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Page 1: Tennis Elbow Treatment Approaches - … Elbow... · Physiotherapy management of lateral epicondylalgia ... principles of management are also presented. ... non-surgical treatments

Tennis Elbow Treatment Approaches

Page 2: Tennis Elbow Treatment Approaches - … Elbow... · Physiotherapy management of lateral epicondylalgia ... principles of management are also presented. ... non-surgical treatments

Invited Topical Review

Physiotherapy management of lateral epicondylalgia

Leanne M Bisset a, Bill Vicenzino b

a Menzies Health Institute Queensland, Griffith University, Gold Coast; b University of Queensland, School of Health and Rehabilitation Sciences: Physiotherapy and the

NHMRC Centre for Research Excellence [7_TD$DIFF] in Spinal Pain, Injury and Health, Brisbane, Australia

Introduction

Lateral epicondylalgia (LE), more commonly known as tenniselbow, is the most common chronic musculoskeletal paincondition affecting the elbow, causing significant pain, disabilityand lost productivity. Despite decades of research investigatingtreatments and the underlying mechanisms of LE, it remains achallenging condition for physiotherapy clinicians and researchersalike. This topical review outlines the prevalence, burden and riskfactors associated with LE. Diagnosis, assessment and theprinciples of management are also presented. The contemporaryevidence for treatment efficacy and directions for future researchare also discussed.

Prevalence of lateral epicondylalgia

Approximately 40% of people will experience LE at some point intheir life.1 It most commonly presents in men and women agedbetween 35 and 54 years.2–4 The reported point prevalence of LE isbetween 1 and 3% within the general population,5–7 and four to sevenper [8_TD$DIFF]1000 patients visiting general medical practitioners.3,6,8,9 Up to50% of all tennis players also experience some type of elbow pain,with 75 to 80% of these elbow complaints attributable to LE.1,10,11

The burden of lateral epicondylalgia

LE most commonly affects the dominant arm, particularly whenperforming repetitive activity, so it is not surprising that thegreatest burden of LE is among manual working populations wheremusculoskeletal upper limb injuries account for some of thelongest work absences.12 Up to 17% of workers within industriesthat involve highly repetitive hand tasks, such as meat processingand factory workers, experience LE.13–16 This results in an absencefrom work of up to 219 workdays, with direct costs of US$8099 perperson.17,18 Data from Workcover Queensland indicates that upperlimb (shoulder and elbow) injuries account for 18% of all work-related claims (2009 to 2013), which is equal to the prevalence ofback injuries.19

Clinical course and risk factors for lateral epicondylalgia

In his seminal paper on tennis elbow in 1936, Dr James Cyriaxproposed that the natural history of LE was between 6 months and2 years,20 which has since been widely cited. In contrast, recentreports have shown that symptoms may persist for many years andrecurrence is common.21–25 Over 50% of patients attending generalpractice for their elbow pain report not being recovered at12 months.21,26 Follow-up of participants in a clinical trial23 ofnon-surgical treatments for LE identified that 20% of respondents(27/134) reported ongoing pain after 3 to 5 years (mean 3.9 years)regardless of the treatment received, and that those with highbaseline severity were 5.5 times more likely to still have symptomsof LE. Therefore, LE is not self-limiting and is associated withongoing pain and disability in a substantial proportion of sufferers.

Workers in manual occupations involving repetitive arm andwrist movements are at increased risk of LE27,28 and are moreresistant to treatment, with a poorer prognosis.29,30 Office work,older age, being female,31 previous tobacco use and concurrentrotator cuff pathology are also significantly associated with LE.32

One plausible reason for persistent pain in LE is the presence ofsensitisation of the nervous system,33,34 given the reducedthresholds to nociceptive withdrawal35 and greater temporalsummation.36 It has previously been shown that people with LEexhibit widespread hyperalgesia (ie, enhanced pain response tovarious stimuli), which is associated with high pain scores,decreased function and longer symptom duration.33,34,37,38

Diagnosis and assessment

LE is a diagnosis based on clinical history and physicalexamination, with diagnostic imaging best used when a differentialdiagnosis is likely. LE is typically diagnosed by the presence of painover the lateral humeral epicondyle that may radiate distally into theforearm. This pain is aggravated by palpation, gripping and resistedwrist and/or second or third finger extension.2,39 While LE is thoughtto result from an overload of the forearm extensor muscles,11 thepain may have an insidious onset with no specific causal activity.21

Journal of Physiotherapy 61 (2015) 174–181

K E Y W O R D S

Tennis elbow

Physiotherapy

Lateral elbow

Physical therapy

[Bisset LM, Vicenzino B (2015) Physiotherapy management of lateral epicondylalgia. Journal ofPhysiotherapy 61: 174–181]� 2015 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article

under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

J o u rn a l o f

PHYSIOTHERAPYjournal homepage: www.e lsev ier .com/ locate / jphys

http://dx.doi.org/10.1016/j.jphys.2015.07.015

1836-9553/� 2015 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://

creativecommons.org/licenses/by-nc-nd/4.0/).

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To assist prognosis,[9_TD$DIFF] assessment of pain and disability[1_TD$DIFF] should beperformed at baseline, as there is some evidence to show thatpeople who present with higher pain and disability are more likelyto have ongoing pain at 12 months.37,40 The Patient Rated TennisElbow Evaluation is a condition-specific questionnaire thatincludes both pain and function subscales, which are aggregatedto give one overall score of 0 (no pain or disability) to 100 (worstpossible pain and disability).41,42 A minimum change of 11 points or37% of the baseline score is considered to be clinically important.43

The most common functional limitation in LE is pain on gripping, andthis can be measured as pain-free grip strength, which is a reliableand valid measure that is more sensitive to change than maximalgrip strength.44 With the patient lying supine, the elbow in relaxedextension and the forearm pronated, the patient is asked to grip adynamometer until the first onset of pain, and the mean of threetests at 1-minute intervals is then calculated.45

Elbow, wrist, and forearm range of motion, stress testing of themedial and lateral collateral elbow ligaments, and specific tests forelbow instability (eg, Posterolateral Rotary Drawer Test,46 andTable Top Relocation Test47) should be assessed to aid thedifferential diagnosis of intra-articular and ligamentous pathology.The clinician needs to be aware that there may be co-pathologiesand an overlap in symptoms, particularly in patients presentingwith signs of central sensitisation, which may be sensory in nature,or associated with neuropathic lesions such as posterior inteross-eous nerve entrapment as it passes between the two heads of thesupinator muscle. In patients with posterior interosseous nerveentrapment, they may report pain over the dorsal aspect of theforearm and exhibit muscle weakness of the finger and thumbextensors without sensory loss.48,49

Evaluation of the cervical and thoracic spine and neurodynamictesting of the radial nerve are also helpful in identifying spinalcontribution to pain. While it is currently unclear as to what impactthe presence of cervical and thoracic impairments have on thecondition, exploratory research indicates that neck pain is morecommon in people with LE compared with their healthy counter-parts.50 Furthermore, people with LE who also report shoulder orneck pain have a poorer prognosis in both the short term and longterm,40 and impairment at C4 to C5 spinal levels has beenidentified on manual examination in people with localisedsymptoms of LE.51 The role of cervical and thoracic spineimpairments in the prognosis of LE requires validation; however,in light of these exploratory studies, the clinician should includecervical and thoracic spine assessment in their examination of thepatient presenting with LE.

Imaging studies, such as ultrasound (US) and magneticresonance imaging, have high sensitivity but [10_TD$DIFF]lower specificity indetecting LE.52–54 Structural abnormalities identified on imagingtend to be consistent across all tendinopathies, and include focalhypoechoic regions, tendon thickening, neovascularisation, disrup-tion of fibrils and intrasubstance tears.52–55 Importantly, structuralchanges on imaging are present in approximately 50% of healthy,asymptomatic age-matched and gender-matched individuals,53,54

indicating that caution must be applied in interpreting the relevanceof such findings. Notwithstanding this, negative image findings canbe used to rule out LE as a diagnosis52,53 and assist with alternativediagnoses such as instability and/or joint pathology.54,56 A notabledifferential diagnosis is the presence of a large tear (� 6 mm) withinthe tendon or lateral collateral ligament, which has been linked tofailed conservative treatment.57

Management of lateral epicondylalgia

Physical interventions for LE have been widely investigated,with the publication of more than 200 clinical trials and severalsystematic reviews. Conservative management is recommended asthe first line of treatment for LE.

In order to facilitate summary and interpretation of this volumeof literature, the present review has focused on summarising the

findings for conservative interventions that have been compared toa control, placebo or other interventions in randomised, controlledtrials (RCTs) of sound methodological quality (defined for thisreview as a rating� 5/10 on the PEDro scale). It has predominantlyfocused on physical therapies and has not comprehensivelyreviewed other medical interventions, including injection thera-pies (see Coombes et al58 for further [11_TD$DIFF]information).

A prevailing notion in tendinopathy management is to regardexercise and load management59,60 as the key element, with allother physical modalities being adjuncts to speed the recuperationor to enhance the effects of exercise and outcomes. Whileacknowledging that a variety of outcomes and follow-up timesare reported in the literature, this review has focused on short-term follow-up data, wherein the primary aim of adjunctivetreatment is to speed up recovery. Outcomes of pain (converted toa 0 to 100 scale; 0 = no pain, 100 = worst pain imaginable) andglobal rating of success are presented in terms of point estimates ofeffect (eg, MD, RR), whereas other outcomes are qualitativelyreported. A summary of the findings from English language papers(or reports therein of non-English original papers), along with thelevel of evidence that underpins their use, is provided. Theinterventions reported in this review include exercise, manualtherapy/manipulation, orthoses, laser, US, acupuncture, shockwave therapy (SWT), and multimodal physiotherapy treatment –many of which have been compared to placebo or control.

Figure 1 is a graphic representation of the number of patients inRCTs that have investigated the effects of different interventions inLE, which interventions have demonstrated a superior effectcompared to the comparator group, as well as where interventionshave not yet been compared head-to-head.

Exercise

Exercise is rarely delivered as a treatment in isolation, withmany RCTs studying a variety of exercise types in combinationwith other interventions. This review identified eight RCTs ofsound methodological quality from five systematic reviews61–65

that investigated the effects of isometric, isokinetic, concentric andeccentric exercises in LE. Three of the trials compared eccentricexercise to other treatments. Tyler et al (n = 21)66 found asignificant benefit of 9 (SD 2) sessions of eccentric exercise over10 (SD 2) sessions of isotonic extensor exercises, with participantsin both groups receiving a multimodal program of stretches, US,friction massage, heat and ice. The eccentric exercises producedgreater pain relief and functional improvement, with nine of the11 participants reporting at least 50% improvement in their painfollowing eccentric exercise, compared to three out of 10 reportingthe same level of improvement in the comparator group. Viswaset al (n = 20)67 also found that a supervised program of eccentricexercises improved pain and function more than friction massagewith Mill’s manipulation at short-term follow-up. Similarly, aprogram of eccentric exercises with an elbow orthosis may providegreater global improvement at the end of treatment (6 weeks RR4.7, 95% CI 1.1 to 19.8) but no difference in pain relief comparedwith an elbow orthosis alone (n = 37).68 In contrast, a 3-monthhome program of eccentric exercises produced variable resultswhen compared with a program of concentric forearm exercises,with both exercise interventions demonstrating significant im-provement over short-term and long-term follow-up.69

For exercise programs other than eccentric-only regimens,there was evidence from one RCT that isometric, concentric andeccentric exercises may be superior to US for pain relief (MD 21,95% CI 1 to 41) and grip strength (MD 101 N, 95% CI 11 to 1914) at8 weeks.70 Compared to placebo US, Selvanetti et al (n = 62)71

found a significant benefit after 4 weeks of eccentric exercises incombination with contract/relax stretching for pain relief at theend of treatment (MD, 95% CI 17 to 21). A 3-month home programof concentric/eccentric forearm exercises reportedly producedgreater reductions in pain but not function, when compared with await-and-see approach.72 However, one other study found no

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difference in pain and function outcomes at 6 weeks betweenconcentric exercises, eccentric exercises and stretching (n = 81).73

In summary, despite conflicting findings, there was evidencefrom several RCTs of sound methodological quality that exercisemay be more effective at reducing pain and improving function[12_TD$DIFF]than other interventions such as US, placebo US, and frictionmassage, but there may be no difference in effect between differenttypes of exercises.

Manual therapy and manipulation

Six RCTs,74–79 reported within four systematic reviews,61,62,64,80

investigated the effects of manual therapy techniques on a range ofoutcomes in people with LE, but importantly, most of thesemeasured the immediate effects of a single treatment session orthe short-term effects after several sessions of manual therapy.Three of the RCTs studied elbow treatments, two studied necktreatments and another treatment to the wrist. There was evidencefrom two within-subject lab-based studies (n = 48)77,79 thatMulligan’s Mobilisation-with-Movement at the elbow is superiorto placebo in providing immediate improvement in pain-free grip(WMD 43 N, 95% CI 30 to 57) and pain on palpation measured asthe pressure pain threshold (WMD 25 kPa, 95% CI 6 to 45).62 Astudy of 23 participants in which six sessions of a craniosacraltechnique called ‘oscillating-energy manual therapy’ (the therapistdelivers ‘oscillating energy’ to the affected elbow via movement ofhis/her fingertips) reported a significantly greater improvement inpain severity at the end of treatment (2 to 3 weeks in total),compared to placebo (MD 21, 95% CI 1 to 42).76

Two further studies of sound methodological quality investi-gated the effects of spinal manual therapy in the management ofLE.74,75 One small pilot trial (n = 10) investigated the effects of localelbow treatment (stretching, concentric/eccentric strengtheningexercises, joint mobilisations to the elbow and wrist), alone and incombination with cervical and thoracic manual therapy techni-ques (Maitland mobilisations).74 Extraction of data found asignificant difference between groups for pain-free grip strengthat the end of treatment (MD 15 kg, 95% CI 10 to 19) but nodifference on pain or function outcomes. Another small studyinvestigated the immediate effects of a single cervical spinemanipulation versus placebo (manual contact) in a within-subjectsstudy design of 10 people with LE.75 There was a significant

immediate improvement in pressure pain threshold of the affectedarm (MD 77 kPa, 95% CI 37 to 116) following cervical manipulationcompared with the placebo, but there was no difference betweeninterventions for heat or cold pain threshold.75

In a separate trial, a maximum of nine treatments ofmanipulation/mobilisation of the wrist (posteroanterior glide ofthe scaphoid) provided superior improvement in pain during theday (MD 20, 95% CI 3 to 37) but not global assessment (RR 1.3, 95%CI 0.8 to 1.9) compared at 6 weeks with a multimodal program ofUS, friction massage and exercise.78

In summary, manual therapy techniques to the elbow, wrist andcervicothoracic spine may reduce pain and increase pain-free gripstrength immediately following treatment, although in manyinstances, meta-[13_TD$DIFF]analysis was not possible due to heterogeneitybetween manual therapy techniques and timing of follow-upassessment. There was insufficient evidence of any long-termclinical effects for manual therapy alone.

Orthotics and taping

Due to differences in the types of orthoses, comparator groups,timing of follow-up and outcome measures used, pooling of datawas not possible for studies investigating the effects of orthoses inLE. The reported effects of an orthosis compared with placebo orcontrol were contrasting between studies. Data from two RCTssuggested that a dynamic wrist extensor bracea or a forearmcounterforce orthosis might provide significant improvement inpain and function at 4 to 12 weeks follow-up compared with notreatment or elbow taping (n = 63).81,82 In contrast, both astandard counterforce orthosisb and a forearm-elbow orthosisc

provided no immediate improvement in pain or grip strengthcompared with no treatment83 or placebo.84 Similarly, thereappeared to be little or no added benefit of one orthosis overanother in improving pain and function in the short term, whencomparing a standard counterforce orthosis against a counterforceorthosis with the addition of a wrist splintd, (n = 43)85 or a forearmextension bar that limits supination.86 Although this latter studyfound a statistically significant difference in the pain subscale ofthe Patient Rated Tennis Elbow Evaluation, the between-groupdifference was too small to be clinically relevant.43

[14_TD$DIFF]Unpooled data from two RCTs revealed that compared withcorticosteroid injection, an elbow orthosis might be as effective at

[(Figure_1)TD$FIG]

SWT

Placebo /control

Manual therapy

Exercise

Acupuncture

Laser

US

OrthosesMultimodal

n = 674

n = 156

n = 208

n = 206

n = 266

n = 321n = 427

n = 87

n = 1376

Figure 1. Network comparison of interventions for lateral epicondylalgia.

Note: The size of the circle represents the total number of participants (n) for each intervention, the solid line and direction of the arrow indicates the intervention with known

superior effect over the comparator, and the dotted line represents head-to-head comparisons reported in the literature but with no clear benefit of one intervention over

another.

SWT = shock wave therapy, US = ultrasound.

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relieving pain, improving function or influencing self-perceivedimprovement in the short term (2 to 6 weeks).87,88 Compared witha multimodal program of friction massage plus US and exercise, anelbow orthosise alone was inferior in relieving pain and overallsatisfaction, but was superior in improving function (ability toperform daily activities) at 6 weeks. There was no difference inoverall success between treatments at 6 weeks (RR 1.2, 95% CI0.9 to 1.7),89 but adding an elbow brace to the multimodal programdid not provide additional pain relief or risk of a successfuloutcome at 6 weeks (RR 1.1, 95% CI 0.8 to 1.7).

In summary, there was conflicting evidence for the effective-ness of orthoses in providing pain relief or improvement infunction compared with placebo or no treatment. Elbow orthosesmay be as effective as corticosteroid injection in the short term;however, there was only one study to support this claim. There wasno compelling evidence that any one orthosis is superior to anotherin the short term, or that adding an orthosis to another treatmentprovides any additional benefit.

Acupuncture/dry needling

Results from four studies indicated that acupuncture may bemore effective than placebo in providing pain relief and improve-ment in function at the end of treatment,90–93 but this effect wasequivocal at 2 to 3 months of follow-up.90,91 Acupuncture mayprovide superior pain relief and functional improvement com-pared with other interventions such as US, where results from twostudies suggest that acupuncture was more effective at the end oftreatment and at the 6-month follow-up.94,95 One other study(n = 86) compared acupuncture plus corticosteroid injection withcorticosteroid injection alone. Extracted data indicated a signifi-cant difference in success (RR 1.5, 95% CI 1.0 to 2.3) but not painrelief (MD 0, 95% CI –1 to 1) between treatments immediately aftertreatment.96 While there appears to be conflicting evidence,acupuncture might be more effective than placebo and moreeffective than US at relieving pain and improving self-assessedtreatment benefit in the short term.

Laser

In one systematic review,97 a subgroup of five trials that used904 nm lasers and doses from 0.5 to 7.2 Joules, reportedsignificantly improved pain relief (MD 17, 95% CI 9 to 26) andlikelihood of global improvement (RR 1.5, 95% CI 1.3 to 1.8) forlaser compared with placebo. The present review found anadditional three RCTs that used a 904 nm laser, all of which foundno benefit from laser compared with the comparator groups in theshort term, perhaps because the comparison groups receivedactive interventions such as exercise.98,99 Two recent RCTs notincluded in the earlier systematic review97 studied dual wave-length 980/810 nm (versus placebo)100 or 820 nm (versus US)101

and reported no differences. The lack of benefit from laser might bedue to an inappropriate selection of wavelength or, in one study, atype II error (n = 16).100,101

In summary, 904 nm laser might be beneficial in the short termcompared with placebo, but there is likely no difference betweenlaser and other active interventions in the short term or long term.Laser wavelengths other than 904 nm do not appear to have anybenefit over that of a placebo.

Ultrasound and phonophoresis

Pooled data from four RCTs (n = 266)102–105 found no differencein the likelihood of global improvement in the short term (up to12 weeks) between US and placebo (RR 1.3, 95% CI 0.9 to 1.9). Therewas low-level evidence from three RCTs that US is no different tophonophoresis alone,106,107 combined with an elbow orthosis,106

acupuncture,94 or friction massage in relieving pain.107 Theconclusions drawn from previous systematic reviews61,62 remainunchanged: US appears to be no more effective than placebo for

pain relief or self-perceived global improvement in the shortterm.61,62

Shock wave therapy

Based on the results of nine placebo-controlled trials (1006 par-ticipants), a 2005 Cochrane review concluded the SWT provideslittle or no benefit in reducing pain or improving function in LE.108

There is clinical controversy as to which method of application forSWT is most efficacious (eg, radial or extracorporeal, with orwithout local anaesthetic), but no studies could be found that havevalidated one technique over another. The present review found anadditional five RCTs comparing SWT with placebo,109,110 US withhot pack and friction massage,111 corticosteroid injection,111,112

and surgery.113 One study reported significant differences infavour of SWT over a placebo for pain and function measures aftertreatment and at a 6-month follow-up, but that data were notincluded in pooled analyses due to a lack of clarity in the statisticsreported therein.109 Gunduz et al found no difference in pain reliefor function between SWT, US with friction massage andcorticosteroid injection at any time point.111 Shock wave therapyappeared to be no different to corticosteroid injection orautologous blood injections in improving pain or function at12 weeks112 and no better than surgical percutaneous tenotomy inproviding pain relief or functional improvement.113 Pooled datafrom the Cochrane review plus one additional study110 found thatcompared with placebo, SWT induced no greater pain relief (MD –8, 95% CI –17 to 3) at 6 weeks. Similarly, the pooled meandifference for pain on resisted wrist extension (Thomsen test) at4 to 6 weeks follow-up was not significantly different betweenSWT and placebo (MD –15, 95% CI –36 to 6).

In summary, pooling data from a previous review and new datasupports the conclusion that SWT is no more effective than placeboor other treatments for relieving pain in LE.

Multimodal programs

[15_TD$DIFF]Several studies [16_TD$DIFF]have [17_TD$DIFF]combined a range of physical modalities inthe rehabilitation program. A commonly reported multimodalprogram involving friction massage in various combinations withMill’s manipulation, US, and stretches has been compared withexercise,66,67,114 laser,115 wrist manipulation,78 manual thera-py,116 elbow brace,89 wait-and-see,117 and corticosteroid injec-tion.117,118 While the heterogeneity between comparator groupslimits pooling, in almost all studies, this approach was eitherinferior or no different to the comparison. One study (n = 60) didshow superior pain relief and functional improvement after4 weeks of a Cyriax program (friction massage plus Mill’smanipulation) compared with phonophoresis plus supervisedexercise.114 A second study (n = 125) found equivocal resultsbetween a program of friction massage, US and exercise comparedwith an elbow orthosisf at a 6-week follow-up, with themultimodal treatment delivering superior pain relief and func-tional improvement, but the brace treatment favoured ability ofdaily activities and less inconvenience, with no difference betweengroups for measures of success (RR 1.2, 95% CI 0.9 to 1.7), severityof complaints, pain-free grip strength, maximum grip strength andpressure pain threshold.89 Despite the diversity of comparisonsand outcomes, it seems that on balance, the majority of theevidence does not support the use of friction massage incombination with other treatments in the management of LE.

Two large RCTs compared a multimodal program of Mulligan’sMobilisation-with-Movement and exercise (one with placeboinjection) with wait-and-see (or placebo injection) and cortico-steroid injection.22,23 Pooled data (n = 205) revealed that physio-therapy was superior to wait-and-see in providing a successfuloutcome in the short term (6 to 8 weeks, RR 2.3, 95% CI 1.6 to 3.3).At 52 weeks there was a significant, but very small, benefit ofphysiotherapy over wait-and-see in terms of the number ofparticipants deeming their treatment a success (pooled data RR

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1.1, 95% CI 1.0 to 1.1). Physiotherapy was similar to corticosteroidinjection in providing a successful outcome in the short term (pooleddata RR 0.9, 95% CI 0.7 to 1.1), but was superior to corticosteroidinjection at 52 weeks follow-up (RR 1.3, 95% CI 1.1 to 1.5).22,23

In summary, a multimodal program of Mobilisation-with-Movement and exercise is likely superior to wait-and-see andplacebo injection in the short term, and superior to corticosteroidinjection in the long term. Multimodal treatment involving frictionmassage may be no different or worse than other treatments inproviding pain relief.

Evidence-informed clinical reasoning

While many treatments for LE have been researched, manyhave small effects that occur in the short term (eg, 6 to 12 weeks)and few have shown consistent effectiveness over other treat-ments. Figure 1 highlights the lack of between-interventionsuperiority, with significant treatment effects largely seen onlywhen an intervention is compared with placebo or control (notreatment). It is also apparent from Figure 1 that several treatmentshave not yet been compared head-to-head. Notwithstanding theselimitations, the current evidence suggests that exercise may bebeneficial in the short term compared with other interventions suchas US, friction massage, and stretches for reducing pain andimproving function. The issue with exercise for the clinician is thatthere is insufficient evidence to support any one type of exercise overanother, and the optimal dose of exercise for LE has yet to beestablished. Elbow orthoses may also be useful in providing painrelief and improvement in function compared with placebo or doingnothing; however, as with exercise, the type of orthosis appears to beless critical. Manual therapy techniques to the elbow, wrist andcervicothoracic spine may be helpful in providing immediate painrelief and improvement in function in people with LE. A multimodalprogram of Mulligan’s Mobilisation-with-Movement and exercise

may be superior to wait-and-see and placebo injection in theshort term, and superior to corticosteroid injection in the longterm. In contrast, multimodal treatment involving frictionmassage may be no different or worse than other treatmentsin providing pain relief. For electrophysical agents, laser using904 nm wavelengths may be beneficial in the short termcompared to placebo; however, there is likely no differencebetween laser and other active interventions in the short or longterm. Laser wavelengths other than 904 nm do not appear tohave any benefit over that of a placebo. Ultrasound appears to beno more effective than placebo in the short term [18_TD$DIFF]; however [19_TD$DIFF],acupuncture may be more effective than US and/or placebo inthe short term. Lastly, despite the addition of new RCTs, theconclusions drawn from a previous Cochrane review remainunchanged for SWT, which appears to be no more effective thanplacebo for relieving pain in LE.

It is proposed that when consulting a patient with LE, theremight be merit in considering treatment recommendations on thebasis of presenting patient characteristics that are known to beassociated with the risk of a good or poor prognosis (Figure 2). It isrecommended that patients with features indicating a goodprognosis (eg, pain duration of < 3 months, no concomitant neckor other arm pain, Patient-Rated Tennis Elbow Evaluation (PRTEE)< 54/100) be counselled on their condition, load managementincluding tools and work station, self-management and thatadopting a wait-and-see approach is likely to be of benefit within12 weeks. This approach is likely of merit for those patients whoare unwilling to perform exercises or visit the physiotherapist for anumber of sessions of Mobilisation-with-Movement with exercise.In contrast, if the patient would prefer to speed up the process,then exercise and Mobilisation-with-Movement would be under-taken because there is evidence of its benefit.

If a patient presents with features that are known to beassociated with poorer outcomes (eg, concomitant neck and arm

[(Figure_2)TD$FIG]

Add adjunctive physical modalities (limited number of sessions):• laser, acupuncture, • elbow and/or spinal manual therapy• taping, orthoses• not friction massage, US, SWT

Education and advice:• tendinopathy explanation• load management• tools and work station• self-management• counsel regarding injections

Good prognosisPRTEE < 54/100

Pain duration < 3 mthNo adverse prognostic indicators

Education and advice:• tendinopathy explanation• load management• tools and work station• self-management• counsel regarding injections

Not improved after 6 to 12 wk

Add exercise (8 wk):• isometric, concentric, eccentric• general upper limb strengthening• ± MWM (pain management)

Poor prognosisPRTEE > 54/100

Multiple adverse prognostic indicators

Consider:• chronic pain management• pain education• referral / medication• differential diagnoses

(imaging, pathology tests)

Not improved after 6 to 8 wk or high pain/disability persists

Not improved after 8 to 12 wk

prognos�c con�nuum

Figure 2. Evidence-based clinical pathway for the physiotherapy management of lateral epicondylalgia (assuming accurate clinical diagnosis at outset). The green arrows

represent the clinical pathway for patients with characteristics indicative of a good prognosis; the orange arrows represent the clinical pathway for patients with

characteristics highly indicative [6_TD$DIFF] of a poor prognosis; the blue arrows represent the initial clinical pathway for patients that fall within the prognostic continuum (ie, exhibit

one or more poor prognostic indicators); the yellow arrows represent the additional treatment options for patients at risk of a poor prognosis who fail to respond to evidence-

based treatment with education, advice, exercise therapy and Mobilisation-with-Movement manual therapy techniques.

MWM = Mobilisation-with-Movement, PRTEE = Patient-Rated Tennis Elbow Evaluation, SWT = shock wave therapy, US = ultrasound.

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pain, highly repetitive manual work, higher levels of pain anddisability such as a PRTEE > 54/100, cold hyperalgesia with coldpain thresholds above 13 8C) then a more involved process ought tobe considered. The approach should be more in line withmanagement of persistent or chronic pain, possibly involvingpain education, referral for medication and – in severe protractedcases – the involvement of pain clinic specialists, in addition to theeducation and advice that all patients with LE should receive. Inaddition, there should be a confirmation of the diagnosis/differential diagnosis through use of diagnostic imaging. It isimportant to understand that patients are likely to present along acontinuum of prognostic features, which requires the clinician touse clinical reasoning skills to navigate the management approachin consultation with the patient. For example, a patient thatappeared to have a good prognosis at the initial consultation but isno better at 6 to 12 weeks could be encouraged to undertakeexercise and Mobilisation-with-Movement. If the condition doesnot improve with a graduated progressive exercise program, otherpassive pain relieving techniques might be introduced to speed upthe resolution (eg, Mobilisation-with-Movement (if not alreadytrialled), laser, acupuncture, spinal manipulation, orthoses). Whenintroducing passive interventions it is important not to engender apatient’s reliance on these interventions, as most of them have onlysmall effects of short-term duration and they do not facilitate self-management by the patient. A patient’s failure to respond whenincorporating passive techniques and exercises over 8 to 12 weeksshould be regarded by the clinician as an indication to escalate themanagement program to one like that for the patient presentingwith features associated with a poor prognosis (Figure 2).5,37,40,51

Future directions for research and practice

A significant gap in the current literature, and an area ofgrowing interest, is the effect of potentially confounding variableson treatment outcomes. Certain clinical characteristics and/orunderlying pathophysiological characteristics may modify treat-ment effects. For example, one study has found that the presence of atear in the lateral collateral ligament and the size of anintrasubstance tendon tear detected by US were each significantlyassociated with poorer prognosis in patients with LE, and indicatedgreater likelihood of failing conservative management, including aneccentric exercise program.57 While certain characteristics areknown prognostic factors for long-term pain and disability, thequestion remains: what is the optimal treatment for individuals whoexhibit one or more of these characteristics? Prognostic factors thathave been identified through retrospective data analysis obtainedfrom clinical trials require confirmation of their role in modifyingtreatment effects through prospective evaluation. If clinical out-comes for LE are to be improved, it is important to understand howthese prognostic factors modify treatment effects.

The role of exercise in managing LE across the severity spectrumshould be clarified, including optimal dosage and type of exercisefor people with mild, moderate or severe symptoms of LE. Giventhat exercise is considered to be the cornerstone of rehabilitation,it is [20_TD$DIFF]understudied compared with other interventions. There is aneed for further well-controlled RCTs investigating the effects ofexercise and the role that supervision of exercise has to play interms of patient compliance. Recent work on patellar tendinopathyhas highlighted the effectiveness of isometric exercises comparedwith isotonic exercises in producing pain relief in the short term,60

which corresponded to normalising cortical inhibition.119 Whileexercise is generally considered to have an analgesic effect andprevent the development of chronic pain, exercise-inducedanalgesia is impaired in some musculoskeletal conditions thatexhibit central sensitisation, and in some cases, may even increasepain.120 The effectiveness of alternative exercise regimens such asisometric exercise in people with LE is worthy of investigation, asare other treatments that specifically target central sensitisation.

LE is a challenging tendinopathic condition with a complexunderlying aetiology. There is a growing body of evidence that

provides some clarity as to what we should and should not beconsidering in our management of the patient with LE. Withcontemporary knowledge of pain processes as well as local tendonchanges, physiotherapists who use a clinical-reasoning-basedapproach to managing musculoskeletal conditions are well placedto manage patients with LE, as conservative treatment remains thebest practice approach for this population.

Footnotes: www.pedro.org.au. a Carp-X, The Netherlands. b

Thermoskin, Australia or Count’R-Force Tennis elbow brace,Arlington, USA. c Go-strap, Australia. d Thamert orthoflex brace,Netherlands. e Epipoint, Zeulenroda, Germany. f Epipoint, Bauer-feind, Germany[21_TD$DIFF].

Ethics approval: Not applicable.Competing interests: Nil.Source(s) of support: Nil [5_TD$DIFF].Acknowledgements: Aoife Stephenson for conducting the

database searches, Prue Tilley for assistance with data extractionand Brooke Coombes for collaborating on the concepts of clinicalpathways[22_TD$DIFF].

Provenance: Commissioned. Not peer-reviewed.Correspondence: Bill Vicenzino, University of Queensland,

School of Health and Rehabilitation Sciences: Physiotherapy andthe NHMRC Centre for Research Excellence Spinal Pain, Injury andHealth, Brisbane, Australia. Email: [email protected]

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http://dx.doi.org/10.4172/2165-7025.1000156

Volume 3 • Issue 3 • 1000156J Nov PhysiotherISSN:2165-7025 JNP, an open access journal

Effectiveness of Cyriax Physiotherapy in Subjects with Tennis ElbowAshish J Prabhakar1*, Vijay Kage2 and Deepak Anap1

1PDVVPFs, COPT, Ahmednagar, KLEU, India2Institute of Physiotherapy, Belgaum, India

Keywords: Pain; Epicondylitis; Handling tools

IntroductionPain over the lateral epicondyle, which is exacerbation by work or

recreational activities that involves gripping action of the hand, such as holding tools, shaking hands, and lifting a kettle, usually signals that the individuals has a condition termed lateral epicondylalgia, epicondylitis, or what is more commonly known as tennis elbow [1]. This condition was first named by Morris (1882) who called it lawn tennis arm [2].

Tennis elbow is a syndrome characterized by an insidious onset of elbow pain brought on by wrist extension with pronation or supination and aggravated by gripping [3].

Lateral epicondylalgia affects 1-3% of the population, only 5% of all patients seen are recreational tennis players [4]. Although the syndrome has been identified in patients ranging from 20 to 60 years old, it predominantly occurs in the fourth and fifth decades. Male and female prevalence rates are reportedly equal. Seventy-five percent of patients are symptomatic in their dominant arms [5-7].

The specific muscle most often implicated clinically and surgically is the extensor carpi radialisbrevis with occasional involvement of the extensor digitorum communis, extensor carpi radialis longus, and extensor carpi ulnaris. The possible reason for this more frequent involvement of the extensor carpi radialisbrevis is its location as one of the most laterally situated muscles on the lateral epicondyle with slips taking origin from the radial collateral ligament. The extensor carpi radialisbrevis is intimately attached to the joint capsule, which is continuous with the radial collateral ligament and because of this proximity adhesions are more likely [3].

Cyriax advocated the use of deep transverse friction massage in combination with mill’s manipulation in treating lateral epicondylalgia [5,8].

Deep transverse friction (DTF) is also known as deep friction massage is a specific type of connective tissue massage applied precisely to the soft tissue structures such as tendons. It was developed in an empirical way by cyriax and is currently used extensively in rehabilitation practice [5].

Mill’s manipulation is the most common manipulative technique used by physiotherapists. Cyriax stated that it should be performed immediately after the DTF is provided that the patient has a full range of passive elbow extension. If passive elbow extension is limited, the manipulative thrust will affect the elbow joint, rather than the common extensor tendon, possibly causing traumatic arthritis. It is defined as a passive movement performed at the end of range—that is, once all the slack has been taken up-and is a minimal amplitude, high

velocity thrust. The aim of this technique, again without properly designed controlled studies to prove this, is to elongate the scar tissue by rupturing adhesions within the teno-oseous junction, making the area mobile and pain free [5].

Cyriax physiotherapy is the technique where DTF and Mill’s are used, but very few studies on cyriax physiotherapy using various outcome measures havebeen conducted. However, the present study is been undertaken to study the effect of cyriax on pain, grip strength and to see change in functional activities level fallowing treatment in cases of tennis elbow.

MethodDesign

This study was conducted at the physiotherapy OPD of KLE Dr. Prabhakar Kore hospital and MRC, Belgaum Karnataka.

Participants were referred by public and private medical practitioners for treatment of chronic tennis elbow. 20 subjects were recruited and received Cyriax physiotherapy, Therapeutic ultrasound and exercisers. The intervention was provided at 7 visits occurring over 1 week. Measurements were recorded once pretreatment i.e 1st day and once post treatment i.e 7th day.

Participants

People entering the trial had to meet the following inclusion criteria, both male and female between 20 to 50 years of age, pain on the lateral side of the elbow, tenderness over the forearm extensor origin, pain with 1 of the following tests: Mill’s test, Cozens test, all subjects with symptoms for duration of more than 3 months. Exclusion criteria were previous surgical history for elbow, fractures around elbow, restricted extension and laxity at elbow, sensitive skin, allergies to adhesive tape, a recent steroid injection for same complaints (3 months).

Intervention

The purpose of this study was explained and a written informed

AbstractPain over the lateral epicondyle, which is exacerbation by work or recreational activities that involves gripping action

of the hand, such as holding tools, shaking hands, and lifting a kettle, usually signals that the individuals has a condition termed lateral epicondylalgia, epicondylitis, or what is more commonly known as tennis elbow.

*Corresponding author: Ashish J Prabhakar, PDVVPFs, COPT, Ahmednagar, KLEU, India, E-mail: [email protected]

Received April 24, 2013; Accepted May 30, 2013; Published June 02, 2013

Citation: Prabhakar AJ, Kage V, Anap D (2013) Effectiveness of Cyriax Physiotherapy in Subjects with Tennis Elbow. J Nov Physiother 3: 156. doi:10.4172/2165-7025.1000156

Copyright: © 2013 Prabhakar AJ, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Citation: Prabhakar AJ, Kage V, Anap D (2013) Effectiveness of Cyriax Physiotherapy in Subjects with Tennis Elbow. J Nov Physiother 3: 156. doi:10.4172/2165-7025.1000156

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Volume 3 • Issue 3 • 1000156J Nov PhysiotherISSN:2165-7025 JNP, an open access journal

consent was obtained from all the participants. The subjects were screened based on the inclusion and exclusion criteria. Demographic data was collected along with initial assessment of VAS, grip strength, Patient rated forearm evaluation questionnaire for lateral epicondylitis.

The subjects received the selected treatment for 7 sessions at 1 session per day.

Therapeutic Ultrasound: Subject received ultrasound and exercises before performing deep friction massage and manipulation. Subject were seated on the chair with shoulder in neutral position, elbow in right angle and fully supported. The ultrasound was administered for 10 minutes in pulsed mode at 1 w/cm2 with ultrasound gel Binder, over the later epicondyle or area of tenderness.

Exercises

Each exercise were repeated 10 times in 3 series, Clenching fist strongly, resisted wrist flexion and extension, wrist rotation with a stick and end range stretching for wrist flexors and extensors for at least 30 sec.

Following these subjects received Cyriax physiotherapy.

Cyriax physiotherapy

Position of the patient-the patient sits with elbow bent to right angle and full supination. The physiotherapist places one hand at the patients’ wrist and holds the forearm in supination.

The pad of the index finger, middle finger or thumb is placed directly over the involved site, the remaining fingers should be used to provide further stabilization of the therapists hand, no lubrication is used, the patient’s skin must move along with the therapist’s fingers.

Beginning with light pressure, the therapist moves the skin over the site of the lesion back and forth in a direction perpendicular to the normal orientation of the fibers of the involved part.

The massage is given for 2 minutes then stopped for 1 to 2 minutes then repeated of 2 minutes, working up to 12 to 15 minutes, followed by the manipulation.

Manipulation Position of patient- patient sits upright with the arm abducted

to the horizontal and so far medially rotated that the olecranon faces upward. The physiotherapist stand behind the patient, the patients forearm must be fully pronated and the wrist flexed.

The physiotherapist now places his left hand on the olecranon, thus extending the elbow, while the tension is strongly maintained; he suddenly forces full extension at the elbow with his left hand with a smart jerk.

This is carried out once each visit, immediately after friction.

Outcome MeasuresPain intensity

By Visual analogue scale-A scale of 10 cm to evaluate intensity of pain where 0 represents no pain and 10 represent unbearable pain.

Grip strength

Grip strength was measured by hand held dynamometer.

Physical function outcome

Patient rated forearm evaluation questionnaire for lateral epicondylitis.

Statistical Analysis Statistical analysis for the present study was done using statistical

package of social sciences (SPSS) version 14 so as to verify the results obtained. For this purpose data was entered into an excel spread sheet, tabulated and subjected to statistical analysis. Comparison of the pre and post intervention outcome measures within the group was done by using paired-t test. Probability values less than 0.05 were considered statistically significant and probability values less than 0.0001 were considered highly significant.

ResultsVAS-VAS score presession on 1st day and post session on 7th day

was 6.0 ± 1.3 and 1.3 ± 1.0 respectively. On comparing these values there was significant difference.

Grip strength-The mean grip strength score presession on 1st day and post session on 7th day was 15.3 ± 2.3 which increased to 18.3 ± 2.3 respectively.

Finally on comparing the pre and post treatment values of PRTEEQ i.e, pre 55.4 ± 14.0 fallowing which post treatment decreased to 21.0 ± 6.2.

DiscussionThe present experimental trial was conducted to study the effect

of, Cyriax physiotherapy with conservative treatment of therapeutic ultrasound and supervised exercise in subjects with lateral epicondylitis (Tennis elbow). Results of this study were focused on pain relief where Pain assessment was done by visual analogue scale (VAS), [9] improvement of grip strength, grip strength was measured with the help of hand held dynamometer, [10] and reduction in function activity impairment scores based on Patient rated forearm evaluation questionnaire for lateral epicondylitis. It was noticed that there was improvement in all the above parameters.

In this study the age group of the participants was between 20 to 50 years, the mean was 41.15 ± 7.73. According to a study by Halpren it was stated that, peak age at which tennis elbow occurs is 40 to 50 years [11]. There is a decrease in the occurrence of tennis elbow cases after 50 years of age, this may be due to diminished intensity of play or activity at these older ages as suggested in a study by Gruchow et al. [12].

Subjects of present study consisted of 11 males and 09 females. According to a study by Alireza Shamsoddini et al. [8] and few others, tennis elbow is equally distributed between men and women. But according to Gruchow et al. [12] there was a fourfold increase in prevalence among men and nearly two fold increases among women. In this study men had a marginally higher prevalence rate than women, but there was no statistically significant difference between men and women prevalence.

The mean values of data from present study showed reduction in pain score on VAS, improved grip strength on hand held dynamometer and functional improvement graded on PRFEQ.

When the intra group mean values of VAS were analyzed it was found statistically significant. In the present study reduction in

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Citation: Prabhakar AJ, Kage V, Anap D (2013) Effectiveness of Cyriax Physiotherapy in Subjects with Tennis Elbow. J Nov Physiother 3: 156. doi:10.4172/2165-7025.1000156

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Volume 3 • Issue 3 • 1000156J Nov PhysiotherISSN:2165-7025 JNP, an open access journal

pain level, as quantified by the VAS with the application of Cyriax is consistent with the findings of previous studies.

It is a common clinical observation that application of DTF leads to immediate pain relief. The patient experiences numbing effect during the session and reassessment immediately after the application of DTF shows reduction in pain and increase in strength and mobility [13] several theories have been put forth to explain the pain relieving effect of DTF. According to Cyriax and Cyriax, DTF also leads to increased destruction of pain provoking metabolites such as Lewis’s substances [5]. Another mechanism by which reduction in pain may be achieved is through diffused noxious inhibitory controls, a pain suppression mechanism that releases endogenous opiates.

The latter are inhibitory neurotransmitters which diminish the intensity of pain transmitted by higher centres [5].

Mill’s manipulation is performed immediately after DTF, where it is done to elongate the scared tissue by rupturing adhesions within the teno-osseous junction making the area mobile and pain free [5,8].

Amit V Nagrale et al. in his study between Cyriax and phonophorosis found Cyriax physiotherapy to be superior treatment approach compared to phonophrosis in terms of pain, pain-free grip, and functional status [14].

It is important to note that all participants were given ultrasound and supervised exercises as a common conventional method. Ultrasound refers to mechanical vibrations which are essentially the same as sound waves but of a higher frequency. Such waves are beyond the range of human hearing and can therefore also be called ultrasonic [15].

In a study by D’Vazet al. [16], they studied the effect of pulsed low-intensity ultrasound therapy for chronic lateral epicondylitis. They concluded that low-intensity ultrasound (LIUS) was no more effective for a large treatment effect than placebo for recalcitrant LE. This is in keeping with other interventional studies for the condition.

Ultrasound has been used over a period of time to control acute and chronic pain over a localized area. Several studies have demonstrated the effectiveness of ultrasound in reducing pain. In study by Binder et al., where they checked for the effectiveness of ultrasound in treating soft tissue lesions, where they conclude that Ultrasound enhances recovery in most patients with lateral epicondylitis [17].

Timnoteboom et al. [18], in his study mentioned that chronic symptoms are commonly associated with inadequate muscle power and endurance. Reduction in grip strength was noted in these subjects and to overcome supervised exercises were prescribed.

This strengthening of these muscles strengthening the damaged attachment of wrist extensors resulted in better repetitive wrist movements performed by the subjects with tennis elbow [19].

It was claimed that the eccentric training results in tendon strengthening by stimulating mechanoreceptors in tenocytes to produce collagen, which is the key cellular mechanism that determines recovery from tendon injuries. Strengthening may improve collagen alignment of the tendon and stimulate cross linkage formation both of which improve the tensile strength of tendon [19].

Literatures suggest that strengthening and stretching both are main components of exercise program, because tendons must be flexible along with strong. Positive effects of exercise program for tendon injuries may be attributable to lengthening of muscle tendon unit by stretching and strengthening exercise which could achieve

loading effect within muscle tendon unit along with hypertrophy and increased tensile strength of the tendon [20].

The results of this study showed significant increase in grip strength.

PRTEE Formerly known as the Patient-Rated Forearm Evaluation Questionnaire (PRFEQ) seems to be a reliable tool for assessing pain and function in patients with chronic lateral epicondylitis. The PRTEE has shown greater reliability and has sufficient width scale to reliably detect improvement or worsening in most subjects. For these reasons, the PRTEE appears to be the one of most commonly reported measure of health status in patients with Tennis elbow [21].

In the present study the means of PRTEE were analyzed, where intra group analyses showed significant improvement.

On comparing pre and post values it showed significant improvement in terms of pain, grip strength and functional performance in subjects with tennis elbow. Therefore it can be concluded that Cyrix physiotherapy can be incorporated with conservative physiotherapy management for better results.

Limitations of the study were, subjects could not be followed up for longer period of time, to assess long term benefit, and occupation relevance was not compared.

Future Scope of the Study, studies with longer follow-up period are recommended to assess long term benefits, Conduct the study with larger sample size, Range of Motion could be taken in to consideration

ConclusionThe present study provided evidence to support the use of

Cyriax physiotherapy in relieving pain, improving grip strength and functional performance in subject with tennis elbow.

Conflict of InterestThe author’s report no conflict of interest.

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Citation: Prabhakar AJ, Kage V, Anap D (2013) Effectiveness of Cyriax Physiotherapy in Subjects with Tennis Elbow. J Nov Physiother 3: 156. doi:10.4172/2165-7025.1000156

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11. Darlene Hertling, R M Kessler Management of common musculoskeletal disorders, Lippincott Williams and Wilkins

12. Gruchow HW, Pelletier D (1979) An epidemiologic study of tennis elbow. Incidence, recurrence, and effectiveness of prevention strategies. Am J Sports Med 7: 234-238.

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16. D’Vaz AP, Ostor AJ, Speed CA, Jenner JR, Bradley M, et al. (2006) Pulsed low-intensity ultrasound therapy for chronic lateral epicondylitis: a randomized controlled trial. Rheumatology (Oxford) 45: 566-570.

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19. Manias P, Stasinopoulos D (2006) A controlled clinical pilot trial to study the effectiveness of ice as a supplement to the exercise programme for the management of lateral elbow tendinopathy. Br J Sports Med 40: 81-85.

20. Söderberg J, Grooten WJ, Ang BO (2012) Effects of eccentric training on hand strength in subjects with lateral epicondylalgia: a randomized-controlled trial. Scand J Med Sci Sports 22: 797-803.

21. Leung HB, Yen CH, Tse PY (2004) Reliability of Hong Kong Chinese version of the Patient-rated Forearm Evaluation Questionnaire for lateral epicondylitis. Hong Kong Med J 10: 172-177.

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“This course was edited and developed from the document: Physiotherapy Management of

Lateral Epicondylalgia – Bisset LM, Vicenzino B (2015), Journal of Physiotherapy 61: 174–1,

(DOI: http://dx.doi.org/10.1016/j.jphys.2015.07.015), used under the Creative Commons Attribution License.”

“This course was edited and developed from the document: Effectiveness of Cyriax Physiotherapy

In Subjects with Tennis Elbow – Prabhakar AJ, Kage V, Anap D (2013), J Nov Physiother 3: 156.

(DOI:10.4172/2165-7025.1000156), used under the Creative Commons Attribution License.”


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