Lateral Epicondylalgia How PABC Journal Club affected my clinical practice November 14, 2012 Timberly George, Sport PT
Lateral Epicondylalgia (LE) Overview What I learned from this PABC Journal Club What I ve since learned because of Journal Club EBP What does the research say? My clinical experience
Lateral Epicondylalgia (LE) Overview Definition: Pain at the lateral elbow specifically related the ECRB Prevalence: Affects 1-10% of population, 35-50 y.o, dominant arm Etiology: Insidious Overuse, overload of extensor muscle group of forearm Several pathophysiological mechanisms with no consensus on exact etiology Prognosis: Most get better in a year regardless of treatment (20% may go longer than 1 year)
What I learned from Journal Club about LE MWM & exercise, corticosteroid injection, or wait and see for TE: Randomised Trial. Bisset et al, BMJ 2006 Aim: to investigate short & long term efficacy of a PT intervention* compared with corticosteroid injections and wait & see Conclusions: PT superior to wait & see in first 6 wks & to injections after 6 wks. Short term benefit to injection is reversed after 6 wks with high recurrence rates and should be used with caution. * PT intervention MWM & exercise based on protocol outlined in Manual Therapy (2003) Vicenzino, B
Questions I had following JC Does this mean that MWM + Exercise is the best PT treatment vs. other PT treatments? What else has been studied that works or not? A/P, IMS, US, Laser, Taping/Bracing, Exercise, C/T spine manual therapy, PRP injections, SWT, Iontophoresis Was injection of corticosteroid the correct/best dosage? Are NSAIDs detrimental like Alex/Alison mentioned? And if so, what do I tell my patients who ask about them? Cochrane Review Green et al 2002 NSAIDS for treating LE in adults Why don t I just tell patients to Wait and See?
What I ve learned about research thanks to Journal Club Biases exist in most research this one had a few Rx groups not the same At baseline, the PT group had symptoms for less time than the other groups Attention bias PT group had 8 visits; injection group 1-2 visits; wait & see 1 visit Recall bias pts asked to average their pain over the week No control of additional not per protocol treatments use of NSAIDS, bracing, acupuncture
Evidence based practice for tennis elbow EBP the integration of best research evidence with clinical expertise and patient values How do we become EB practitioners? 1. Ask the question 2. Find, and then appraise the best evidence*** 3. Apply the evidence in combo with clinical expertise and patient values 4. Measure the outcomes
What I found in the literature about LE treatment No one study that tells us the best treatment Complicated by: Low quality &/or lack of # of good/high quality research studies Acute vs Chronic Exclusion/inclusion criteria Short vs Long term follow-up Interventions studied (PT vs medical interventions ) Does it help us to know if PT is better/worse than a medical intervention we can t provide (i.e CSI) or do we want to know which of our PT modalities works best? Patient populations Isolated LE vs Csp radiculopathy vs Shoulder or hand pathology
So what now? How do we treat Tennis Elbow? Wait & See!! Sort of PABC Tendinopathy Taskforce Lateral Epicondyle Tendinopathy Toolkit Coming soon!! What s your clinical experience what has worked for you?
Current research says While still no high quality research or results, some would suggest using : Manual therapy (massage, MWM, mobilizations of elbow and Csp) Trial of bracing/splinting/taping in conjunction with multimodal approach Exercise for chronic LE (combo of ecc/iso/concentric & stretching) Acupuncture - may be ok for short term pain relief? Laser may be ok for short term pain relief?
Current research says Low quality &/or lack of good evidence &/or conflicting views for: Ultrasound Electrotherapy (TENS, NMES, IFC, HVG) ESWT CSI Iontophoresis
My clinical experience Thorough assessment - subjective and objective Acute or chronic? Mechanism of injury traumatic or repetitive strain Neck and/or shoulder &/or wrist issues in past? Pattern of pain Night? Day? With activity or at rest? Swelling? Tender on palpation? Pain on grip or wrist extension? Look at posture and functional movement patterns of the whole UE including C/T spine
My clinical experience Determine functional needs for Sport? Work? ADLs? If they need to be able to reach, throw, push or pull, how do they do this? What are their movement patterns? Posture? Where are their weaknesses? Posture education static and dynamic Scapular & glenohumeral - stability & strength Tsp/Csp and scapular mobility; Csp stability Elbow MWM lateral glides see Vicenzino 2003 Wrist/forearm strength and self soft-tissue mgmt Integration back to sport/work Outcome measures NPRS & DASH
Interesting articles Green et al; 2009 Cochrane Collaboration: NSAIDS for treating lateral elbow pain in adults Hume et al; 2006 Sports Medicine: Epicondylar injury in sport Bisset et al; 2005 BJSM: A SR & MA of clinical trials on PT interventions for LE Bisset et al; 2011 Clinical Evidence: Tennis Elbow Vincenzino; 2003 Manual Therapy: LE A musculoskeletal PT perspective