The effect of lateral epicondylosis on upper limb mechanical parameters

Effects of the Tyler Twist Technique Versus Active Release Technique on Pain and Grip Strength in Patients With Lateral Epicondylitis

Background Lateral epicondylitis is one of the most prevalent repetitive strain injuries or overuse injuries of the upper limb. Lateral epicondylitis also known as tennis elbow can be caused by repeated wrist and forearm movements. Treatment strategies have evolved significantly to treat tennis elbow, ranging from simple exercises to the use of various electrotherapy modalities. Soft-tissue release treatments such as myofascial release and active release techniques (ARTs) have also been tested. Better therapeutic approaches for chronic lateral epicondylitis remained a point of contention until recently when additional therapy alternatives became available. The purpose of this study was to investigate and assess the physiotherapy alternatives for lateral epicondylitis. Methods We did a comparative study between the Tyler twist technique and the ART in patients suffering from lateral epicondylitis. This study included 30 individuals based on inclusion and exclusion criteria. Group A patients were taught the Tyler twist technique exercise along with conventional therapy. Patients in group B were treated with ART and conventional therapy. The treatment session lasted for 30 minutes including appropriate breaks in between the session. Outcome measures for this study were a numerical pain rating scale (NPRS) and grip strength measurement by a handheld dynamometer. The unit of measurement of grip strength was kilograms (Kg). Descriptive and inferential statistics were used in the statistical analysis. Results A total of 30 subjects with lateral epicondylitis were included. Participants were randomly distributed into two groups, that is, 15 in each group. Group A was the Tyler twist technique group and group B was the ART group. The treatment was given in four sessions each week for three weeks. The pain reduced from 5.8 to 2 after the Tyler twist technique in group A and 5.53 to 3.46 after the ART in group B. On comparative analysis, the post-treatment mean grip strength of the Tyler twist technique group was 24.13 kg and that of the ART group was 21.33 kg. The p-value was statistically significant with a value of 0.0001. The Tyler twist technique was more effective in improving the grip strength than ART. Conclusion The Tyler twist technique was found to be a more effective therapeutic intervention for lateral epicondylitis as a significant decrease in pain on the NPRS and an increase in grip strength on a handheld dynamometer were observed.

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lateral epicondylitis of the humerus - Secondary publication

BACKGROUND

The guidelines presented herein provide recommendations for the management of patients with lateral epicondylitis of the humerus. These recommendations are endorsed by the Japanese Orthopaedic Association (JOA) and Japan Elbow Society.

METHODS

The JOA lateral epicondylitis guideline committee revised the previous guidelines on the basis of the "Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014", which emphasized the importance of the balance between benefit and harm, and proposed a desirable method for preparing clinical guidelines in Japan. These guidelines consist of 11 clinical questions (CQs), 9 background questions (BQs), and 3 future research questions (FRQs). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design.

RESULTS

The committee proposed recommendations for each CQ by determining the level of evidence and assessing the consensus rate. Physical therapy was the best recommendation with the best evidence. The BQs and FRQs were answered by collecting evidence based on the literature.

CONCLUSIONS

The guidelines presented herein were reviewed systematically, and recommendations were proposed for each CQ. These guidelines are expected to be widely used not only by surgeons or physicians but also by other healthcare providers, such as nurses, therapists, and athletic trainers.

Reorganized Force Control in Elbow Pain Patients During Isometric Wrist Extension

INTRODUCTION

Reorganized force control may be an important adaptation following painful traumas. In this study, force control adaptations were assessed in elbow pain patients. Increasing the contraction demand may overcome pain interference on the motor control and as such act as an internal control. It was hypothesized that elbow pain patients compared with controls would present greater change in the direction of force when increasing the demand of the motor task.

METHODS

Elbow pain patients (n=19) and asymptomatic participants (n=21) performed isometric wrist extensions at 5% to 70% of maximum voluntary contraction. Pressure pain thresholds were recorded at the lateral epicondyle and tibialis anterior muscle. Contraction force was recorded using a 3-directional force transducer. Participants performed contractions according to visual feedback of the task-related force intensity (main direction of wrist extension) and another set of contractions with feedback of the 3 force directions. Going from the simple to the detailed force feedback will increase the demand of the motor task. Force steadiness in all 3 dimensions and force directions were extracted.

RESULTS

Compared with controls, elbow pain patients presented lower pressure pain thresholds at both sites (P<0.05). Force steadiness was not significantly different between groups or feedback methods. The change in force direction when providing simple visual feedback in contrast with feedback of all force components at all contraction levels was greater for patients compared with controls (P<0.05).

CONCLUSION

The larger change in force direction in pain patients implies redistribution of loads across the arm as an associated effect of pain.

Chronic hyperglycemia increases the risk of lateral epicondylitis: the Locomotive Syndrome and Health Outcome in Aizu Cohort Study (LOHAS)

Background

Although humeral epicondylitis is a common health problem, there have been no reports that describe its prevalence in Japanese general population, and relatively little is known about its etiology and associated risk factors.

Questions/purposes

This study aimed to clarify the prevalence of humeral epicondilitis in Japanese general population, and investigate the associated risk factors using the data from a cross-sectional study of the Locomotive Syndrome and Health Outcome in Aizu Cohort Study (LOHAS).

Methods

A total of 1,777 participants who participated in health checkups conducted at rural area in Japan in 2010 were enrolled. The prevalence of lateral and medial epicondylitis was investigated. Logistic regression models were performed to examine the relationship between lateral epicondylitis and correlated factors such as occupational status, smoking and alcohol preferences, and medical characteristics.

Results

The overall prevalence of lateral and medial epicondylitis was 2.5 % and 0.3 %, respectively. A shortened version of the disabilities of the arm, shoulder and hand (The QuickDASH) score was significantly higher in subjects with lateral epicondylitis than in those without (15.0 ± 12.7 vs 8.5 ± 11.1). Subjects with definite chronic hyperglycemia (HbA1c ≥ 6.5) showed a 3.37-times higher risk of lateral epicondylitis than those with favorable glycemic control (HbA1c < 5.5) (95 % confidence interval (CI) 1.16–8.56). Age and sex, as well as occupational status, smoking and alcohol preference, and other metabolic factors were not significantly related to higher risk of lateral epicondylitis.

Conclusions

Lateral epicondylitis influences activities of daily living. Chronic hyperglycemia might be one of the risk factor for lateral epicondylitis.

Clinical relevance

Chronic hyperglycemia is significantly associated with lateral epicondylitis.

Influence of volar and dorsal static orthoses in different wrist positions on muscle activation and grip strength in healthy subjects

Introduction

Orthoses are indicated for injuries of the wrist, although there is weak evidence for its influence on extensor muscle activation patterns. The purpose of this study was to compare two designs of volar and dorsal wrist orthoses in several positions, from flexion to extension, by surface electromyography wrist extensor muscle activation and grip strength in healthy subjects.

Methods

We analysed extensor carpi radialis brevis and longus, extensor carpi ulnaris and extensor digitorum comunis muscle activity by surface electromyography. The volunteers performed maximum and submaximum (50%) isometric grips, which were evaluated with a Jamar™ dynamometer using volar and dorsal orthoses with several positions of the wrist (0°, 15° and 30°), both in flexion and extension ( p < 0.05).

Results

Our results showed a significant decrease in extensor muscle activation at 15° and 30° of wrist extension in both volar and dorsal orthoses at 100% and 50% of maximum task. A decrease was also found at rest at 15° of wrist flexion volar orthoses. Decreased grip strength was found at 15° and 30° of wrist flexion in both volar and dorsal orthoses.

Conclusions

Based on the results of this sample, we would suggest, as orthotic prescriptions, 15° or 30° wrist extension orthoses as a supporting therapeutic modality for performance in new studies with lateral epicondylitis in association with low-intensity grip activity; or 15° of wrist flexion volar orthoses for rest, depending on the chronicity of the disease and individual assessment. Future studies with symptomatic patients are needed to confirm these findings.

Relationships between biomechanics, tendon pathology, and function in individuals with lateral epicondylosis

STUDY DESIGN

Single-cohort descriptive and correlational study.

OBJECTIVES

To investigate the relationships between tendon pathology, biomechanical measures, and self-reported pain and function in individuals with chronic lateral epicondylosis.

BACKGROUND

Lateral epicondylosis has a multifactorial etiology and its pathophysiology is not well understood. Consequently, treatment remains challenging, and lateral epicondylosis is prone to recurrence. While tendon pathology, pain system changes, and motor impairments due to lateral epicondylosis are considered related, their relationships have not been thoroughly investigated.

METHODS

Twenty-six participants with either unilateral (n = 11) or bilateral (n = 15) chronic lateral epicondylosis participated in this study. Biomechanical measures (grip strength, rate of force development, and electromechanical delay) and measures of tendon pathology (magnetic resonance imaging and ultrasound) and self-reported pain and function (Patient-Rated Tennis Elbow Evaluation) were performed. Partial Spearman correlations, adjusting for covariates (age, gender, weight, and height), were used to evaluate the relationship between self-reported pain, function, and biomechanical and tendon pathology measures.

RESULTS

Statistically significant correlations between biomechanical measures and the Patient-Rated Tennis Elbow Evaluation ranged in magnitude from 0.44 to 0.68 (P<.05); however, no significant correlation was observed between tendon pathology (magnetic resonance imaging and ultrasound) measures and the Patient-Rated Tennis Elbow Evaluation (r = -0.02 to 0.31, P>.05). Rate of force development had a stronger correlation (r = 0.54-0.68, P<.05) with self-reported function score than with grip strength (r = 0.35-0.47, P<.05) or electromechanical delay (r = 0.5, P<.05).

CONCLUSION

Biomechanical measures (pain-free grip strength, rate of force development, electromechanical delay) have the potential to be used as outcome measures to monitor progress in lateral epicondylosis. In comparison, the imaging measures (magnetic resonance imaging and ultrasound) were useful for visualizing the pathophysiology of lateral epicondylosis. However, the severity of the pathophysiology was not related to pain and function, indicating that imaging measures may not provide the best clinical assessment.

Effect of lateral epicondylosis on grip force development

STUDY DESIGN

Case-Control.

INTRODUCTION

Although it is well known that grip strength is adversely affected by lateral epicondylosis (LE), the effect of LE on rapid grip force generation is unclear.

PURPOSE OF THE STUDY

To evaluate the effect of LE on the ability to rapidly generate grip force.

METHODS

Twenty-eight participants with LE (13 unilateral and 15 bilateral LE) and 13 healthy controls participated in this study. A multiaxis profile dynamometer was used to evaluate grip strength and rapid grip force generation. The ability to rapidly produce force is composed of the electromechanical delay and rate of force development. Electromechanical delay is defined as the time between the onset of electrical activity and the onset of muscle force production. The Patient-rated Tennis Elbow Evaluation (PRTEE) questionnaire was used to assess pain and functional disability. Magnetic resonance imaging was used to evaluate tendon degeneration.

RESULTS

LE-injured upper extremities had lower rate of force development (50 lb/sec, confidence interval [CI]: 17, 84) and less grip strength (7.8 lb, CI: 3.3, 12.4) than nonnjured extremities. Participants in the LE group had a longer electromechanical delay (- 59% , CI: 29, 97) than controls. Peak rate of force development had a higher correlation (r = 0.56; p<0.05) with PRTEE function than grip strength (r = 0.47; p<0.05) and electromechanical delay (r = 0.30; p>0.05) for participants with LE. In addition to a reduction in grip strength, those with LE had a reduction in rate of force development and an increase in electromechanical delay.

CONCLUSIONS

Collectively, these changes may contribute to an increase in reaction time, which may affect risk for recurrent symptoms. These findings suggest that therapists may need to address both strength and rapid force development deficits in patients with LE.

LEVEL OF EVIDENCE

3B.