Therapeutic Effects of Manual Therapy on Lateral Epicondylitis: A Randomised Controlled Trial

Abstract

Background Epicondylopathia humeri radialis is often diagnosed by general practitioners. Usually, the therapy comprises transcutaneous electrical nerve stimulation using a forearm brace. Manual therapy, performed by specialised physiotherapists, is prescribed before transcutaneous electrical nerve stimulation and forearm brace use. However, studies comparing the effectiveness of all methods are scarce.

Objective To compare the therapeutic effects of manual therapy, transcutaneous electrical nerve stimulation, and forearm brace use, as well as the combination of all three.

Methods Fifty-two patients diagnosed with epicondylopathia humeri radialis were randomised into three treatment arms: a combination of manual therapy, transcutaneous nerve stimulation, and forearm brace use (n=19); manual therapy only (n=18); and a combination of forearm brace use and transcutaneous nerve stimulation (n=15). All measurements and therapies, excluding manual therapy, were performed at the first author’s practice premises. The primary outcomes included range of motion and pain intensity; the secondary outcomes were elbow function and psychological well-being. Primary and secondary outcomes were measured before and at 4 and 8 weeks after treatment using the Patient Rated Tennis Elbow Evaluation Questionnaire and the Short Form Health Survey Questionnaire.

Results The range of motion and pain intensity did not differ among the groups.

Conclusion Manual therapy alone was as effective as the combination of transcutaneous nerve stimulation and forearm brace use for epicondylopathia humeri radialis. Our findings support the inclusion of manual therapy as a stand-alone therapy option in the guidelines for treating patients with epicondylopathia humeri radialis.

Zusammenfassung

Hintergrund Epicondylopathia humeri radialis wird häufig von Hausärzten diagnostiziert. Die Therapie erfolgt oft mit transkutaner, elektrischer Nervenstimulation oder einer Epicondylitisspange. Darüber hinaus wird manuelle Therapie, ausgeführt durch darin ausgebildete Physiotherapeuten, durch Ärzte rezeptiert. Studien, die die Wirksamkeit dieser Methoden vergleichen, sind rar.

Fragestellung Vergleich der therapeutischen Wirkungen von manueller Therapie, transkutaner elektrischen Nervenstimulation und Epicondylitisspangen, sowie deren Kombination.

Methoden Zweiundfünfzig Patienten, bei denen Epicondylopathia humeri radialis diagnostiziert wurde, wurden in drei Behandlungsarme randomisiert: eine Kombination aus manueller Therapie, transkutaner Nervenstimulation und Verwendung von Epicondylitisspangen (n=19); nur manuelle Therapie (n=18); und eine Kombination aus Epicondylitisspange und transkutaner Nervenstimulation (n=15). Alle Messungen und Therapien, mit Ausnahme der manuellen Therapie, wurden in den Praxisräumen des Erstautors durchgeführt. Zu den primären Outcomes gehörten der Bewegungsumfang des Ellenbogengelenkes und die Schmerzintensität; Die sekundären Outcomes waren die Ellenbogenfunktion und das psychische Wohlbefinden unter Verwendung des Patient Rated Tennis Elbow Evaluation Fragebogens und der Short Form Health Survey Fragebogens. Die primären und sekundären Outcomes wurden vor und nach 4 und 8 Wochen nach der Behandlung ermittelt.

Ergebnisse Der Bewegungsumfang und die Schmerzintensität unterschieden sich nicht zwischen den Gruppen.

Schlussfolgerung Die manuelle Therapie allein war ebenso wirksam wie die Kombination aus transkutaner Nervenstimulation und Epicondylitisspange bei Epicondylopathia humeri radialis. Unsere Ergebnisse unterstützen die Aufnahme der manuellen Therapie als eigenständige Therapieoption in die Leitlinien zur Behandlung von Patienten mit Epicondylopathia humeri radialis.

Key words

Musculoskeletal Manipulations - Tennis Elbow - Trigger Points - Elbow Joint - General Practice - Tendinopathy

Schlüsselwörter

trigger points - musculoskeletal diseases - musculoskeletal pain

Publication History

Received: 11 May 2022

Accepted: 07 June 2022

Article published online:
14 July 2022

• References

• 1 Tischer T. Leitlinie Epicondylopathia radialis humeri (German guidelines epicondylopathia humeri radialis). 2019 Online https://www.awmf.org/leitlinien/detail/ll/033-019.html last accessed: 24.06.2019
• 2 Hegmann KT, Hoffman HE, Belcourt RM. et al. ACOEM practice guidelines: elbow disorders. J Occup Environ Med 2013; 55 (11) 1365-1374 DOI: 10.1097/JOM.0b013e3182a0d7ec.
• 3 Struijs PA, Smidt N, Arola H. et al. Orthotic devices for the treatment of tennis elbow. Cochrane Database Syst Rev 2002; 1: CD001821 DOI: 10.1002/14651858.CD001821.
• 4 Unyó C, Chaler J, Rojas-Martínez M. et al. A cross-sectional study comparing strength profile of dorsal and palmar flexor muscles of the wrist in epicondylitis and healthy men. Eur J Phys Rehabil Med 2013; 49 (04) 507-515
• 5 Chaitow L. Muscle Energy Techniques. 3rd ed. London: Churchill Livingstone; 2006
• 6 Dommerholt J. How have the views on myofascial pain and its treatment evolved in the past 20 years? From spray and stretch and injections to pain science, dry needling and fascial treatments. Pain Manag 2020; 10 (02) 63-66 DOI: 10.2217/pmt-2019-0055.
• 7 Rompe JD, Riedel C, Betz U. et al. 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 (05) 578-582 DOI: 10.1053/apmr.2001.22337.
• 8 Nourbakhsh MR, Fearon FJ. The effect of oscillating-energy manual therapy on lateral epicondylitis: a randomized, placebo-control, double-blinded study. J Hand Ther 2008; 21 (01) 4-13 DOI: 10.1197/j.jht.2007.09.005.
• 9 Rodríguez-Fernández AL, Garrido-Santofimia V, Güeita-Rodríguez J. et al. Effects of burst-type transcutaneous electrical nerve stimulation on cervical range of motion and latent myofascial trigger point pain sensitivity. Arch Phys Med Rehabil 2011; 92 (09) 1353-1358 DOI: 10.1016/j.apmr.2011.04.010.
• 10 Faes M, van den Akker B, de Lint JA. et al. Dynamic extensor brace for lateral epicondylitis. Clin Orthop Relat Res 2006; 442: 149-157 DOI: 10.1097/01.blo.0000187057.35196.57.
• 11 Fähndrich E, Linden M. Reliability and validity of the Visual Analogue Scale (VAS) (author's transl). Pharmacopsychiatria 1982; 15 (03) 90-94 DOI: 10.1055/s-2007-1019515.
• 12 van de Pol RJ, van Trijffel E, Lucas C. Inter-rater reliability for measurement of passive physiological range of motion of upper extremity joints is better if instruments are used: a systematic review. J Physiother 2010; 56 (01) 7-17 DOI: 10.1016/s1836-9553(10)70049-7.
• 13 Rompe JD, Overend TJ, MacDermid JC. Validation of the Patient-rated Tennis Elbow Evaluation Questionnaire. J Hand Ther 2007; 20 (01) 3-10 DOI: 10.1197/j.jht.2006.10.003.
• 14 Tarlov AR, Ware JE, Greenfield S. et al. The Medical Outcomes Study. An application of methods for monitoring the results of medical care. JAMA 1989; 262 (07) 925-930 DOI: 10.1001/jama.262.7.925.
• 15 Bellach B, Ellert U. The application of the Short Form Questionnaire 36 within the National Health Survey – first results and new questions. Bundesgesundheitsblatt- Gesundheitsforschung- Gesundheitsschutz 2000; 43: 210-216
• 16 Erdfelder E, Faul F, Buchner A. GPOWER: a general power analysis program. Behav Res Methods Instrum Comput 1996; 28: 1-11
• 17 Mohr W. Pathologie des Bandapparates (Pathology of the Tendons and Ligaments). Switzerland: Springer; 1987
• 18 Savnik A, Jensen B, Nørregaard J. et al. Magnetic resonance imaging in the evaluation of treatment response of lateral epicondylitis of the elbow. Eur Radiol 2004; 14 (06) 964-969 DOI: 10.1007/s00330-003-2165-4.
• 19 Cloward RB. Cervical diskography. A contribution to the etiology and mechanism of neck, shoulder and arm pain. Ann Sur 1959; 150: 1052-1064
• 20 Yamashita T, Cavanaugh JM, el-Bohy AA. et al. Mechanosensitive afferent units in the lumbar facet joint. J Bone Joint Surg Am 1990; 72 (06) 865-870
• 21 Simons DG. New views of myofascial trigger points: etiology and diagnosis. Arch Phys Med Rehabil 2008; 89 (01) 157-159 DOI: 10.1016/j.apmr.2007.11.016.
• 22 Windisch A, Reitinger A, Traxler H. et al. Morphology and histochemistry of myogelosis. Clin Anat 1999; 12 (04) 266-271 DOI: 10.1002/(SICI)1098-2353(1999)12:4<266::AID-CA5>3.0.CO;2-G.
• 23 Shah JP, Danoff JV, Desai MJ. et al. Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Arch Phys Med Rehabil 2008; 89 (01) 16-23 DOI: 10.1016/j.apmr.2007.10.018.
• 24 Buchmann J, Neustadt B, Buchmann-Barthel K. et al. Objective measurement of tissue tension in myofascial trigger point areas before and during the administration of anesthesia with complete blocking of neuromuscular transmission. Clin J Pain 2014; 30 (03) 191-198 DOI: 10.1097/AJP.0b013e3182971866.
• 25 Fernández-Carnero J, Fernández-de-Las-Peñas C, de la Llave-Rincón AI. et al. Prevalence of and referred pain from myofascial trigger points in the forearm muscles in patients with lateral epicondylalgia. Clin J Pain 2007; 23 (04) 353-360 DOI: 10.1097/AJP.0b013e31803b3785.
• 26 Tesarz J, Hoheisel U, Wiedenhöfer B. et al. Sensory innervation of the thoracolumbar fascia in rats and humans. Neuroscience 2011; 194: 302-308 DOI: 10.1016/j.neuroscience.2011.07.066.
• 27 Hoheisel U, Reuter R, de Freitas MF. et al. Injection of nerve growth factor into a low back muscle induces long-lasting latent hypersensitivity in rat dorsal horn neurons. Pain 2013; 154 (10) 1953-1960 DOI: 10.1016/j.pain.2013.05.006.
• 28 Coombes BK, Bisset L, Vicenzino B. . Bilateral cervical dysfunction in patients with unilateral lateral epicondylalgia without concomitant cervical or upper limb symptoms: a cross-sectional case-control study. J Manipulative Physiol Ther 2014; 37: 86-46 DOI: 10.1016/j.jmpt.2013.12.005.
• 29 Lucado AM, Dale RB, Vincent J. et al. Do joint mobilizations assist in the recovery of lateral elbow tendinopathy? A systematic review and meta-analysis. J Hand Ther 2019; 32 (02) 262-276 DOI: 10.1016/j.jht.2018.01.010.
• 30 Struijs PA, Korthals-de Bos IB, van Tulder MW. et al. Cost effectiveness of brace, physiotherapy, or both for treatment of tennis elbow. Br J Sports Med 2006; 40 (07) 637-643 DOI: 10.1136/bjsm.2006.026187.