FACULTY OF HEALTH, PSYCHOLOGY AND SOCIAL CARE DEPARTMENT OF PHYSIOTHERAPY M.Sc. PHYSIOTHERAPY
Orthopaedic Medicine Approach to Management of Peripheral Conditions
Literature Review
I.D: 11502029
Total word count: 2260
Total pages: 9
The Use of frictions in Tennis elbow.
Introduction:
Tennis elbow or Lateral Epicondylitis is defined as pain at or near the lateral epicondyle of the humerus where the wrist extensor muscles take origin (Trudel et al., 2004). According to Anap et al, (2012) 1-3 % of the general population is affected, but between the age of 30-60, the incidence increases to 19 %.This condition is a work related or sport related pain disorder where there is evidence of fibroblastic and vascular degeneration associated with continuous repetitive activity, particularly with rotation of the forearm and forceful gripping (Stasinopoulos and Johnson, 2012). There are microscopic and macroscopic tears in the extensor tendon particularly in the extensor carpi radialis brevis tendon (Trudel et al., 2004). This condition can be persistent from 6 months to up to 2 years; with dominant arm getting affected most commonly (Atkins et al., 2010). The symptoms consist of pain, tenderness over the lateral epicondyle, radial head, and the common extensor origin. Often the pain can radiate in the forearm, (Anap et al., 2012).
The treatment starts by evaluating the causative factor first and the primary aims of treatment are to reduce pain and restoration of muscle function (Atkins et al., 2010). The treatment techniques used by the physiotherapists for this ailment includes mainly the manipulation, electrical modalities, injections, frictions, taping, and exercise programmes (Barr et al., 2009).
The first line of treatment for tennis elbow in orthopaedic medicine is to friction at the site of lesion (Cyriax, 1993). According to Atkins et al., (2010) musculotendinous junction responds well to the transverse frictions. The technique attempts to reduce abnormal fibrous adhesions and improve scar tissue mobility by encouraging normal alignment of collagen fibres in the tendons (Atkins et al., 2010). It has been proposed that pressure helps in stimulating the low threshold mechanoreceptors A-Beta fibres which inhibits the noxious stimuli from the A-delta and C fibres by presynaptic inhibition by closing the gate on the pain (Atkins et al., 2010).
Due to varied recommendation’s presented in the evidence with respect to the treatment of tennis elbow, no ideal treatment can be considered as best. The aim of this literature review is to find the effectiveness of transverse friction in comparison with other modalities for the management of tennis elbow.
A literature Search was performed in CINAHL, MEDLINE, PEDro, ScienceDirect, and SCOPUS databases respectively. Key words in the search included lateral epicondylalgia, lateral epicondyitits, Tennis elbow, deep transverse friction (DTF), and Cyriax physiotherapy. These words were used either alone or in combination. The articles which were published in English language and which were freely available via the University library were included. Initially only randomised controlled trials (RCT) were considered since they are the gold standard in evidence based medicine (Hicks, 2005). However due to the lack of RCTs on the topic, studies using other methodologies were also taken into consideration. For this literature review, 1 randomised controlled trial, 2 randomised clinical trials and 1 clinical controlled trial were considered as they reflect the use of friction in clinical practice for tennis elbow.
Literature review
Cyriax physiotherapy incorporates the use transverse frictions and Mill’s manipulation for treatment of tennis elbow. However, we are going to highlight the use of frictions in this review.
In a randomised control trial by Smidt et al., (2009), the effectiveness of physiotherapy, corticosteroid injections were compared with a control group of patients. Computerised random allocation of 185 patients was done and they were assigned to one of the three groups. Patients assigned to the corticosteroid injection group were treated by their local Doctors for a maximum of 3 sessions during 6 weeks with local infiltration of 1 ml of triamcinoloneacetonide and 1 ml of lidocaine. Patients in the physiotherapy group were treated with ultrasound, DTF, and an exercise programme for 9 sessions for a period of 6 weeks. A control group of patients were assigned in the wait and see policy; however they were examined once during period of 6 weeks. The primary outcome measure used in the study was numerical rating scale (NRS) and a modified pain free function questionnaire. Pain free grip strength and maximum grip strength was calculated by using the Jamar hand dynamometer. Pressure Pain threshold was calculated using an algometer. Patient satisfaction using an 11 point scale was also measured. The results proved corticosteroid injection therapy to be the best among the physiotherapy and exercise group. However, long term benefits showed physiotherapy to be more effective than the injections.
According to Hicks, (2005) a randomised control trial with a larger sample size helps in eliminating the risk of being unrepresentative to the target population. In the above study, grip strength was assessed using the Jamar dynamometer, but the author failed to mention about its reliability and validity. This could have an impact on the outcome measure readings. The study has succeeded by taking a true control group to find out the effectiveness of the physiotherapy and corticosteroid injections, but the participants were not blinded from the study which could involve a risk of bias (Altman and Schulz, 2001). The design of the study which eliminates various types of bias determines the strength of the randomised trial (Altman and Schulz, 2001).
In a study by Viswas et al., (2012) a randomised clinical trial was conducted with a sample size of 20 subjects assigned into two groups. Inclusion criteria and exclusion criteria were clearly mentioned in the study. Group A received a supervised exercise programme of passive stretching followed by eccentric strengthening of the extensors and Group B received Cyriax physiotherapy which consisted of DTF followed by Mill’s manipulation once every session. Patients were seen 3 times a week for 4 weeks for a total of 12 treatment sessions. Outcome measures used in the study were the Visual Analogue Scale (VAS) and functional status was assessed by using Tennis elbow functional status (TEFS). Both the groups showed a significant reduction in the outcome measure scores at the end of the programme; however, inter group analysis showed that the supervised exercise programme showed better results than the Cyriax physiotherapy group.
Despite the study randomly allocated the subjects, concealed allocation was absent which could affect the internal validity of the study (Altman and Schulz, 2001). In addition, the sample size was small to be able to generalize the conclusions to the targeted population and hence external validity of the study could be questioned (Elridge et al., 2008). This might lead the researcher to make invalid assumptions about that population (Hicks, 2005). The study did not keep a follow up on the long term effects of the intervention on the subjects. Since there was no treatment group included in the trial, it is difficult to define the active element from the above intervention (Greenhalgh, 2010).
In a more clinical oriented study by Nagrale et al., (2007) a comparison between Cyriax physiotherapy and Mill’s manipulation versus phonophoresis and a supervised exercise programme for the treatment of Tennis elbow was conducted. Patients with teno osseous variety of tennis elbow of at least one month’s duration and between 30-60 years of age were divided into two groups. Group A received the treatment of phonophoresis followed by a supervised exercise programme which mainly included strengthening and stretching exercise. Group B were given deep transverse frictions for 10 minutes followed by Mill’s manipulation. All the patients were treated for a total of 3 times in a week for 4 weeks. Outcome measures used were the VAS scale, pain free grip strength and TEFS. The results showed that both the groups showed significant improvement with respect to their outcome measures, however between group analyses showed that the patients which were treated with Cyriax principled physiotherapy had significantly better outcome scores at all follow-up periods compared to those receiving phonophoresis, strengthening and static stretching exercises.
Although the study showed good reliability by taking a sufficient number of subjects, concealed allocation was absent which could affect internal validity of the study (Elridge et al., 2008). In this study the therapist and the subjects were not blinded which is a potential risk for bias in the study (Hicks, 2005). The bias would be in terms of expectations of the therapist which could affect the internal validity of the study (Elridge et al., 2008). The studies with poor internal validity could lead to inaccurate results and have a less impact on the target population (Grimes and Schulz, 2002). The study however, showed an intention to treat analysis and also had a long term follow up with the sample. According to Cyriax (1993), the four possible sites of lesion in tennis elbow are the teno osseous junction, supracondylar ridge, body of the tendon and the muscle bellies. However, the conclusions of this study can only be applied to the teno osseous type of tennis elbow.
In another study by Stasinopoulous and Stasinopoulos, (2009), a clinical controlled trial was conducted which compared the effectiveness of Cyriax physiotherapy, a supervised exercise programme and polychromatic non-coherent light (Bioptron light). A total of 75 subjects were included in the study and the subjects were sequentially allocated to three different intervention (Group A, B and C respectively). Group A patients were treated with a supervised exercise programme which was slow progressive eccentric exercises and static stretching with a set amount of 10 repetitions for 3 times each. Patients in Group B received treatment which included DTF followed by a single intervention of Mill’s manipulation. Group C were treated with a polychromatic non-coherent light at three sites for 6 min each covering an area of 18 mm. Pain was measured using a VAS and pain along with the grip strength using a dynamometer was used to measure the functional status of the patient. The results showed that the supervised exercise programme resulted in better outcomes after 4, 8, 16 and 28 weeks than Cyariax Physiotherapy and polychromatic non-coherent light. There was no significant difference found in the outcomes at the end of 4, 8, 16 and 28 weeks between the patients subjected to Cyriax physiotherapy and polychromatic non-coherent light.
Although the long term effects of the three groups were conducted in the study, it lacked random and concealed allocation which affects the internal validity of the study (Young and Solomon, 2009, Greenhalgh, 2010). Randomisation of patient in a study makes the characteristics of the patients same on average and helps to reduce the imbalance in a particular trial (Altman and Schulz, 2001). The number of treatment session given to the patient was according to the description of pain the patient experienced. Hence, it lacked in standardisation which could lead to bias. The study came up with the conclusion that supervised exercise programme was more beneficial in comparison to the Cyriax physiotherapy and polychromatic light; however, exercise which caused the actual reduction in patient symptoms remains a question. The therapists were not blinded to the study, which could lead to selection bias (Greenhalgh, 2010).
Discussion:
Orthopedic medicine advocates the use of DTF and Mill’s manipulation as the line of treatment for tennis elbow (Atkins et al., 2010). DTF helps in modulating the pain impulses at the spinal cord level using the pain gate control theory (Nagrale et al., 2009). The only study which proved that DTF when used in isolation is more effective compared to phonophoresis was done by Stratford et al., (1989), however the study lacked appropriate statistical calculations and hence its reliability could be questioned. In the current literature review, Viswas et al., (2012) and Stasinopoulos and Stasinopoulos, (2009) proved that supervised exercise programme is more beneficial than the Cyriax physiotherapy; in contrast to that, Nagrale et al., (2009) proved Cyriax physiotherapy to be more effective than the supervised exercise programme and phonophoresis. The evidence shows that deep transverse friction was effective when used with a supervised exercise programme, ultrasound or Mill’s manipulation; however there are no recent studies which compare the efficacy of deep transverse frictions alone for the treatment.
In orthopaedic medicine, deep transverse frictions are used in chronic conditions by causing traumatic hyperaemia and superficial transverse frictions are used in acute lesions for the purpose of aligning of the disrupted collagen fibres (Atkins et al., 2010). In all the studies reviewed, the patients with acute or chronic lateral epicondyltits were included, but they were treated with deep transverse friction, which could be the reason that the authors did not find any pain relief. The studies conducted by Viswas et al., (2012), Satsinopoulos and Stasinopoulos, (2006) and Nagrale et al., (2009), lacked a true control group, in contrast to the study done by Smidt et al., (2002) where a control group was taken, but the study had its own shortcomings. Thus the treatment which caused actual benefit to the patient symptoms remains a question.
Conclusion:
The findings of this review suggest that transverse frictions alone are not the best treatment option for patients with lateral epicondylitis. The difference in the outcome measure was evident and clinically relevant only when it was used as an adjunct with other forms of treatment modalities.
There is evidence of vast research in the conservative treatment for lateral epicondylitis, however there have been no high quality studies to summarize the evidence on this topic. Further research is warranted with larger follow up periods as well as inclusion of friction alone with a control group. The author recommends using friction as a part of a multimodal treatment regimen. Due to the lack of evidence for the use of frictions alone, clinicians are expected to progress with a treatment plan based on their judgements and clinical experiences.
References
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