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
- 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)?
- Yes
- Were study participants and providers blinded to treatment group assignment?
- Yes
- Were the people assessing the outcomes blinded to the participants’ group assignments?
- No
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
- Yes
- 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?
- Cannot Determine, Not Reported, or Not Applicable
- 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?
- Yes
- 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
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.
