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| Lateral elbow tendinopathy is a kind of soft tissue condition | |
| that is affecting 1%-3% of population. 1 Pain around the lateral epi- | |
| condyle has variety of names including epicondylalgia, epicondyli- | |
| tis, periostitis, and tendinosis of Extensor Carpi Radialis Brevis. The | |
| definitions referring epicondylitis and periositis are discontinued | |
| over time. These descriptions were likely indicated an inflamma- | |
| tory origin. 2 , 3 Under chronic conditions, the affected tissue gen- | |
| erally lacked inflammatory cells (macrophages, lymphocytes, and | |
| neutrophils). 4 In chronic cases, the problem was often degenera- | |
| tion origined and angiofibroblastic hyperplasia was the proof of | |
| immature tissue repair. For this reason, the term lateral epicondyli- | |
| tis may be revised as lateral elbow tendinopathy. 5 | |
| Range-of-motion (ROM) exercises, stretching, strengthening, | |
| and functional exercises are advised to be included in the treat- | |
| ment programs according to the current literature. 5 Stretching ex- | |
| ercises cause elongation in the muscle-tendon unit. However, it is | |
| still unknown whether the stretching should be static or ballistic, | |
| also the issue of selection in isometric or isotonic strengthening | |
| exercises still persists in this area. 1 , 2 Viswas et al claimed that ec- | |
| centric exercises were better for pain management and function- | |
| ality in tendinopathies. 6 Dimitrios advocated for the heavy slow | |
| resistance program which includes both concentric and eccentric | |
| exercises. It is hypothesized to be more beneficial than only eccen- | |
| tric training in management of pain and function in LET. 7 | |
| All the upper quadrant muscles should properly function in or- | |
| der to carry out the activities of daily living. Otherwise, upper ex- | |
| tremity problems like lateral elbow tendinopathy may cause dete- | |
| rioration of the function and decrease in quality of life. However, | |
| there isn’t any specific exercise protocol in the literature about | |
| the management of LET as it exists in shoulder and knee injuries. | |
| In the literature it was emphasized that the exercises should be | |
| modified to the tolerance and the capability of the patients. 7 Pa- | |
| tients with LET may have difficulty in performing exercises in an | |
| appropriate manner due to pain. The pain causes alterations in | |
| movement strategies and postural deviations, affecting other joints | |
| which in turn causes functional disability in time. To avoid the | |
| pain-related inactivity during the early stages of the disease, we | |
| planned a graded exercise model. The main focus of our supervised | |
| graded exercise plan revolves around the pain tolerance and tis- | |
| sue healing process. This regulation enables us to re-structure our | |
| exercise program accordingly with patients’ tolerance in a graded | |
| manner. 8 | |
| In the beginning, a program including warm-up, isometric | |
| strengthening, and functionally oriented exercises are collectively | |
| named as basic protocol. The transition to the advanced program | |
| is decided with the symptomatic feedback and the change in VAS | |
| activity scores, inquired during basic exercises. Advanced exercise | |
| program consists of stretching along with both concentric and | |
| eccentric strengthening exercises. It was hypothesized that more | |
| benefit would be obtained because of the transition between two | |
| grades of exercises, which is planned accordingly with tolerance of | |
| patients with LET. The primary aim of our study; was to determine | |
| the effectiveness of basic exercise protocol on pain, functional sta- | |
| tus, grip strength and the change in Nirschl Pain Scale (NPS) ( Table | |
| 2 ). Secondary aim was to reveal the effects of the re-structured | |
| advanced exercise protocol on these parameters after the pain in- | |
| tensity was reduced as a result of the basic exercise protocol. | |
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| Materials and methods | |
| A prospective case series study was conducted on patients with | |
| LET. Patients were referred to the physiotherapy unit of the au- | |
| thors’ institution from the Department of Orthopedics and Trau- | |
| matology of a University. They received written and verbal expla- | |
| nations about the procedures of the study protocol to be applied. | |
| They signed informed consent forms, which were approved by the | |
| ethical committee of a Public Hospital. | |
| Patients eligible for inclusion in this study were aged between | |
| 30 and 50 years due to this range being the most common for this | |
| diagnosis, and all had a prior LET diagnosis. 9 , 10 There was atleast | |
| a year before the last treatmet received for LET for all participants. | |
| In the clinic where our research was conducted, the diagnosis of | |
| lateral epicondylitis is made by anamnesis and clinical examina- | |
| tion. Typical pain location, spread and special tests (Cozen Test | |
| and Mills Test) are applied by the orthopedist and, if necessary, | |
| ultrasound imaging is done and sent to the PT department with a | |
| confirmed diagnosis. These diagnostic procedures were conducted | |
| by a single doctor for the duration of the study. The participants | |
| were outlined in Figure 1 . The patients were between the stages | |
| 4-6 of NPS ( Fig. 2 ). All patients diagnosed with lateral epicondyli- | |
| tis between NPS stages 4-6 were referred to the clinic, patients | |
| with NPS stages 1 through 3 are referred for a home exercise pro- | |
| gram. Electrotherapy and injection protocol is applied to patients | |
| who are in stage 7 of NPS. The exclusion criteria were neopla- | |
| sia, pregnancy, neurologic deficits, cervical radiculopathy, periferal | |
| nerve disease, rheumatoid arthritis, shoulder disease, radial tunnel | |
| syndrome, previous surgery of the affected upper extremities, con-genital or acquired bone deformity in ipsilateral upper extremity, | |
| the initiation of opioid analgesia or corticosteroid or analgesic in- | |
| jection interventions within the previous year, any physical therapy | |
| intervention on the upper extremity in the previous year, bilateral | |
| elbow tendinopathy and secondary orthopedics problems. 11 | |
| Intervention | |
| Initially, all groups received basic exercise program for four | |
| weeks, three times a week. Exercises were evaluated monthly by | |
| a physiotherapist; all complaints and suggestions were recorded. | |
| Equipment required for the exercises were elastic finger band, one | |
| kilogram weight or an equivalent dumbell, hand exercise ball and a | |
| towel. The physiotherapist checked and revised their exercise pro- | |
| grams according to the change of VAS-Activity scores. At the end of | |
| four weeks of basic treatment, three-unit decrease (Minimal Clin- | |
| ical Important Difference for VAS Score) was aimed for progres- | |
| sion. 12 For home exercises, patients were provided with a logbook | |
| and were asked to log all their exercises. For clinical applications | |
| there was constant physiotherapist supervision for the entire du- | |
| ration, there was no specific qualifications required for the provid- | |
| ing physiotherapist other than a minimum of five years in clinical | |
| practice, due to the exercises being under the definition of the pro- | |
| fession. The participants who fulfilled these criteria continued their | |
| advanced exercises for another four weeks. Both the basic and two | |
| exercises were conducted for four weeks, for a total of 12 sessions. | |
| Additionally, at the beginning of an exercise program, a brief pa- | |
| tient education was given to teach how to act during any work | |
| activity or computer use. The maintenance of the neutral wrist po- | |
| sition, especially avoiding the palm down position, along with the | |
| proper usage of the two-handed position and a two-kilogram limit | |
| of load per hand during any carrying activities were emphasized. 13 | |
| Basic Exercise Program: Basic exercise program consisted of | |
| a warm-up, isometric strengthening exercise and functionally- | |
| oriented exercises which adapt to the patients daily activities were | |
| applied three times daily with 10 repetitions. 14 (Appendix A). How- | |
| ever, neither stretching nor isotonic strengthening exercises were | |
| allowed in the basic rehabilitation, so as not to disrupt the healing | |
| process. | |
| Advanced Exercise Program: During prior clinical observations, | |
| we determined that the stretching exercises and isotonic strength- | |
| ening exercises, including both concentric and eccentric, might | |
| create discomfort and/or irritating sensation during the first four | |
| weeks of the rehabilitation. 14 For this reason, it was decided that | |
| these exercises were not appropriate for the basic protocol. After | |
| basic exercises were terminated, stretching and isotonic strength- | |
| ening exercises are used to retrain in the bearable limits with pa- | |
| tients for another four weeks. Stretching for wrist extension mo- | |
| tion was applied daily with five repetitions. For wrist extensor | |
| muscle, eccentric strengthening exercises were practiced two times | |
| a day with 10 repetitions. The concentric and eccentric strength- | |
| ening exercises were started with the use of a dumbell or thera- | |
| band according to the capabilities of patients. Warm-up exercises | |
| existing in basic protocol were replaced by stretching, along with | |
| concentric and eccentric strengthening exercises (Appendix A). Pa- | |
| tients have continued their re-structured exercise program for an- | |
| other four weeks. | |
| Outcome measurement | |
| Pain was measured by VAS, Pain Pressure Threshold (PPT), the | |
| level of function determined with the PRTEE Questionnaire, and | |
| grip strength measurement. The outcome measurements were per- | |
| formed at baseline, after basic, and two exercise programs. | |
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| Pain | |
| Visual Analog Scale (VAS): Pain intensity was assessed with VAS, | |
| during rest, activity and at night (0-10 visual analog scale, with | |
| zero as no pain and 10 as worst imaginable pain). 12 | |
| Pain Pressure Threshold: The pain was measured by using a | |
| Baseline 1200-304 system (Push-Pull Force Gauge; Fabrication En- | |
| terprises, Inc). The handheld pressure algometer enables a linear | |
| response to force application between 0 and 10 kg (22lbs × 1/4 | |
| lb and 10 kgs × 100 gm). The PPT was assessed in all participants | |
| at the lateral epicondyle. 15 The patient was sitting with the shoul- | |
| der at 300 abduction, the elbow at 90 ° flexion; the forearm, wrist, | |
| and hand supported on the table. Three measurements of PPT were | |
| taken as the amount of pressure required to elicit a sensation of | |
| pain, distinct from pressure sensation. 16 | |
| Level of function | |
| Patient Rated Tennis Elbow Evaluation (PRTEE): PRTEE is a sim- | |
| ple, reliable, and valid form for the evaluation of pain and func- | |
| tion that is specifically oriented for patients diagnosed with lateral | |
| epicondylosis. 17 , 18 The tool was developed by MacDermid and pub- | |
| lished with reliability statistics in 1999, 19 had an update in 2005, 20 | |
| and was independently evaluated by Rompe et al in 2007. 21 The | |
| Turkish version demonstrated high reliability and validity as re- | |
| ported by Altan et al in 2010. 22 The tool consists of two subscales. | |
| The first part includes five questions investigating the pain status | |
| and the second part involves 10 questions investigating the level of | |
| function in both daily (four items) and usual activities (six items) | |
| during the previous week. The symptoms are inquired by using a | |
| 0-10 numeric pain rating. 21 In our study, we calculated total PRTEE | |
| scores as well as subscales of PRTEE score that include PRTEE-P | |
| (pain) and PRTEE-F (function) scores. | |
| Grip Strength Measurement: A hand-held dynamometer (Baseline | |
| Hydraulic Hand Dynamometer; Fabrication Enterprises Inc, Irving- | |
| ton, NY) was used for the measurement. The handle of the meter | |
| was adjusted in the position, as advised by Mathiowetz et al. 23 The | |
| diameter of the dynamometer is 1,5 inches. The American Society | |
| of Hand Therapists proposed a standardized arm position for grip | |
| strength evaluation described as the shoulder in adduction, elbow | |
| at an angle of 90 ° flexion, and wrist in neutral. 23 , 24 The mean val- | |
| ues of three evaluations (kilograms force) were recorded and used | |
| in the analyses. 22 | |
| Statistical analyses | |
| All the data was evaluated using SPSS (the Statistical Pack- | |
| age for the Social Sciences) version 20.0 for Windows. Descriptive | |
| statistics were analyzed (frequency, mean and standard deviation). | |
| NPS was given as a percentage value before treatment and after | |
| each grade of exercise. Before the statistical analysis, Shapiro-Wilk | |
| test was used to assess the distribution of data. Collected data was | |
| found to be normally distributed and thus a parametric test was | |
| used for the statistical analysis. Paired sample t tests were used | |
| for statistical analysis of the before- after basic and two exercises | |
| comparisons for pain level, muscle strength, and function. Effect | |
| size was separately calculated for each phase of treatment. 25 ES | |
| of 0.2 was considered small, 0.5 moderate, and 0.8 large. P values | |
| lower than 0.05 were considered statistically significant for all of | |
| the analysis results. | |
| Results | |
| Thirty-four patients were evaluated for possible inclusion. | |
| Thirty patients meeting with inclusion criteria of the study were | |
| included. At baseline, 13 of 30 patients belonged to the stage four, | |
| nine of 30 patients belonged to stage five and eight of 30 patients | |
| belonged to stage six according to NPS LET stages. After basic exer- | |
| cise distribution of patients’ stages according to NPS were changed | |
| respectively to values zero (one participant), one (one participants), | |
| two (four participants), three (13 participants), four (nine partici- | |
| pants), five (two participants). Advanced exercise progression was | |
| not planned for two people who took place, they were stage one | |
| and two according to NPS due to the lack of symptoms after basic | |
| exercises, as not to affect the distribution of results in the study | |
| ( Fig. 1 ) [ https://www.nirschl.com/elbow-tendinosis/ ]. Twenty-eight | |
| patients were re-assessed after basic exercise program to recruit | |
| in the advanced exercise program. After advanced exercises, dis- | |
| tribution of patients’ pain stages according to NPS was changed | |
| to respectively to values zero (three participants), one (two par- | |
| ticipants), two (11 participants), three (12 participants). The demo- | |
| graphic data of the participants are presented in Table 1 . The mean | |
| age and body mass index were similar in both groups, also all the | |
| participants were right-handed. | |
| According to the pain in VAS and in PPT scores, after basic | |
| exercise, patients had a lower score than before treatment in- | |
| dicating improvement (VAS-Activity p > 0.001, ES = 1.35; VAS- | |
| Rest p = 0.007, ES = 0.72; VAS-night p > 0.001, ES = 0.73; | |
| PPT p = 0.002, ES = 0.91). Additionally, a significant decrease | |
| in VAS and PPT scores were found after advanced exercise in | |
| patients with LET (VAS-Activity p = 0.005, ES = 1.73; VAS-Rest | |
| p = 0.01, ES = 1.00; VAS-Night p = 0.01, ES = 1.03; PPT p = 0.002 | |
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