Evidence in Motion, LLCEvidence in Motion, LLC

Evidence of Manual Therapy Interventions for Lateral Epicondylalgia

By Dr. Ernest Gamble, PT, DPT, OCS October 2, 2011

Objectives

1. Briefly describe the current best evidence for joint mobilization/manipulation techniques directed to the elbow in the management of lateral epicondylalgia.

2. Briefly describe the current best evidence for joint mobilization/manipulation directed to distant regions (cervical spine and wrist) in the management of lateral epicondylalgia.

• “Current evidence supports Mulligan’s mobilization with movement in providing not only immediate benefits but also improving outcomes at short- and long-term follow-up. “

• “There exists a potential for improvement with cervical spine mobilization, indicating the need for further research. Perhaps a subgroup of patients with LE exists who would benefit from treatment directed at the cervical spine. “

Mobilization with Movement:Sustained Lateral Glide with Pain Free Grip

• Vicenzino et al2 (2001) investigated the immediate effects of MWM on PFGP and PPT in 24 patients with LE.– Double blind , placebo controlled repeated

measures design– 58% increase in PFGS during application of

MWM – 46% increase in PFGS following application

of MWM– 10% improvement in PPT after MWM

(significant over changes in placebo and control groups)

– These changes only observed in the affected arm, not unaffected.

Mobilization with Movement:Sustained Lateral Glide with Pain Free Grip

• Abbott et al3 (2000) showed immediate improvements in pain free grip strength and maximum grip strength.– PFGS is more responsive measure than maximum grip strength in

patients with LE– 92% of patients with LE were able to perform previously painful active

movements pain free while the lateral glide was being applied.

• Abbott et al4 (2001) showed immediate improvements in shoulder IR/ER ROM following the MWM in patients with LE.– Improvements observed on both affected and unaffected limb.– Theorized that limitations in shoulder ROM due to facilitated shoulder

muscle activity in response to elbow pain. MWM may reduce this facilitation and allow increased shoulder ROM.

• Subjects (n=198)– 18 to 65 yo– At least 6 weeks of symptoms– Diagnosis LE: lateral elbow pain increased with palpation, resisted

wrist extension, or second or third finger extension

• PEDro score 8/10• Randomization

– MWM+Exercise – Injection– Wait & see

• Outcomes (3, 6,12, 26, and 52 weeks)– Global improvement– Pain free Grip Force (PFGF)– Assessor’s rating of severity

• Purpose: investigate the physiologic effects of MWM in 24 patients with LE.

• PEDro Score 8/10• Placebo, control, repeated measure design with at least 48

hours between sessions.• Outcomes assessed before, during, and immediately

following MWM.– Pain related measures (PFGF, PPT, TPT)– SNS-related measures (HR, BP, skin conductance,

cutaneous blood flux, temperature)

• Results following MWM– 47.5% increase in PFGF in MWM group– PPT increased from 281.4 kPa to 300.8 kPa– Increased HR, SBP, DBP– On the affected side, the cutaneous SNS functions

(skin temperature, cutaneous blood flux, and skin conductance) were activated (sympathoexcitation)

• None of these changes observed in control or placebo conditions.

Mobilization with Movement:Sustained Lateral Glide with Pain Free Grip

• Considerations: Orientation of the lateral glide and the amount of manual force applied by the therapist3.– Directing the lateral glide force somewhat posterior or

directly lateral has been found to be most effective. – A manual force of 1.9N/cm applied during the glide

(standardized to the circumference of the patient’s proximal forearm in cm), which was approximately two-thirds of the maximum force that the practitioner was willing to apply, has been shown to maximize the hypoalgesic effect.

Mobilization with Movement:Sustained Lateral Glide with Pain Free Grip

• Vicenzino et al. (Manual Therapy, 2009)– Post hoc analysis of Bisset et al RCT (Level IV CPR requiring further

validation)– Categorized as improved or not improved after 3 weeks of treatment

based on GPE score on a 6-point scale– 3 Predictor variables

• Age < 49 years (+LR 2.6)• PFGS affected side > 112 N (+LR 2.3)• PFGS unaffected side < 336 N (+LR 2.1)

– All variables present probability of success rose from 79% to 100% (only 4/64 subjects met this criteria)

– 2/3 variables present resulted in 93% probability of success (+LR 3.7)– Limitations

Mobilization with Movement:Sustained Lateral Glide with Pain Free Grip

• N=31 randomized to receive manipulation to wrist or combination of US, TFM, exercise.

• PEDro Score 7/10– 3 subjects lost to follow-up and not included in analysis (no ITT)

• Follow-up at 3 & 6 weeks with primary outcome GPE on 6 point scale (1=“completely recovered” or 2 = “much improved)

• Scaphoid manipulated ventrally with wrist in position of extension. •9 sessions over 6 weeks• Maneuver repeated 15-20 times at each session•Passive extension performed between applications

• Results – 8/15 in the manipulation group either “much improved” or

“completely recovered” vs. 3/15 in comparison group after 3 weeks of treatment (p=.05)

– Differences at 6 weeks were small and not significant (p=0.40)• 11/13 in manipulation group• 10/15 in US, TFM, exercise group

– Other outcome measures improved in both groups but did not show a significant difference between groups – PPT, PFGS, maximum grip, pain scores.

• Randomized double blind, placebo controlled repeated measures design (n=15)

• PEDro Score 3/10• Significant improvements in PFGS (33 N), PPT(45 kPa), and

upper limb tension test 2b (ULTT2b) position immediately following a cervical spine lateral glide mobilization to C5-C6 segment .

• Small (non-significant) improvement in VAS-pain scores 24 hours later but no change in VAS-function scores.

• PEDro score 6/10• 10 subjects randomized to receive local treatments (LT) at

elbow (stretching, strengthening, mobilization to elbow) or LT plus manual therapy to the CT spine (LT+MTCT)

• LT+MTCT– Grade III & IV techniques (all non-thrust)– Left up to discretion of treating physical therapist– Central PA’s, Unilateral PA’s, Physiological Rotations, etc

• Outcomes at 6 weeks (discharge) and 6-month follow-up: PFGS, DASH, NPRS, GROC

• “The trends towards greater improvement in the LT + MTCT group suggest that incorporating manual therapy techniques directed at the cervicothoracic spine may provide an additional benefit over treatment solely directed at the elbow. Future clinical trials incorporating LT + MTCT in lateral epicondylalgia are warranted.”

• 18 Subjects with LE randomized to receive either– Cervical spine manipulation (C5-6)– Thoracic spine manipulation (Supine)

• PPT, PFGS assessed pre and 5 minutes post• Cervical spine manipulation produced greater

changes in PPT (bilateral) than thoracic spine manipulation inpatients with LE. – Pre/Post change PPT: cervical 88.6 kPa, thoracic 18.6 kPa

• No differences between groups were identified for pain-free grip.

Subgroups of Responders to Manual Therapy

• Subgroups?– MWM based on PFGS?– Treating the CT spine based on PPT?

• Further research needed…

Conclusions

• A sustained lateral glide mobilization with movement technique + exercise has been shown to result in short and long term improvements in patients with LE.

• Wrist joint manipulation may provide some short-term benefit (3 weeks) in patients with LE but further research is needed to investigate any long term benefits.

• Incorporating manual therapy interventions directed to the cervicothoracic spine may produce additional benefits to local treatments.

• Further research is needed to identify which patients may respond best to which interventions.

Thank You!

References

1. Herd CR, Meserve BB. A systematic review of the effectiveness of manipulative therapy in treating lateral epicondylalgia. JMMT 2008;16(4):226-237.

2. Vicenzino B, Paungmali A, Buratowski S, Wright A. Specific manipulative therapy treatment for chronic lateral epicondylalgia produces uniquely characteristic hypoalgesia. Man Ther 2001;6:205–212.

3. Abbott JH, Patla CE, Jensen RH. The initial effects of an elbow mobilization with movement technique on grip strength in subjects with lateral epicondylalgia. Man Ther 2001; 6:163–169.

4. Abbott JH. Mobilization with movement applied to the elbow affects shoulder range of movement in subjects with lateral epicondylalgia. Man Ther 2001;6:170–177.

5. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: Randomized trial. BMJ 2006;333:939.

6. Paungmali A, O’Leary S, Souvlis T, Vicenzino B. Hypoalgesic and sympathoexcitatory effects of mobilization with movement for lateral epicondylalgia. Phys Ther 2003;83: 374–383.

7. Vicenzino B, Smith D, Cleland J, Bisset L. Development of a clinical prediction rule to identify initial responders to mobilization with movement and exercise for lateral epicondylalgia. Manual Therapy 2009; 14(5):550-4.

8. Struijs PA, Damen PJ, Bakker E, Blankevoort L, Assendelft W, van Dijk CN. Manipulation of the wrist for management of lateral epicondylitis: A randomized pilot study. Phys Ther 2003;83:608–616.

9. Vicenzino B, Collins B, Wright A. The initial effects of a cervical spine manipulative physiotherapy physiotherapy treatment on the pain and dysfunction of lateral epicondylalgia. Pain 1996;68:69–74.

10. Cleland JA, Flynn TW, Palmer JA. Incorporation of manual therapy directed at the cervicothoracic spine in patients with lateral epicondylalgia: A pilot clinical trial. J Man Manip Ther 2005;13:143–151.

Evidence in Motion, LLCEvidence in Motion, LLC

Evidence for Manual Therapy Interventions of Lateral Epicondylalgia

By Dr. Ernest Gamble, PT, DPT, OCS October 2, 2011