Comparative Study of Conventional Tens Versus Phonophoresis Along With Exercises in Lateral Epicondylitis

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1 Index Copernicus Value Volume 5 Issue 07 July-2017 Pages ISSN(e): Website: DOI: Comparative Study of Conventional Tens Versus Phonophoresis Along With Exercises in Lateral Epicondylitis Authors Tushar J. Palekar 1, Monica N. Dhanani 2*, Ajay Malshikhare 3, Shilpa Khandare 4 1 Principal and Professor, Dr.D.Y.Patil College of Physiotherapy, Dr.D. Y. Patil Vidyapeeth, Pune, India. 2* PG Resident, Dr. D. Y. Patil College of Physiotherapy, Dr.D.Y.Patil Vidyapeeth, Pune, India. 3Assistant Professor,Dr.D.Y. Patil College of Physiotherapy, Dr.D.Y.Patil Vidyapeeth, Pune, India. 4 Professor, Dr.D.Y. Patil College of Physiotherapy, Dr.D.Y.Patil Vidyapeeth, Pune, India. Corresponding author Monica N. Dhanani 2 Id- 1,2,3,4 Principal.Physio@dpu.edu.in, monicadhanani92@gmail.com, ajaymalu29@gmail.com, Shil287@yahoo.in ABSTRACT: The estimated annual incidence in the general population is 1-3% among them most patients are between the ages 30 and 55 years. In clinical practice the condition is found more often in non-athelets than atheletes; probably less than 5% of patients with epicondylitis are golf or tennis players.there is scant data available regarding the relative efficacy of TENS, Phonophoresis and Exercises in the management of Lateral Epicondylitis. So this study was design to compare the effectiveness of TENS versus Phonophoresis along with Exercises in Lateral Epicondylitis.60 subjects were selected according to inclusion criteria and VAS, ROM and Grip Strength were measured on Day1 pre-treatment, Day6 and Day12 post-treatment. Patients were divided randomly into two groups by simple random sampling. Group A received Phonophoresis and exercises & Group B received Conventional TENS and exercises. Exercises included static stretching and eccentric strengthening. Each group was treated 6days a week for 2weeks.Results of this study showed significant improvement in Group A when compared to Group B with significant p value< Keywords: Lateral epicondylitis, Phonophoresis, Conventional TENS, Grip Strength. INTRODUCTION: Lateral epicondylitis, also known as tennis elbow, is a condition in which the outer part of the elbow that attaches the Extensor Carpi Radialis Brevis (ECRB) sore and tender 1.In addition, the anterior edge of the origin of the Extensor Digitorum Communis is involved in 30% of cases and rarely, the underside of the Extensor Carpi Radialis Longus or the origin of the Extensor carpi ulnaris is involved. Dr R. Nirschl and Pettrone was the first to describe this condition as a degenerative more than inflammatory process involving primarily the Extensor Carpi Radialis Brevis. Cyriax stated that the Extensor Carpi Radialis Brevis is involved at the tenoperiosteal insertion at the humeral lateral epicondyle at the body of the tendon or at the muscle belly 2. Tushar J. Palekar et al IJSRE Volume 05 Issue 07 July 2017 Page 6711

2 Patients initially complain of activity-related lateral elbow pain, often a dull, aching, lateral pain, and may show weakness of grip strength. Symptoms can progress to pain at rest in the more severe stages and difficulty holding a cup, lifting a milk carton, or opening a door. On examination patients have tenderness approximately 1 to 2 cm distal to the lateral epicondyle. Patient may experience pain with passive wrist flexion, resisted active wrist extension, and during grasping or lifting 3. Usually, flexion and extension of the elbow are complete, but in some cases of chronic tennis elbow, the patient lacks 50 to 150 of wrist extension 4. Lateral epicondylitis can be confirmed by performing following 3 tests- 1) Cozen s test The patient is asked to make the fist, pronate the forearm, radially deviate and extend the wrist while the examiner resists the motion. 2) Mill s test The examiner passively pronates the forearm, flexes the wrist fully and extends the elbow. 3) The examiner resists the extension of the third digit of the hand proximal to the interphalangeal joint, stressing the extensor digitorum muscle and tendon All the above tests are positive if the patient experiences pain at the lateral epicondyle of the humerus. The primary goals of the treatment of tendinosis are the control of pain; the preservation of motion, flexibility, and strength; and the development of endurance over time. Excessive internal strain to the tendon is to be minimized during stressful activities. It can be achieved by optimizing tissue extensibility. No vigorous activities are allowed until the muscle-tendon complex has sufficient extensibility. Gentle and slow stretches to the tissue by holding the elbow extended, the forearm pronated, and the wrist ulnarly deviated, while flexing the wrist and fingers 5. TENS is an inexpensive, non-invasive, non-pharmacological form of analgesia that is commonly used in the treatment of pain 6.It reduces pain through stimulation of afferent peripheral nerves and the subsequent activation of the pain gate mechanism within the spinal cord and the descending pain inhibitory mechanisms including endogenous opiates in the spinal cord and brain stem 7. Phonophoresis is the movement of drugs through skin into the subcutaneous tissues under the influence of ultrasound. Many drugs are absorbed through the skin very slowly; high frequency sonic vibration may accelerate this process 8. Topical 2% diclofenac in pleuronic lecithin liposomal organo-gel appears to provide effective short-term reduction in elbow pain and wrist extensor weakness associated with chronic lateral epicondylitis 9. Thus, phonophoresis offers the potential advantage of delivering a pharmacologic agent in a relatively safe, pain less, and easy manner to structures that lie somewhat deep within the body 10. Eccentric strengthening loads the musculotendinous unit to induce hypertrophy and increased tensile strength, reducing the strain on the tendon during movement 11. Wrist extensor strengthening exercises are always necessary, since the muscles invariably undergo atrophy from disuse and reflex inhibition. Good extensor strength is necessary to protect the tendon from high strainrate passive loading, which may occur with many types of activities. Maximum strengthening of the muscles must necessarily include eccentric exercise 5. MATERIALS AND METHODS : Patients satisfying inclusion and exclusion criteria were included in the study.patients were divided randomly into two groups- Group A & Group B by simple random sampling. Each group contained 30 participants. Group A received Phonophoresis with exercises and Group B received Conventional TENS with exercises. In both the groups total session was between 25-30mins, 6 days a week for 2 weeks. Each patient was evaluated by VAS, Goniometer and Baseline Hand Dynamometer on Day 1 pre-treatment, Day 6 during the treatment and Day 12th post-treatment. Tushar J. Palekar et al IJSRE Volume 05 Issue 07 July 2017 Page 6712

3 DOSAGE(Ultrasound): FREQUENCY : 3 MHz MODE : Pulse Mode INTENSITY : 0.75/1W/cm 2 DURATION : 7mins TREATMENT PROTOCOL : 6 days weekly for 2 weeks DOSAGE(TENS): FREQUENCY : Hz MODE : Conventional INTENSITY : maximum tolerable intensity by the patient DURATION : 10mins TREATMENT PROTOCOL : 6 days weekly for 2 weeks Inclusion criteria: 1)Patients having Lateral elbow pain with the age group from years incliuding both gender, also having Tenderness over lateral aspect of elbow and Patients having positive Cozens/Mills test. Exclusion criteria: Recent trauma to the affected upper limb,rheumatoid arthritis,recent surgery at elbow joint,any structural abnormality of elbow,any Fracture in Upper limb. Table 1 Shows Age distribution of patients studied in Group A and B AGE (YEARS) GROUP A GROUP B NO % NO % TOTAL Table 2 Shows Gender distribution of patients studied in Group A and B GENDER GROUP A GROUP B NO % NO % Male Female TOTAL Table 3 Shows comparision of grip strength among 2 groups mean and sd of group a & b taken pre, day6 & day12 PRE_GRIP STRENGTH GROUP MEAN SD A B Total A DAY6_GRIP STRENGTH B Total A DAY12_GRIP STRENGTH B Total There was a difference in grip strength of group a & group b on day6 &day12 After applying repeated measure anova To compare grip strength among & between the groups Tushar J. Palekar et al IJSRE Volume 05 Issue 07 July 2017 Page 6713

4 EFFECT Factor1 factor1 * Group VALUE F HYPOTHESIS df ERROR df P value Partial Eta Squared b < b < Table 4 shows comparision of rom among 2 groups mean and sd of group a & b pre, day6 & day12 GROUP MEAN SD PRE_ROM Total DAY6_ROM DAY 12_ROM Total Total There Was Slight Difference in Rom of Group A & Group B After applying repeated measure ANOVA To compare rom among & between the groups EFFECT VALUE F HYPOTHESIS df ERROR df P value Partial Eta Squared Factor b < factor1 * Group b Table 5 Shows comparision of vas among 2 groups mean and sd of group a & b taken pre, day6 & day1 GROUP MEAN SD PRE_VAS DAY6_VAS POST_VAS Total Total Total Tushar J. Palekar et al IJSRE Volume 05 Issue 07 July 2017 Page 6714

5 There Was A Difference In Vas Of Group1 & Group2 On Dady 6 &Day 12 After Applying Repeated Measure ANOVA To Compare Vas Among & Between The Groups EFFECT Factor1 factor1 * Group VALUE F HYPOTHESIS df ERROR df P value Partial Eta Squared b < b < RESULT: Table 1 show the distribution of age in both the groups In Group A out of 30 subjects, 20 were aged between years and 10 were aged between years whereas in Group B, there were 19 subjects aged between years and 11 aged between years. Hence Group A had 67 % subjects aged between years and 33% between years whereas Group B had 63% between years and 37% between years. Table 2 show the distribution of gender in both the groups. In group A out of 30 subjects, there were 11 males and 19 females whereas in Group B there were 13 males and 17 females. Hence Group A had 37% males and 63% females whereas Group B had 43% males and 57% females. Table 3 represents the mean and standard deviation of Pre, Day 6 and Day 12 values of Grip Strength for the groups A and B. Along with the difference in pre, day6 and day12 treatment values and percent improvement with the statistically significant p value of In Group A and Group B, Mean value of Grip Strength increased from on Day 6 to on Day12.Hence statistically and graphically significant difference is seen between pre treatment, Day 6 and Day12 post treatment. Table 4 represents the mean and standard deviation of Pre, Day 6 and Day 12 values of Range of Motion (ROM) for the groups A and B. Along with the difference in pre, day6 and day12 treatment values and percent improvement with the statistically significant p value of In Group A and Group B, there was slight difference in Mean value of ROM i.e, pre treatment, Day6 and Day12.Hence statistically and graphically slight difference is seen between pre treatment, Day 6 and Day12 post treatment. Table 5 represents the mean and standard deviation of Pre, Day 6 and Day 12 values of Grip Strength for the groups A and B. Along with the difference in pre, day6 and day12 treatment values and percent improvement with the statistically significant p value of In Group A and Group B, Mean value of VAS Decreased from 5.90 pre treatment, 3.83 on Day 6 to 2.13 on Day12.Hence statistically and graphically significant difference is seen between pre treatment, Day 6 and Day12 post treatment. DISCUSSION: The results in the current study showed significant improvement in pain and Grip strength on Day 6 and Day 12 in group A (Phonophoresis along with Exercises) as compared to group B (Conventional TENS and Exercises) with differences in ROM and VAS values in both the groups. Mean value of Grip Strength increased from on Day 6 to on Day12 in both the groups. Hence, statistically and graphically significant difference was seen on Day 6 and Day12 post treatment with P value < There was slight difference in Mean value of ROM i.e., from pre-treatment value of to on Day 6 and on Day 12 in both the groups. Hence statistically and graphically slight difference was seen on Day 6 and Day 12 post- treatment. Tushar J. Palekar et al IJSRE Volume 05 Issue 07 July 2017 Page 6715

6 Mean value of VAS Decreased from pre treatment value of 5.90 to 3.83 on Day 6 and 2.13 on Day 12 in both the groups. Hence statistically and graphically significant difference was seen on Day 6 and Day 12 post-treatment. After applying REPEATED MEASURE ANOVA comparison was done among and between the groups for Grip strength, ROM AND VAS which showed significant P value < In this study, there was statistically significant improvement in pain measured by the VAS, ROM and pain free grip strength in group A receiving phonophoresis therapy. Therefore, present study provides information which may be useful when considering the use of sodium diclofenac preparation as couplant during ultrasound treatment of soft tissue injuries and musculoskeletal conditions. Similar studies have been conducted by Mohamed Faisal C.K. et al. (2013) 12 who compared the Effectiveness of Low Level Laser Therapy versus Phonophoresis in Management of Lateral Epicondylitis. Participants were allocated to Laser therapy group which received 904nm Semi conductor Gallium Arsenide Laser thrice weekly for total 8 treatment sessions and to Phonophoresis group which received the treatment through a transducer with coupling agent 1% sodium Diclofenac with frequency of 1MHz for 7 minutes, three times weekly for 8 treatment sessions. The study concluded that phonophoresis as well as low level laser therapy gives good result in the management of lateral epicondylitis. Topical diclofenac appears to provide effective short-term reduction in elbow pain and wrist extensor weakness associated with chronic lateral epicondylitis. The outermost layer of the epidermis or the stratum corneum is recognized as the primary barrier to the transdermal penetration of medications and physical agents. Therapeutic ultrasound irradiation enhances the percutaneous penetration of topical Diclofenac gel. This was the study done by Burnham R et al. Similarly, in our study we used sodium Diclofenac as the coupling medium in the patients who were treated with phonophoresis and the study showed significant improvement in pain and grip strength. Therefore, the use of a sodium diclofenac as coupling medium in the treatment of tennis elbow is an attractive concept. TENS is commonly used in the treatment of pain. It reduces pain through stimulation of afferent peripheral nerves and the subsequent activation of the pain gate mechanism within the spinal cord and the descending pain inhibitory mechanisms including endogenous opiates in the spinal cord and brain stem. In the current study, Group B received Conventional TENS and exercises which showed comparatively less improvement in pain and grip strength as compared to Group A (Phonophoresis and exercises). A study was conducted by Linda S Chesterton et al. (2013) 3 with TENS as adjunct to primary care management for tennis elbow. Participants were randomly allocated to primary care management alone or primary care management plus TENS to be used once a day for 45 mins over six weeks for pain relief. Both intervention groups showed large improvements in pain and secondary outcomes. The study concluded that this trial does not provide evidence for additional benefit of TENS as an adjunct to primary care management of tennis elbow. Hence, TENS reduces pain in patients with tennis elbow but is not that effective as compared to Phonophoresis. Strain in Extensor Carpi Radialis Brevis tendon was reduced by static stretching and eccentric strengthening exercises which showed improvement in tissue extensibility and tensile strength. In this study, there was significant improvement in group A (phonophoresis with exercises). Similarly, a study was conducted by Svernlov and Adolfsson(2001) 13 in which participants with stretching group and eccentric strengthening group achieved reductions in pain. Participants were randomized to a stretching group, a stretching + eccentric strengthening group, or a stretching + concentric exercise group. Study concluded that all 3 groups improved over time with no statistical differences among them. Hence, it is seen that exercises can be given as an adjuvant to the management of tennis elbow. Hence, hypothetically it is proved that Phonophoresis with exercises is more effective than conventional TENS with exercises in treatment of lateral epicondylitis which proves Alternative Hypothesis (H2). Tushar J. Palekar et al IJSRE Volume 05 Issue 07 July 2017 Page 6716

7 Hence, it is seen that Phonophoresis along with exercises helps in reducing pain and improving range of motion and grip strength as ultrasound is used to drive Diclofenac sodium through the skin and into underlying tissues which causes increased tissue temperature and hydration, acoustic streaming, radiation pressure wave, increasing the drug's kinetic energy, and altering membrane potential along with pain relieving effect of the drug. CONCLUSION: The above study concluded that Phonophoresis along with exercises is effective in reducing pain, Improving ROM and Grip strength as compared to Conventional TENS along with exercises. REFERENCES: 1. Soyoung Lee, YoungjunKo, Wanhee Lee. Changes in pain, dysfunction & grip strength of patients with acute lateral epicondylitis caused by frequency of physical therapy, Journal of Physical Therapy Science, 2014,7: Warren I. Hammer, The elbow and forearm; Functional soft tissue examination and treatment by Manual Methods The Extremities. 3. Alan J. Thurston The Early history of Tennis Elbow : 1873 to the 1950s Aust. N.Z. J. Surg. (1998) 68, Leonardo Viola. A Critical Review of the current conservative therapies for Tennis elbow (Lateral Epicondylitis). ACOJuly1998 Vol 7; Number 2 5. Darlene Hurtling and Randolph M. Kessler. The elbow and forearm. Management of Common Musculoskeletal Disorders, Physical Therapy Principles and Methods by Darlene Hertling and Randolph M. Kessler. 3rd edition 6. Linda S Chesterton, Danielle A van der Windt, Julius Sim, Martyn Lewis, Christian D Mallen, Elizabeth E Mason, Catherine Warlow, KanchanVohora, and Elaine M Hay, TENS for management of Tennis Elbow,BMC,2009,10: Linda S Chesterton, A Martyn Lewis, Julius Sim,Christian D Mallen, Elizabeth E Mason, Elaine M Hay, A van der Windt, TENS as adunct to primary care management foe Tennis Elbow BMJ. 2013, 347:F Burnham R, Gregg R Healy P, Steaword. The Effectiveness of topical Diclofenac for lateral epicondylitis. Clinical Journal of Sports Medicine, 1998,8(2): Kleinkon JA, Wood F. Phonophoresis with one percent versus 10 percent hydrocortisone. Phys Ther,1975, 55: Ciccone CD, Leggin BG, Callamum JJ Effects of ultrasound and tmlamine salicylate phonophorea on delayed-onset muscle soreness, PhysTher., 1991; 71: Leanne Bisset, Elaine Beller, et al, Mobilization with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomized trial. BMJ, doi: /bmj ae (published 29 September 2006). 12. William E Garrett Jr, Kevin P.Speer and Donald T.kirkendall.Principles and practice of Orthopaedic Sports Medicine.Philadelphia:Lippincott WilliamsP Wilkins; Svernlöv B et al. Non-operative treatment regime including eccentric training for lateral humeral epicondylalgia. Scand J Med Sci Sports Dec;11(6): Tushar J. Palekar et al IJSRE Volume 05 Issue 07 July 2017 Page 6717