive effect on both pain and/or functional grip scores across all time frames compared to control groups in the management of LET.

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?

Were eligibility criteria for included and excluded studies predefined and specified?

Did the literature search strategy use a comprehensive, systematic approach?

Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

Cannot Determine, Not Reported, Not Applicable

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?

Cannot Determine, Not Reported, Not Applicable

Was publication bias assessed?

Cannot Determine, Not Reported, Not Applicable

Was heterogeneity assessed? (This question applies only to meta-analyses.)

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

The pooled data showed that in patients with lateral elbow tendinopathy, mobilization with movement improved pain rating and grip strength (effect size of 0.43 and 0.31 respectively) and Mill’s manipulation improved pain rating but not pain free grip strength (effect size of 0.47 and -0.01 respectively).

Key Finding #2

Pain, grip strength, and functional outcomes were improved with regional mobilizations in patients with lateral elbow tendinopathy.

Key Finding #3

Joint mobilizations have shown to have a positive effect on both pain and/or functional grip scores compared to control groups in patients with lateral elbow tendinopathy.

Please provide your summary of the paper

This study was a systematic review that aimed to address the varying opinions of whether joint mobilizations assist in the recovery of patients with lateral elbow tendinopathy. The purpose of this study in specific was to determine if joint mobilizations are effective in improving pain, grip strength, and disability in adults with lateral elbow tendinopathy. Appropriate data was screened for quality and then pooled for meta-analysis using a random-effects model. The article found 20 studies that met the inclusion criteria and of the 7 that were included, they were classified into 3 groups: mobilization with movement, Mill’s manipulation, and regional mobilization techniques. The pooled data showed that mobilization with movement improved pain rating and grip strength (effect size of 0.43 and 0.31 respectively) and that Mill’s manipulation improved pain rating but not pain free grip strength (effect size of 0.47 and -0.01 respectively). It also showed that pain, grip strength, and functional outcomes were improved with regional mobilizations. Overall, the article concluded that joint mobilizations have shown to have a positive effect on both pain and/or functional grip scores compared to control groups in patients with lateral elbow tendinopathy.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

This review has its fair share of limitations. While it included higher quality (PEDro of >8/11) studies in the pooled data, it still included some lower/moderate quality ones (PEDro of 5-8/11) in the rest of the evaluation. It also noted that as a whole, the studies that examined mobilization with movement were of lower quality than the studies that examined the Mill’s manipulation and regional mobilization techniques. The study also stated that it was difficult to find studies with a true control group. Overall, it is difficult to account for all the varying factors that are present when performing a systematic review and meta analysis. All being said, this article shows that there is evidence that elbow joint mobilizations improve both pain and functional grip scores in patients with lateral elbow tendinopathy. More research is needed to isolate different subcategories of the condition, improve study quality and effect size, and compare against a true control group. In the meantime, these elbow mobilizations appear to be a safe and effective method to utilize in the clinic for patients with lateral elbow tendinopathy.

A Systematic Review of the Effectiveness of Manipulative Therapy in Treating Lateral Epicondylalgia

Author Names

Herd, C. & Meserve, B.

Reviewer Name

Emilija Peleckas, SPT, B.S

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Lateral epicondylalgia is a commonly encountered musculoskeletal complaint. Currently, there is no agreement regarding the exact underlying pathoanatomical cause or the most effective management strategy. Various forms of joint manipulation have been recommended as treatment. The purpose of this study was to systematically review available literature regarding the effectiveness of manipulation in treating lateral epicondylalgia. A comprehensive search of Medline, CINAHL, Health Source, SPORTDiscus, and the Physiotherapy Evidence Database ending in November 2007 was conducted. Thirteen studies, both randomized and non-randomized clinical trials, met inclusion criteria. Articles were assessed for quality by one reviewer using the 10-point PEDro scale. Quality scores ranged from 1–8 with a mean score of 5.15 ± 1.85. This score represented fair quality overall; however, trends indicated the presence of consistent methodological flaws. Specifically, no study achieved successful blinding of the patient or treating therapist, and less than 50% used a blinded outcome assessor. Additionally, studies varied significantly in terms of outcome measures, follow-up, and comparison treatments, thus making comparing results across studies difficult. Results of this review support the use of Mulligan’s mobilization with movement in providing immediate, short-, and long-term benefits. In addition, positive results were demonstrated with manipulative therapy directed at the cervical spine, although data regarding long-term effects were limited. Currently, limited evidence exists to support a synthesis of any particular technique whether directed at the elbow or cervical spine. Overall, this review identified the need for further high-quality studies using larger sample sizes, valid functional outcome measures, and longer follow-up periods. KEYWORDS: Joint Manipulation, Lateral Epicondylalgia, Systematic Review, Tennis Elbow

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?

Were eligibility criteria for included and excluded studies predefined and specified?

Did the literature search strategy use a comprehensive, systematic approach?

Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

Cannot Determine, Not Reported, Not Applicable

Were the included studies listed along with important characteristics and results of each study?

Was publication bias assessed?

Was heterogeneity assessed? (This question applies only to meta-analyses.)

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

The Mulligan’s mobilization with movement technique used at the elbow showed short- and long-term improvement in pain and grip strength for patients with lateral epicondylalgia.

Key Finding #2

More research is needed to determine if mobilizations at the cervical spine have a positive effect on pain free grip and disability scores associated with lateral epicondylalgia.

Please provide your summary of the paper

This study utilized a systematic review to explore the effect of various manual therapy techniques on outcomes in patients with lateral epicondylalgia. Thirteen studies were reviewed, finding that the Mulligan’s mobilization with movement had good short- and long-term outcomes for pain and grip strength. No other techniques had enough published studies to allow for a conclusion to be drawn on their effects. A few studies showed immediate improvement with different cervical spine mobilizations on outcomes of patients with lateral epicondylalgia. More research with high quality studies and similar outcome measures is needed to say whether cervical spine mobilizations have short- or long-term effects in this population. There is also limited research available regarding wrist mobilizations however some evidence suggests when used as an adjunct therapy or in isolation, wrist mobilizations have a positive effect on global improvement ratings in patients with lateral epicondylalgia.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

This study analyzed 13 studies using variable manipulative techniques, on various parts of the body, and used different outcome measures and variable follow up-times. The broad selection criteria limited the ability to draw conclusions and allow for comparisons to be made between studies and their findings. With such small sample sizes in the studies included in this systematic review the general improvements seen from some mobilizations have limited generalizability to larger populations with lateral epicondylalgia. Therefore, clinicians should continue to explore different manual therapy techniques for patients with lateral epicondylalgia as there is a need for further research to confirm the potential benefits explored here.

Comparison of Effectiveness of Supervised Exercise Program and Cyriax Physiotherapy in Patients with Tennis Elbow (Lateral Epicondylitis): A Randomized Clinical Trial

Author Names

Viswas, R.; Ramachandran, R.; Anantkumar, P.

Reviewer Name

Abigail Reichow, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective: To compare the effectiveness of supervised exercise program and Cyriax physiotherapy in the treatment of tennis elbow (lateral epicondylitis). Design: Randomized clinical trial. Setting: Physiotherapy and rehabilitation centre. Subjects: This study was carried out with 20 patients, who had tennis elbow (lateral epicondylitis). Intervention: Group A (n = 10) had received supervised exercise program. Group B (n = 10) was treated with Cyriax physiotherapy. All patients received three treatment sessions per week for four weeks (12 treatment sessions). Outcome measures: Pain was evaluated using a visual analogue scale (VAS), and functional status was evaluated by completion of the Tennis Elbow Function Scale (TEFS) which were recorded at base line and at the end of fourth week. Results: Both the supervised exercise program and Cyriax physiotherapy were found to be significantly effective in reduction of pain and in the improvement of functional status. The supervised exercise programme resulted in greater improvement in comparison to those who received Cyriax physiotherapy. Conclusion: The results of this clinical trial demonstrate that the supervised exercise program may be the first treatment choice for therapist in managing tennis elbow.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Cannot Determine, Not Reported, or Not Applicable

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Cannot Determine, Not Reported, or Not Applicable

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Cannot Determine, Not Reported, or Not Applicable

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Cannot Determine, Not Reported, or Not Applicable

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

Both supervised exercise programs (group A) and Cyriax physiotherapy treatment (group b) demonstrated significant improvement in function and pain after 4 weeks when compared to their pretest scores.

Key Finding #2

While both groups showed significant reductions in pain scores, the group receiving supervised exercise programs (group A), had significantly lower pain ratings when compared to the Cyriax physiotherapy treatment (group b) at the end of the 4 weeks of treatment.

Key Finding #3

While both groups showed significant improvements in functional status, the group receiving supervised exercise programs (group A), had significantly lower functional disability scores when compared to the Cyriax physiotherapy treatment (group b) at the end of the 4 weeks of treatment.

Please provide your summary of the paper

This study was a randomized control trial that aimed to determine how to best structure physical therapy interventions for lateral epicondylitis. Twenty participants (10 men, 10 women) met the inclusion criteria and were randomly assigned to two intervention groups and received physical therapy three times a week for four weeks for a total of 12 session. Participants in group A participated in supervised exercise programs consisting of static stretching of Extensor Carpi Radialis Brevis as well as overall eccentric strengthening of the wrist extensors with instructions to stop if the pain became disabling. Participants in group B received Cyriax physiotherapy which includes 10 minutes of deep transverse friction massage followed by Mill’s manipulation. Pain was measure using the Visual Analog Scale (VAS) and functional status was measured using the Tennis Elbow Function Scale (TEFS), with higher scores indicating greater functional disability. Both outcome measures were administered at initial evaluation and following four weeks of treatment. There were no significant differences between the groups at the time of initial evaluation. The results of the study found that at the end of the four weeks of treatment, both groups experienced significant improvements in pain and functional scale when compared to the initial evaluation. When comparing the two groups, group A demonstrated significantly greater improvements in pain and function at the end of four weeks.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

The findings of this study demonstrate that while both supervised exercise programs and the use of manual therapy through the Cyriax physiotherapy treatment method are effective in reducing pain and increasing function in patients with lateral epicondylitis, supervised exercise programs of stretching and eccentric strengthening produce better results. Lateral epicondylitis is rising in prevalence and can be debilitating, especially when present in the dominant arm. Currently, while there is research on several forms of treatment options, there is no consensus on the most effective management. The Cyriax physiotherapy intervention has been proposed in other studies but was lacking the support of higher-level evidence with participant randomization. This study, therefore, can impact clinical practice, especially in the outpatient setting, and inform treatment of lateral epicondylitis. While the study was able to show that Cyriax physiotherapy was effective, more traditional physical therapy interventions of stretching and eccentric strengthening still prove to be more efficient in treating this condition.

Incorporation of Manual Therapy Directed at the Cervicothoracic Spine in Patients with Lateral Epicondylalgia: A Pilot Clinical Trial

Author Names

Cleland, Joshua., Flynn, Timothy., Palmer, Jessica.

Reviewer Name

Megan Saunders

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Recent trends in the use of manual therapy directed at the cervicothoracic spine in patients with lateral epicondylalgia have been observed. However, only short-term pre- liminary evidence exists to support the use of these techniques. This pilot clinical trial describes the outcomes of patients with lateral epicondylalgia undergoing local treatment (LT) solely directed at the elbow and a program consisting of local treatment plus manual therapy aimed at the cervicothoracic spine (LT + MTCT). Ten consecutive patients referred to physical therapy by their primary care physician with a diagnosis of lateral epicondylalgia were randomly assigned to receive LT or LT + MTCT. Both groups received 10 treatments over a 6-week period. Outcome measures, including the Numeric Pain Rating Scale; pain-free grip strength; Disability of the Arm, Shoulder, and Hand questionnaire; and a global rating of change were completed at discharge and at 6-month follow-up. Patients in both groups exhibited clinically meaningful improvement at discharge and at the 6-month follow-up. The LT + MTCT group demonstrated greater improvement in all outcome measures as compared to the LT group. The results suggest that the incorporation of manual therapy directed at the cervicothoracic spine may be an effective adjunct to treatment directed solely at the elbow for patients with lateral epicondylalgia.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

Improvement was greater in the LT + MTCT group for all variables at discharge and at 6-month follow-up.

Key Finding #2

For self-reported outcome measures of disability, patients in both groups reported improvement at the time of discharge and at follow-up. Specifically, all patients in the LT+MTCT group perceived themselves as being “a great deal better” at the 6-month follow-up, while 80% of the LT group perceived themselves as being “quite a bit better” and one patient experienced a worsening of symptoms.

Key Finding #3

Differences in pain-free grip strength were the most pronounced between the two groups, with the LT group scoring an average of 17.8 versus the LT+MTCT group scoring 37.4.

Please provide your summary of the paper

This paper assessed whether local manual therapy (LT) to the elbow or local therapy plus cervicothoracic therapy (LT+MTCT) would produce better improvements in patients with lateral epicondylalgia. Patients in both groups were treated for 6-weeks with a total of 10 treatment sessions, including both manual therapy and a strengthening regimen. The LT+MTCT group had greater improvement for all variables (pain-free grip strength, reduction in pain and disability, perception of change) when compared to the LT group. However, both groups demonstrated clinical meaningful change at the 6-month follow-up visit.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

The results of this study may indicate that including cervicothoracic treatment in the plan of care for a patient with lateral epicondylalgia could produce better results than treating the elbow alone. This paper cites a connection between cervicothoracic limitations and lateral elbow involvement, but their diagnostic criteria to diagnose lateral epicondylalgia has not been scientifically validated. It is possible that patients have been misdiagnosed by their primary care physician and that pain could be referred from areas up-the-chain that are producing elbow symptoms. Although a thorough examination was performed, it is unclear what special tests or other physical performance measures were evaluated to rule out or rule in structures of involvement surrounding the elbow. Furthermore, there was a limited number of patients included in this study (10 patients), and not all of the patients were able to attend the 10 physical therapy sessions; this limited number makes it difficult to generalize clinically significant findings as a traditional statistical analysis was not able to be performed. The authors of this paper stated these limitations of their study. Like other structures of the body, this paper brings an important point to clinical practice, that we must take into account other structures up or down the chain that may be contributing to their conditions.

The Forgotten Radial Nerve: A Conceptual Framework for Treatment of Lateral Elbow Pain

Author Names

Taylor, A., & Wolff, A. L.

Reviewer Name

Alli Shaw, SPT

Reviewer Affiliation(s)

Duke University Physical Therapy Division

Paper Abstract

Background: Lateral elbow pain is a prevalent musculoskeletal overuse disorder that has serious consequences for musculoskeletal health, occupational performance, and overall healthcare burden. Available treatment options (traditional therapy and steroid injections) have been studied rigorously, yet supporting evidence is weak. The majority of treatment options available are targeted at the local pathology of the common extensor tendon as the apparent source of pain, and do not adequately address the cause, the source of overuse, and mechanism of injury. Purpose: The purpose of this paper is to describe a novel approach, a regional interdependence model, to reduce symptoms of upper extremity musculoskeletal overuse in populations at risk by addressing a broader systematic approach versus a localized symptom driven approach for the assessment and treatment of lateral elbow pain. Methods: The proposed framework – Think in nerve length and layers (TINLL)- accounts for nerve tension and muscle balance in the entire extremity. In this paper we describe the application of the TINLL model for assessment and treatment of SRSN irritation in individuals with lateral elbow pain and propose a method for treatment and for further studies. The proposed treatment approach combines mobilization with movement, elastic taping, and isometric exercises to address impairment at each level: joint alignment, neural tension, and the superficial sensory nervous system. Results: Our findings of reduced pain with a relatively small number of therapy sessions in a small retrospective cohort of patients using the TINLL framework for assessment and treatment supports further formal study of this approach in a larger cohort with longer follow-up to determine effectiveness compared to current treatments. Conclusion: Future studies will test and compare the efficacy of the TINLL framework and model of treatment on the short- and long-term outcomes in individuals with chronic lateral elbow pain compared to traditional therapy.

NIH Risk of Bias Tool

Was the research question or objective in this paper clearly stated?

Was the study population clearly specified and defined?

Was the participation rate of eligible persons at least 50%?

Cannot Determine, Not Reported, Not Applicable

Were all the subjects selected or recruited from the same or similar populations (including the same time period)? Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants?

Cannot Determine, Not Reported, Not Applicable

Was a sample size justification, power description, or variance and effect estimates provided?

Cannot Determine, Not Reported, Not Applicable

For the analyses in this paper, were the exposure(s) of interest measured prior to the outcome(s) being measured?

Was the timeframe sufficient so that one could reasonably expect to see an association between exposure and outcome if it existed?

For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the outcome (e.g., categories of exposure, or exposure measured as continuous variable)?

Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?

Cannot Determine, Not Reported, Not Applicable

Was the exposure(s) assessed more than once over time?

Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?

Were the outcome assessors blinded to the exposure status of participants?

Cannot Determine, Not Reported, Not Applicable

Was loss to follow-up after baseline 20% or less?

Cannot Determine, Not Reported, Not Applicable

Were key potential confounding variables measured and adjusted statistically for their impact on the relationship between exposure(s) and outcome(s)?

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

Clinical management of lateral elbow pain that included mobilization with movement (MWM) techniques, stretches, strengthening, and elastic taping resulted in reduced pain in a small retrospective cohort of patients.

Key Finding #2

Clinical management of lateral elbow pain that solely addresses the local pathology is not adequate. Addressing nerve tension and muscle balance throughout the entire extremity, rather than just the elbow, will result in superior outcomes.

Key Finding #3

Think in nerve length and layers (TINLL) is a clinical framework that can be applied to treatment of lateral elbow pain to ensure various components of the kinetic chain have been addressed.

Key Finding #4

MWM approaches are effective at correcting joint alignment and should be coupled with elastic taping to maintain proper movement and alignment of the mobilized joint.

Please provide your summary of the paper

The TINLL framework proposed by Taylor and Wolff addresses the fact that the radial nerve is frequently forgotten as a contributor to pain experienced by those who have been diagnosed with lateral epicondylitis. This framework aids therapists in taking a broader approach, to not forget about the interdependence of the kinetic chain. As part of this framework, the authors recommend the use of proximal radio-ulnar joint mobilizations in supine at various degrees of supination to increase range of motion limitations often reported with this patient population. Following joint mobilizations, mobilizations with movement (MWM) techniques were implemented at both the elbow and the shoulder to further increase range of motion limitations and decrease pain levels. In addition to the other recommended components of the TINLL framework, the aforementioned interventions resulted in complete absence of symptoms following 4 visits to hand therapy. Limitations of this study include the relatively small cohort (23 patients) and the nature of the study (retrospective cohort study). These limitations were noted by authors, who called for further assessment of the TINLL framework with a larger cohort and longer follow-up duration. Further limitations of this study include neglecting to address potential confounding variables, poorly defined independent and dependent variables, and lack of specifics provided regarding timeframe of treatment, statistics used to analyze results, and the inclusion and exclusion criteria utilized for selection of participants used.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

Management and treatment of lateral elbow pain should include various intervention strategies, including manual therapy (i.e., mobilizations with and without movement), strengthening (specifically isometric strengthening to aid in joint “setting”), stretching, and other modalities (i.e., elastic taping). Additionally, it is essential to address the involvement of both proximal (glenohumeral joint) and distal joints (distal radioulnar joint, radiocarpal joint) in order to provide treatment that goes beyond addressing only the local pathology.

Decrease in Elbow Flexor Inhibition After Cervical Spine Manipulation in Patients with Chronic Neck Pain

Author Names

Esther Suter, Gordon McMorland

Reviewer Name

Makayla Spade

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Muscle inhibition, i.e., the inability to fully activate a muscle, has been observed following joint pathologies and in low back pain conditions. Although chronic neck pain has been associated with changes in muscle recruitment and coordination in the shoulder and arms, the possibility of muscle inhibition has not been explored.

Was the study question or objective clearly stated?

Were eligibility/selection criteria for the study population prespecified and clearly described?

Were the participants in the study representative of those who would be eligible for the test/service/intervention in the general or clinical population of interest?

Cannot Determine, Not Reported, Not Applicable

Were all eligible participants that met the prespecified entry criteria enrolled?

Was the sample size sufficiently large to provide confidence in the findings?

Was the test/service/intervention clearly described and delivered consistently across the study population?

Were the outcome measures prespecified, clearly defined, valid, reliable, and assessed consistently across all study participants?

Were the people assessing the outcomes blinded to the participants’ exposures/interventions?

Was the loss to follow-up after baseline 20% or less? Were those lost to follow-up accounted for in the analysis?

Did the statistical methods examine changes in outcome measures from before to after the intervention? Were statistical tests done that provided p values for the pre-to-post changes?

Were outcome measures of interest taken multiple times before the intervention and multiple times after the intervention (i.e., did they use an interrupted time-series design)?

Cannot Determine, Not Reported, Not Applicable

If the intervention was conducted at a group level (e.g., a whole hospital, a community, etc.) did the statistical analysis take into account the use of individual-level data to determine effects at the group level?

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

Significant dysfunction in biceps activation was evident in patients with chronic neck pain, indicating that this muscle group cannot be used to the full extent

Key Finding #2

Chronic neck pain has been found to have changes in muscle contracting and coordination in the shoulder and arms, however, more exploring needs to be done to assume the possibility of muscle inhibition

Key Finding #3

Cervical spine manipulation was applied at the level of C5/6/7 and found to have good results with repeated assessment.

Please provide your summary of the paper

Several methods were used in this study of 16 participants; biceps incitement all along a maximum willing elbow flexor shortening was evaluated utilizing the interpolated twitch method and electromyography, cervical range of motion and pressure pain thresholds were assessed utilizing a goniometer and an algometer and manipulation of the cervical spine at level C5/6/7 with repeated mobilizations. Before cervical spine manipulation, patients showed inhibition in bicep muscles, restriction in cervical range of motion laterally and report of high pressure pain sensitivity. Following the cervical spine manipulation, not only was cervical motion and pressure pain significantly improved but decrease in inhibition and increase force were found in the biceps. Further research is necessary to confirm whether muscle restriction is linked with clinical symptoms and functional outcome.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

Muscle restriction in the biceps has not been previously reported or charted in patients who suffer of chronic neck pain. With that being said, more research and studies will need to be establish in order to prove muscle inhibition is related to the clinical symptoms and functional outcome. However, improved muscle function, cervical range of motion and pain sensitivity were all reported with spinal manipulation, and may include a benefit for treating patients with chronic neck pain.

Physiotherapy Treatment of Lateral Epicondylitis: A Systematic Review

Author Names

Landesa-Piñeiro, Laura; Leirós-Rodríguez, Raquel

Reviewer Name

Chance Thorkelson, SPT

Reviewer Affiliation(s)

Duke University School of Medicine Doctor of Physical Therapy Program

Paper Abstract

BACKGROUND: Lateral epicondylitis is a tendinopathy with a prevalence of between 1–3% of the population aged 35–54 years. It is a pathology with a favorable evolution, but with frequent recurrences (which imply an economic extra cost). OBJECTIVE: The objective of this review was to determine the efficacy of physiotherapy treatment for the treatment of epicondylitis and, if any, to identify the most appropriate techniques. METHODS: A systematic search was carried out in October 2020 in the databases of PubMed, Cinahl, Scopus, Medline and Web of Science using the search terms: Physical therapy modalities, Physical and rehabilitation medicine, Rehabilitation, Tennis elbow and Elbow tendinopathy. RESULTS: Nineteen articles were found, of which seven applied shock waves, three applied orthoses, three applied different manual therapy techniques, two applied some kind of bandage, one applied therapeutic exercise, one applied diacutaneous fibrolysis, one applied high intensity laser, and one applied vibration. CONCLUSIONS: Manual therapy and eccentric strength training are the two physiotherapeutic treatment methods that have the greatest beneficial effects, and, furthermore, their cost-benefit ratio is very favorable. Its complementation with other techniques, such as shock waves, bandages or Kinesio® taping, among others, facilitates the achievement of therapeutic objectives, but entails an added cost.

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?

Were eligibility criteria for included and excluded studies predefined and specified?

Did the literature search strategy use a comprehensive, systematic approach?

Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

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?

Was publication bias assessed?

Was heterogeneity assessed? (This question applies only to meta-analyses.)

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

The systematic review suggest that manual therapy and eccentric strength training were the most beneficial to treating LE as well possessed the best cost-benefit ratio.

Key Finding #2

A manual therapy (MT) study performed deep friction massage and corticosteroid injection and compared them to a control of wrist splint and a daily protocol of PT. It found that after MT pain intensity, grip strength, and functionally improved significantly whereas the group with a splint and a PT protocol did not.

Key Finding #3

Another study looked at corticosteroids in combination and comparison with a PT intervention that included MT techniques such as deep transverse friction massage at the origin of the tendon, Mill’s manipulation, and wrist stretching exercises. It found that the PT group had significant progressive improvement in all variables, at 3, 6, and 12 months. In the corticosteroid group they had a better improvement percentage at 6 months compared to subsequent evaluations. After 12 months both groups did not possess a statistical difference.

Please provide your summary of the paper

The systematic review compared the benefits of a variety of different interventions for the diagnosis of lateral epicondylitis (LE). They found that many provide a benefit for the patient to avoid surgery. It explained the general treatment progression for this disorder as generic pain relievers combined with rest, but that they often failed further prevention and relapses. Surgical interventions were considered with 80-97% gaining immediate pain relief. To avoid needless surgery the review found interventions that relieved pain and prevented relapses. They gave a precursor that tendinopathies improve with strengthening the affected area and LE is no different. The interventions they reviewed included shock wave, platelet rich plasma, conventional physiotherapy techniques, manual therapy, US, orthosis and taping, and laser. There were strong findings in many areas observed in the studies and highlights the benefits of PT intervention for the use in overcoming LE.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

As patients look to relieve themselves of pain and discomfort, we seek to provide them with the best outcomes with minimal impact on daily function and quality of life. Before surgery should be considered patients should be educated on the different options available to them. This systematic review found among many interventions that manual therapy, and eccentric strength training to be the most beneficial in the treatment of LE. Proper clinical decision making is necessary to choose between appropriate interventions but where applicable these two interventions were seen to be beneficial as well as cost-effective.

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