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A Pragmatic Evidence Informed Approach to Chronic Lateral
Elbow Tendinopathy with Lessons for Other Sites
Bill Vicenzino
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What is Tennis Elbow? Clinical presentation
Slater et al Pain (2005) 114: 118-30
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What is Tennis Elbow?
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Epidemiology of Tennis Elbow? Sex and age bias?
5-7 1st episode / 1000 patients in
GMP (Verhaar 1992)
3-15% prevalence rates (Allander
1974, Ranney et al 1995, Chiang et al 1993)
12 weeks absenteeism for 10-30%
of sufferers
5-10% undergo surgery Nirschl 1979; Baker 2000
High baseline pain & concurrent neck and shoulder pain is a indicator of poorer long-term outcome Smidt 2006; Lewis 2002; Haahr 2003; Solheim
Prone to recurrence
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Differential Causes of Lateral Elbow Pain Common Causes:
• Extensor tendinosis
• Referred pain
Less Common: • RH synovitis / bursitis
• Posterior Interoseous Nerve
Not to be missed: • Osteochondritis dissecans
ocapitellum / radius Clinical Sports
Medicine
BRUKNERBAHRBLAIRCOOK
CROSSLEYMcCONNELLMcCRORYNOAKESKHAN
F O U R T H E D I T I O N
Brukner & Khan’s
http://www.optp.com/
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Hush JM & Alison JA (2011) EBP: lost in translation? J Physiotherapy 57 (3)143-4
The 3 components of EBP
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Short term gain - long term pain
Aetiology
Alternative construct
Role of Phty & Exercise
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Smidt N and Van de Windt D (2006) Tennis elbow in primary care: Corticosteroid injections provide only short term relief. BMJ BMJ 2006;333;927-928 doi:10.1136/bmj.39017.396389.BE
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Bisset, L, Smidt, N, Van der Windt, D A, Bouter, L M, Jull, G, Brooks, P, Vicenzino, B (2007) Conservative treatments for tennis elbow: do subgroups respond differently? Rheumatology 46(10): 1601-5
N = 388
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…7/13 patients were relieved of pain from 1-5 months after the injection of hydrocortisone, only to have recurrence of symptoms…
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Coombes BK, Bisset L, Vicenzino B (2010) Efficacy and safety of cortico-steroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet.
www.the.lancet.com DOI:10.1016/S0140-6736(10)61160-9
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Coombes BK, Bisset L, Vicenzino B (2010) Efficacy and safety of cortico-steroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet.
www.the.lancet.com DOI:10.1016/S0140-6736(10)61160-9
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Coombes BK, Bisset L, Vicenzino B (2010) Efficacy and safety of cortico-steroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet.
www.the.lancet.com DOI:10.1016/S0140-6736(10)61160-9
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Wait and see policy: reassured that they will get better (n = 67)
Corticosteroid Injection:
1 ml quantity of 1% lidocaine + 10 mg of triaminolone acetonide in 1 ml (n = 65)
Physiotherapy:
MWM & exercise: 8 x 30’ sessions over 6 weeks (n = 66)
Advice to all: ergonomics and self management …
Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. British Medical Journal 2006, doi: 10.1136/bmj.38961.584653.AE
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MWM + exercise are beneficial:
Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. British Medical Journal 2006, doi: 10.1136/bmj.38961.584653.AE
NNT = 3 (RR: 2.44 [95CI: 1.55 to 3.85)]
NNT = 2 (RR: 1.88 [95CI: 1.41 to 2.5)]
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MWM + exercise are beneficial:
Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. British Medical Journal 2006, doi: 10.1136/bmj.38961.584653.AE
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Short term gain - long term pain:
Corticosteroid injection for
tennis elbow - clear evidence of worse
outcome in mid to long term with higher
recurrence rates and less satisfaction
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Short term gain - long term pain √
Aetiology
Alternative construct
Role of Phty & Exercise
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Pain system(s) changes
Motor system
impairments
Local tendon
pathology
Coombes B, Bisset L, Vicenzino B. A new integrative model of tennis elbow.
BJSM Online First, published on December 2, 2008 as 10.1136/bjsm.
2008.052738
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McMinn & Hutchings (1982)
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Abnormal appearance: • Disordered arrangement
of collagen fibres • Increase in vascularity • Mucoid degeneration of
collagen fibres • Thin frayed fibrils • Presence of stainable
ground substance • Absence of classic
inflammatory cells (Coonrad & Hooper 1973, Verhaar et al
1993, Doran et al 1990)
Loss of continuity of collagen Loss of reflectivity Frank defect present
angiofibroblastic hyperplasia (Nirschl 1979)
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Tissue specimens → Figure →
Rounded tenocytes
Prom tenocytes abn matrix
Abn tenocytes/matrix Fascicle rupture
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Zezig E, Ohberg L, Alfredson H. Extensor origin vascularity related to pain in patients with TE. Knee Surg Sports Traumatol Arthrosc (2006) 14: 659-63
17 patients: 22 elbows (5 bilateral; 7 male; age 45 years; 18 months duration) v 11 controls (6 male; age 45 years) US + Doppler study
Neovessels: TE = 21/22 (95%) v Controls = 2/22 (9%) LA into neovessels reduces pain with extensor loading Neovessels closely related to neural structures
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Short term gain - long term pain
Aetiology: does not
support an anti-inflammatory treatment
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Short term gain - long term pain√
Aetiology √
Alternative construct
Role of Phty & Exercise
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Pain system(s) changes
Motor system
impairments
Local tendon
pathology
Coombes B, Bisset L, Vicenzino B. A new integrative model of tennis elbow.
BJSM Online First, published on December 2, 2008 as 10.1136/bjsm.
2008.052738
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PFG or PFGS: Pain free grip strength (force) = to onset of pain
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Ljung B-O, Lieber RL, Friden J. Wrist extensor muscle pahtology in LE. J Hand Surgery (1999) 24B: 177-83.
20 patients (mean duration 23.9 (7-72) months; mean age 36 (23-58) years; 11 male) & 9 normal (4 autopsy & 5 alive, 8 male, 36 (23-58) years old)
Morphological changes greater in LE LE related changes:
– moth eaten fibres – fibre necrosis – high % fast-twitch oxidative (type 2A) fibre type
Morphological changes may contribute to decreased muscle performance in LE (along with pain)
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Female Control
Male Control
Male LE Female LE 50
100
150
200
250
300
350
Grip
Stre
ngth
(New
tons
)
Bisset L, Russell T, Ha B, Bradley S, Vicenzino B (2006) Bilateral sesnorimotor abnormalities in unilateral lateral epicondylalgia. Arch Phys Med Rehabil. 87: 490-5.
N = 24 male + 16 female unilateral chronic lateral
epicondylalgia (24 male; 49.5 years (32-66; mean
duration: 7.7 ± 10 months) & 40 age-gender
matched controls
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Alizadehkhaiyat et al (2008) Assessment of functional recovery in tennis elbow. J Electromyogr & Kinesiol, doi:10.1016/j.jelekin.2008.01.008 Strength: 1. Metacarpophangeal extension/flexion ratio: Control (0.56, n8) < recovered TE (0.87, n6) and TE (0.83, n7)
…no differences found for wrist F/E ratios. 2. Grip, Wrist F & E, Shoulder ABD, ER & IR
…all weaker in TE and recovered TE …MCP E stronger in TE
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Mean Deficit: 11° Lower 95CI: 7° Upper 95CI: 14° No effect of Age, Gender, Side
Bisset L, Russell T, Ha B, Bradley S, Vicenzino B (2006) Bilateral sesnorimotor abnormalities in unilateral lateral epicondylalgia. Arch Phys Med Rehabil. 87: 490-5.
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Reaction Time
150 175 200 225 250 275 300 325 350 375
Control LE group
SRT
RT1
RT2
Rea
ctio
n Ti
me
(mse
c)
Bisset L, Russell T, Ha B, Bradley S, Vicenzino B (2006) Bilateral sesnorimotor abnormalities in unilateral lateral epicondylalgia. Arch Phys Med Rehabil. 87: 490-5.
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Speed of Movement
LE group
Spee
d of
Mov
emen
t (cm
s-1 )
Control 80
90
100
110
120
130
Bisset L, Russell T, Ha B, Bradley S, Vicenzino B (2006) Bilateral sesnorimotor abnormalities in unilateral lateral epicondylalgia. Arch Phys Med Rehabil. 87: 490-5.
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Pienimaki T, Kauranen K, Vanharanta H (1997) Bilaterally decreased motor performance of arms in patients with CLE, Archives Phys Med Rehab 78(10): 1092-5.
Subjects: 32 CLE (median duration = 31 months) 11 male, 21 female aged 43 yrs 32 gender matched controls
Results: Compared to normal the patients had: 19-36% slower reaction times for both arms 31-32% slower speed of movement for both arms There was no difference between affected and
unaffected arm Conclusion:
Unclear mechanisms at play May be indicative of altered central processing What comes first the pain of tennis elbow or motor
control deficit
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Pienimaki et al (1997)
Bisset et al (2005)
Deficit ~30%
~15%
Age 43 Male:Female 11:21 Duration of LE* 31 months
49
24:16 4.5 months
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Bilateral changes: scenario 1?
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Kelly JD, Lombardo SJ, Pink M, Perry J, Giangarra CE (1994) EMG and cinematographic analysis of elbow function in tennis players with LE, AJSM 22: 359-63
• 8 with LE and 14 normal • Backhand stroke (single hand) • Muscles sampled:
– ECRB – ECRL – EDC – Pronator teres – FCR
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Kelly JD, Lombardo SJ, Pink M, Perry J, Giangarra CE (1994) EMG and cinematographic analysis of elbow function in tennis players with LE, AJSM 22: 359-63
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Kelly JD, Lombardo SJ, Pink M, Perry J, Giangarra CE (1994) EMG and cinematographic analysis of elbow function in tennis players with LE, AJSM 22: 359-63
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Kelly JD, Lombardo SJ, Pink M, Perry J, Giangarra CE (1994) EMG and cinematographic analysis of elbow function in tennis players with LE, AJSM 22: 359-63
• Leading elbow = wrist extended and open racqet face near impact
• Greater activity in wrist extensors and pronator teres
• Motor dysfunction (?control)
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Motor system
impairments
morphological deficits
strength imbalance
global changes
sensori-motor (bilateral)
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Pain system(s) changes
Motor system
impairments
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Pain system(s) changes
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Fernàndez-Carnero J, Fernàndez-de-las-Penas C, Sterling M, Souvlis T, Arendt-Nielsen L, Vicenzino B (2009) Exploration of the extent of somato-sensory impairment in patients with unilateral lateral epicondylalgia. J of Pain 10 (11): 1179-85.
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Fernàndez-Carnero J et al (2009) Widespread mechanical pain hypersensitivity as sign of central sensitization in unilateral epicondylalgia. Clin J Pain 25: 555-561.
PPT C5-6
PPT Tibialis Anterior
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Fernàndez-Carnero J, Fernàndez-de-las-Penas C, Sterling M, Souvlis T, Arendt-Nielsen L, Vicenzino B (2009) Exploration of the extent of somato-sensory impairment in patients with unilateral lateral epicondylalgia. J of Pain 10 (11): 1179-85.
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Coombes B, Bisset L, Vicenzino B. Thermal hyperalgesia distinguishes those with severe pain & disability in unilateral lateral epicondylalgia. Clinical Journal of Pain (accepted 18th October 2011)
n=53 n=27 n=84
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Coombes B, Bisset L, Vicenzino B. Thermal hyperalgesia distinguishes those with severe pain & disability in unilateral lateral epicondylalgia. Clinical Journal of Pain (accepted 18th October 2011)
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Coombes B, Bisset L, Vicenzino B. Thermal hyperalgesia distinguishes those with severe pain & disability in unilateral lateral epicondylalgia. Clinical Journal of Pain (accepted 18th October 2011)
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As an aside… • Poorer health-related quality of life in severe LE
relative to mild & moderate LE
• No differences in anxiety, depression & kinesiophobia between groups
Coombes B, Bisset L, Vicenzino B. Thermal hyperalgesia distinguishes those with severe pain & disability in unilateral lateral epicondylalgia. Clinical Journal of Pain (accepted 18th October 2011)
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Pain system(s) changes
deep tissue sensitivity
mechanical hyperalgesia
central sensitization
local neurotransmitters
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Pain system(s) changes
Motor system
impairments
morphological deficits
strength imbalance
global changes
sensori-motor (bilateral)
deep tissue sensitivity
mechanical hyperalgesia
central sensitization
local neurotransmitters
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Pain system(s) changes
Motor system
impairments
morphological deficits
strength imbalance
global changes
sensori-motor (bilateral)
deep tissue sensitivity
mechanical hyperalgesia
central sensitization
local neurotransmitters
Pain system(s) changes
Motor system
impairments
Local tendon
pathology
Local tendon
pathology
hypercellularity
neovascularisation increased matrix protein
collagen fibrils disarray
angiofibroblastic hyperplasia
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Pain system(s) changes
Motor system
impairments
morphological deficits
strength imbalance
global changes
sensori-motor (bilateral)
deep tissue sensitivity
mechanical hyperalgesia
central sensitization
local neurotransmitters
Pain system(s) changes
Motor system
impairments
Local tendon
pathology
Local tendon
pathology
hypercellularity
neovascularisation increased matrix protein
collagen fibrils disarray
angiofibroblastic hyperplasia
Blood, Prolotherapy, Polydocinal, NO, Exercise
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Short term gain - long term pain
Aetiology
Alternative construct:
motor, sensorimotor and pain system impairments
Role of Phty & Exercise
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www.us.elsevierhealth.com
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Mobilisation with Movement
PFG not MGS: • Discriminates affected
from unaffected and normal (Bisset et al 2006)
• Sensitive to change over time (Stafford et al 1987, 1994)
Pain Free Grip is affected in all patients with LE
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Mobilisation with Movement Test position: 1. Elbow extension with palm
facing treatment table = internal rotation of arm, pronation of forearm.
2. Most provocative position
3. Note variation from 90° elbow flexion in sitting position
PFG not MGS: • Discriminates affected
from unaffected and normal (Bisset et al 2006)
• Sensitive to change over time (Stafford et al 1987, 1994)
PFG is affected in all patients with LE
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Mobilisation with Movement Test procedure: 1. Always test unaffected side first 2. Perform 3 to 6 grip actions 3. Ask patient to memorize rate of
gripping 4. Practitioner monitors rate of
gripping action 5. Test affected after unaffected 6. Ask patient to grip at same rate
as unaffected side 7. Practitioner monitors rate of
force application 8. Perform 3 to 6 tests 9. Average the tests for both sides
to arrive at the outcome measure.
PFG not MGS: • Discriminates affected
from unaffected and normal (Bisset et al 2006)
• Sensitive to change over time (Stafford et al 1987, 1994)
PFG is affected in all patients with LE
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Mobilisation with Movement
Pain free grip force = amount of force to first onset of pain (pain threshold test)
50 N
200 N
Grip force in Newtons
PFG not MGS: • Discriminates affected
from unaffected and normal (Bisset et al 2006)
• Sensitive to change over time (Stafford et al 1987, 1994)
PFG is affected in all patients with LE
0 N
Maximum grip force = maximum amount of force that the patient can produce
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Mobilisation with Movement
50 N
200 N
Grip force in Newtons
PFG not MGS: • Discriminates affected
from unaffected and normal (Bisset et al 2006)
• Sensitive to change over time (Stafford et al 1987, 1994)
PFG is affected in all patients with LE
0 N
Aim of MWM: To substantially increase PFG towards MGS (+ ~10% if dominant side affected) …with each application of the MWM.
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Mobilisation with Movement
50 N
200 N
Grip force in Newtons
PFG not MGS: • Discriminates affected
from unaffected and normal (Bisset et al 2006)
• Sensitive to change over time (Stafford et al 1987, 1994)
PFG is affected in all patients with LE
0 N
How much = substantial?
?
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Mobilisation with Movement
50 N
200 N
Grip force in Newtons
PFG not MGS: • Discriminates affected
from unaffected and normal (Bisset et al 2006)
• Sensitive to change over time (Stafford et al 1987, 1994)
PFG is affected in all patients with LE
0 N
How do we make a substantial improvement in force generation to pain onset?
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Mobilisation with Movement
50 N
200 N
Grip force in Newtons
0 N
How do we make a substantial improvement in force generation to pain onset?
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Mobilisation with Movement
50 N
200 N
Grip force in Newtons
0 N
How do we make a substantial improvement in force generation to pain onset?
Location of contact • Joint (local or distant)
• Contact point on bone Applied Force
• Direction (gross, subtle) • Level (amount of force) • Overpressure (OP) • How applied (manual, belt, tape)
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Mobilisation with Movement
50 N
200 N
Grip force in Newtons
0 N
How do we make a substantial improvement in force generation to pain onset?
Location of contact • Joint (local or distant) • Contact point on bone
Applied Force • Direction (gross, subtle) • Level (amount of force) • Overpressure (OP) • How applied (manual, belt, tape)
Perpendicular to impaired action or movement direction: • Transverse plane in 56% of all peripheral techniques in
Mulligan book compared to 28% in Sagittal plane. • Lateral in 44% of all peripheral techniques (~79% of all
transverse plane MWM)
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Mobilisation with Movement
50 N
200 N
Grip force in Newtons
0 N
How do we make a substantial improvement in force generation to pain onset?
Location of contact • Joint (local or distant) • Contact point on bone
Applied Force • Direction (gross, subtle) • Level (amount of force) • Overpressure (OP) • How applied (manual, belt, tape)
Abbott J, Patla C, Jensen R 2001 The initial effects of an elbow MWM technique on grip strength in subjects with LE. Manual Therapy 6: 163-169. 5° posterior to directl lateral or lateral produces greater effect than 5° anterior of lateral
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Mobilisation with Movement
50 N
200 N
Grip force in Newtons
0 N
How do we make a substantial improvement in force generation to pain onset?
Location of contact • Joint (local or distant) • Contact point on bone
Applied Force • Direction (gross, subtle) • Level (amount of force) • Overpressure (OP) • How applied (manual, belt, tape)
McLean S, Naish R, Reed L, Urry S, Vicenzino B, 2002 A pilot study of manual force levels required to produce manipulation induced hypoalgesia. Clinical Biomechanics 17: 304-8. A threshold level of lateral glide force has to be met for the MWM to be beneficial in improving PFG.
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www.us.elsevierhealth.com
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Mobilisation with Movement
50 N
200 N
Grip force in Newtons
0 N
How do we make a substantial improvement in force generation to pain onset?
Location of contact • Joint (local or distant)
• Contact point on bone Applied Force
• Direction (gross, subtle) • Level (amount of force) • Overpressure (OP) • How applied (manual, belt, tape)
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Vicenzino B, Brooksbank J, Minto J, Offord S, Paungmali A (2003) Initial effects of elbow taping on PFGS and PPT, JOSPT 33: 400-7.
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Exercises
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Concepts No pain during or after (DOMS?) Slow contraction (8 sec total) Endurance in first instance (15+ reps) 1st 2-3 weeks light load high reps Next 4-6 weeks endurance-strength
(15-20/8-12 reps X 3 sets, short rest) May need in some to do high strength with
hi loads low reps (4-6 reps X 3 sets, long rest)
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Limited levels of evidence exist to suggest that eccentric exercise has a +ve effect on clinical
outcomes (P, function, patient satisfaction, RTW) when compared to various control interventions
(concentric exercise, stretching, splinting, frictions and ultrasound).
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Woodley, B. L., R. J. Newsham-West, et al. (2007). "Chronic tendinopathy: effectiveness of eccentric exercise." Br J Sports Med 41(4): 188-198.
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Woodley, B. L., R. J. Newsham-West, et al. (2007). "Chronic tendinopathy: effectiveness of eccentric exercise." Br J Sports Med 41(4): 188-198.
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Woodley, B. L., R. J. Newsham-West, et al. (2007). "Chronic tendinopathy: effectiveness of eccentric exercise." Br J Sports Med 41(4): 188-198.
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Woodley, B. L., R. J. Newsham-West, et al. (2007). "Chronic tendinopathy: effectiveness of eccentric exercise." Br J Sports Med 41(4): 188-198.
(>6mth)
EE v stretching
EE v US
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Woodley, B. L., R. J. Newsham-West, et al. (2007). "Chronic tendinopathy: effectiveness of eccentric exercise." Br J Sports Med 41(4): 188-198.
(3 mth)
EE v CE
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Eccentric exercise considerations:������
(a) ~80% of unaffected and little pain���(b) Lower limb tendon v tennis elbow:���
pain during exercise���tendon v enthesis
Eccentric or concentric? or …is it all about staging?
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Enthesis organ v mid tendon
Brukner and Khan
Prof Mike Benjamin Cardiff University
enthesis fibrocartilage
sesamoid fibrocartilage
periosteal fibrocartilage
superior tuberosity
retrocalcaneal bursa
Kager’s fat pad
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Exercise���prevents���recurrence���&���chronicity
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PARTICIPANTS Exercise (n=20) US (n=19) Men / women 8/12 6/13
Mean age (years) 43 (33-53) 41 (31-53)
Duration 9 < 6 months 11 > 6 months
11 < 6 months 8 > 6 months
Sick leave 6.3 weeks 7.1 weeks
Failed previous treatment*
20 19
* Immobilisation (4/4), injections (20/15), oral meds (18/18), percutaneous med (11/7), support (11/7), PT (12/7)
Pienimaki, T., et al., Progressive strengthening and stretching exercises and ultrasound for chronic lateral epicondylitis. Physiotherapy, 1996. 82(9): p. 522-30
RCT: 4 stage program of progressive slow, repetitive wrist/forearm stretching & strengthening, and occupational exercises; 6-8 weeks with weekly visits to physiotherapist
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• Compared to the pulsed US, the exercise program produced significant improvements in: – Pain @ rest and under strain
– Subjective ability to work & sick leave
– Sleep disturbances
– Isokinetic flexion torque and isometric grip
• No long term follow up in this study
Pienimaki, T., et al., Progressive strengthening and stretching exercises and ultrasound for chronic lateral epicondylitis. Physiotherapy, 1996. 82(9): p. 522-30
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Pienimaki, T., et al., (1998) Long term follow up of conservatively treated chronic TE patients. A prospective & retrospective analysis. Scand J Rehab Med 30: 159-166
Similar treatments (exercise versus US)
N = 30 (12 male, 18 female, mean age 42.3 years)
16 (12) exercise and 14 (11) US
Follow up time was a mean of 36 months
After exercise there was: Significantly less PT and GP treatment required Fewer sick leave days Less pain on VAS
Operation: 5 in US group and 1 in Exercise group No spontaneous healing nor self limiting observed Exercise may prevent chronicity
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Short term gain - long term pain
Aetiology
Alternative construct
Role of Phty & Exercise