Original Article
EFFECTIVENESS OF M OBILIZATION W ITH M OVEM ENT OF ELBOW
COM PARED W ITH M ANIPULATION OF W RIST IN PATIENTS OF
LATERAL EPICONDYLITIS
Namrata Patel.
Lect urer, sigm a college of physiot herapy, Vadodara, India.
Purpose:To evaluat e t he effect iveness of m obilizat ion w it h m ovem ent of elbow com pared w it h m anipulat ion o f w r i st o n p ai n , st r e n gt h an d act i v i t i es o f d ai l y l i vi n g i n p at i e n t s o f l at e r al ep i co n d yl i t i s.
M et hodology:An int er vent ional com parat ive st udy w as conduct ed on 30 pat ient s having sym pt om at ic lat eral epicondylit is. They w ere random ly assigned t o one of t he t hree groups. Group A (n=10) cont rol group, Group B (n=10) M obilization w ith m ovem ent group and Group C (n=10) w rist m anipulation. All t he 3 groups w ere received convent ional t reat m ent of ult rasound, st ret ching and st rengt hening of w rist ext ensors. Baseline m easurem ent s of pain (VAS score), f unct ional stat us (PRTEE quest ionnaire) and st rengt h (m axim al isom et r ic grip st rengt h) w ere taken on day 1 and af t er 10t h t reat m ent session. Results:The data analysis w as perfor m ed w it h Graph Pad Instat t rial version 3 sof t w are. All t hree groups show ed im provem ent in VAS, m axim al isom et r ics grip st rengt h and PRTEEquest ionnaire. There isst at ist ically signif icant dif ference bet w een groups B (M obilizat ion w it h m ovem ent ) and Group C (M anipulat ion of w rist ) for VAS and PRTEEquest ionnaire score. But No stat ist ically significant difference is found in m axim al isom et r ic gr ip st rengt h. M obilizat ion w it h m ovem ent of elbow along w it h convent ional t herapy show ed significant im provem ent in Pain and f unct ional stat us as com pared t o w r ist m anipulat ion. Conclusion: It can be concluded t hat m obi lizat ion w it h m ovem ent of elbow along w it h convent ional t herapy program is effect ive in t reat ing chronic lat eral epicondylit is.
KEYW ORDS:Lat eral epicondylit is; M obilizat ion w it h m ovem ent ; Wrist m anipulat ion.
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International Journal of Physiotherapy and Research
ISSN 2321- 1822
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Received: 13 Sept 2013 Accept ed: 03 Oct ober 2013
Published: 11 Oct ober 2013
ABSTRACT
INTRODUCTION
Address for correspondence: M s. Nam rat a Pat el, 13/152, Net ajinagar, M eghaninagar, Ahm edabad,
India. Email: pat elnam rat a27@gm ail.com , pat elnam rat a27@hot m ail.com
Int J Physiother Res 2013, Vol1(4):177-82. ISSN 2321-1822
Lat eral epicondylit is (t ennis elbow ) is t he m ost frequent t ype of m yot endinosis and can be responsible for subst ant ial pain and loss of funct ion of t he affect ed lim b.1 It specifically
involves t he origin of t he ext ensor carpi radialis brevis m uscle, usually 1-2cm dist al t o lat eral epicondyle.2
It is generallyw ork relat ed or sport relat ed pain disorder of t he forearm .Repet it ive ext ension-flexion or pronat ion-supinat ion act ivit y leads t o overuse injury. Overuse is encount ered when t he body’s physiological abilit y t o heal lags behind t he m icro t raum a caused by repet it ive m ot ion.
It is also seen t hat flexibilit y deficiencies in t he forearm extensor m uscle or inadequat e forearm ext ensor pow er and endurance t o w it hst and norm al forceful repet it ive m ovement s is also one of t he causes of lat eral epicondylit is.3
The dom inant arm is usually affect ed, but t he condit ion is occasionally bilat eral. M en are more likely t o suffer t han wom en.4
lat eral epicondylit is are m ore com m on at t he age of 30- 55 years.5
Conservat ive t reat m ent program for people w it h lat eral epicondylit is have focused prim arily on t he p ai n co n t ro l by u lt r aso u n d, ant i -inflam m at ory m edicat ion and phonophoresis follow ed by rehabilit at ion program including flexibilit y and st rengt hening.
M ETHODS
Acupunct ure, ort hot ics, t aping, ext ra corporeal shock wave t herapy, LASER and ionizat ion have also been st udied for m anagem ent of lat eral epicondylit is.6 Act ivit y m odificat ions such as
av oi d ance of grasp in g in p ro n at i o n an d subst it ut ing cont rolled supinat ion during lift ing m ay relieve sym pt om s.5
There are several recom m endat ions regarding p r ev en t i o n , t r eat m en t an d av o i dan ce o f recurrence t hat is largely speculat ive including st r et ch i n g an d p r ogr essi v e st ren gt h en in g exercises t o prevent re-irrit at ion of t he t endon.7
t here is lit t le evidence t o support t he value of t hese int ervent ions for lat eral epicondylit is.8
scient ific evidence in favors of any specific t reat m ent for lat eral epicondylit is is poor.9
M o bi l i zat i on w it h m o v em en t f o r l at er al epicondylit isis t heoret ically int ended t o cause r epo si t i o n in g of ‘ po si t i o n al f au l t s’.10 t h e
m echanism by w hich m anipulat ion m ay w ork is poor ly underst ood. The clinical ef f icacy of m anipulat ive t herapy has been dem onst rat ed in random ized clinical t rials w hich report benefit s in t erms of pain relief and more rapid rest orat ion of funct ion.11
The object ive of t his st udy is t o evaluat e t he effect iveness of m obilizat ion w it h m ovem ent of elbow com pared w it h m anipulat ion of w rist on pain, st rengt h and act ivit ies of daily living in pat ient s w it h lat eral epicondylit is.
An int ervent ional st udy was conduct ed t o find out t he ef fect iveness of m obi lizat ion w it h m o vem ent o f el bo w com p ared w i t h m anipulat ion of w r ist in relieving pain, on m axi m al i som et r i c gr i p st r en gt h an d o n funct ional out com e in pat ient s w it h lat eral epicondylit is.
STUDY SETTING:
This st udy was conduct ed for 6 m ont hs durat ion in physiot herapy depart m ent of Governm ent Physi o t h er ap y Co l l ege, ci v i l h osp i t al , ahm edabad. All t he pat ient s w ere referred from or t h opedic out pat ient depar t m en t of civi l hospit al, ahm edabad.
SAM PLE SELECTION:
Tot al 30 subject s w ere select ed for t he st udy w it h age group 30 – 55 years and unilat eral
lat eral epi condy lit i s (sym pt o m s >3m on t hs durat ion).5
Subject s w it h Cervical radiculopat hy, recent surgical procedure around elbow, subject s have received st eroid inject ion w it hin last 30 days in t he elbow, any neurological disorder like st roke, head injury, et c w ere excluded.12 Subject s
w ere assigned t o Gro up A: Co nt rol gr oup, Group B: M obilizat ion w it h m ovem ent of elbow group and Group C: Wrist m anipulat ion group according t o t heir order of appearance.
SAM PLE DESIGN: Convenience sam pling
M ATERIALS:
M ulligan belt , Dum bbells of different w eight , Jam ar hydraulic hand dynam om et er
M AIN STUDY:
Su bj ect s w ho w ere foun d su it ab le f or t he part icipat ion in t he st udy w ere request ed t o sign consent form s. Visual analogue scale (VAS)13,
Pat ient rat ed t ennis elbow evaluat ion (PRTEE) quest ionnaire14 and Isom et ric grip st rengt h15
w ere t aken . Isom et r i c gr i p st r engt h w as m easu r ed w it h Jam ar hydr au li c han d dynam om et er. M ean value of 3 repet it ions was recorded. The t reat m ent for each group was cont inued for 3 w eeks during t hat t im e t hey had no ot her t reat m ent . The pat ient s w ere t reat ed o n al t er n at e d ay (excep t Su nd ay ) f o r 10 t reat m ent sessions. All out com e m easures w ere t aken w it h sam e prot ocol aft er 10t h
t reat m ent session.
PROTOCOL:
GROUP A: CONTROL GROUP
Subject s w ere given convent ional t reat m ent p ro gr am . It i n cl u des: Ul t raso u nd : (Pu l sed ult rasound w it h 20% Dut y cycle and 3 M Hz Frequency is delivered at 1.3 Wat t / cm2 Int ensit y
for 5 m inut es) .16, 17
st ret ching: St at ic st ret ching t o forearm ext ensors should be applied for 30secs. Tot al 6 repet i t ions w it h rest of 30 seconds bet w een each session w ere given.7
St rengt hening exercise: Perform wrist ext ension slow ly and m aint ain t he posit ion of ext ension for 2 seconds and gradually ret urn t o st art ing posit ion. Act ive m ot ion of w rist ext ension w it h elbow flexed 900
RESULTS
m u scl es 1 po u n d o f w ei gh t is add ed an d perform ed 3 set s of 10 repet it ion progress t o 5 set s. Then add 1 pound of w eight and progress t ill 3 pound w eight . As t olerance im proves elbow is t aken in t o ext ension. 18
GROUP B: M OBILIZATION W ITH M OVEM ENT GROUP
Subject s were given convent ional t reat ment and M ob i l izat io n w i t h m o v em en t o f el b ow . M obilizat ion w it h m ovem ent w as given w it h subject lying in supine posit ion having t heir elbow ext ended and forear m pronat ed. The t herapist was st anding at side of subject t o be t reat ed. Placing t he belt around t herapist shoulder and subject ’s forear m , belt placed clo sed t o el b ow j oi n t l i n e. The t her api st perform ed t he lat eral glide of forearm using belt sust aining t his glide, subject s w ere asked t o p er f o r m f i st w i t h o u t p ain .19 Dosage - 10
M obilizat ions w it h m ovem ent in one set . 3 set s w ere given per session. Treat m ent was given for 10 sessions.
GROUP C: W RIST M ANIPULATION GROUP
Subject s w ere given convent ional t reat m ent program and w rist m anipulat ion.
The m anipulat ive m aneuver is high velocit y low am plit ude t hrust t echnique andwas perform ed w it h affect ed side forearm rest ed on a table wit h t he pal m ar side of t h e hand facing dow n. Subject ’sscaphoid bone is gripped bet w een t hum b and index finger by t he t herapist and w rist is ext ended dorsally at t he sam e t im e t he scaphoid
bone w as m anipulat ed vent rally. Dosage – 10 w rist manipulat ion in one set . 3 set s w ere given per session. Treat m ent was given for 10 sessions. 11
Dat a analysis was perform ed w it h Graph Pad Inst at t rial version 3 soft ware.
DATA ANALYSIS OF VAS SCORE:
Dat a was not norm ally dist ribut ed so W ilcoxon m at ched-pairs signed ranks t est was applied for comparison of pre and post t reat m ent VAS score w it h i n each gro u p . Th e r esu l t s sh ow ed significant improvem ent in each group at p<0.05. kruskal wallis t est was applied for com parison of post t reat m ent VAS score bet w een Group A, Group B and Group C.
The t est show ed significant difference bet w een groups. Post-hoc Dunn’s m ult iple com parisons Test was applied t o subst it ut e t he findings.
Group M ean
rank difference p value Significance
Group A & B 12.25 < 0.01 Significant
Group A & C 2.4 > 0.05 Not significant
Group B & C 9.8 < 0.05 Significant
Table no.1: Com par ison of VAS score bet w een t w o groups.
DATA ANALYSIS OF M AXIM AL ISOM ETRIC GRIP STRENGTH:
Paired t t est was applied for com parison of pre and post t reat m ent m axim al isom et ric gr ip st rengt h w it hin t hree Groups as t he dat a is norm ally dist ribut ed. The t est show ed significant im provem ent in each group. One way analysis of variance ANOVA was applied t o com pare post t reat m ent M axim al isom et ric grip st rengt h bet w een t hree Groups. P value was found t o be 0.2320 (>0.10) w hich show ed t hat t here was no st at ist ically significant difference in m axim al isom et r ic grip st rengt h bet w een 3 groups. Post –ho c an al ysi s Bo n fer r on i m u l t ip l e com parison t est was applied t o subst ant iat e t he findings and result is show n below :
Group M ean
difference p value t value Significance Group A & B 4.598 > 0.05 1.287 Not significant Group A & C 1.399 > 0.05 0.3916 Not significant Group B & C 5.997 >0.05 5.997 Not Significant Tab le no.2: Com p ar i son of M axim al iso m et r ic gr ip st rengt h score bet w een t w o groups.
DATA ANALYSIS OF PRTEE QUESTION NAIRE SCORE:
Group M ean
rank difference p value Significance
Group A & B 12.3 < 0.01 Significant
Group A & C 1.5 > 0.05 Not significant
Group B & C 10.8 < 0.05 Significant
Table no. 3: Com par ison of PRTEE score bet w een t w o groups.
The st ud y sho w ed st at ist icall y si gn i f i can t difference bet w een groups B (M obilizat ion w it h m ovem ent ) and Group C(M anipulat ion of w rist ) as w ell as bet w een group A(Cont rol) and group B for VAS and PRTEE quest ionnaire score. No st at ist ically signif i can t di f fer ence is fou nd bet w een t hree groups in gr ip st rengt h. No st at ist ically signif i can t di f fer ence is fou nd bet ween group A and Group C for VAS and PRTEE quest ionnaire score.
M o bi l i zat i on w it h m ov em en t of elb o w t reat m ent is significant ly effect ive in relieving pain and im proving funct ional st at us com pared t o w rist m anipulat ion and cont rol group in case of chronic lat eral epicondylit is.
DISCUSSION
change in abilit y t o w ork in PRTEE quest ionnaire not ed w it hin each group is im port ant . In M WM gr ou p si gn if i can t im p r ov em en t occu r i n funct ional out com e. Hence im provem ent in abilit y t o do t heir usual w ork occurs. The pain reduct ion m ight be result ed in perform ance of act ivit ies, w hich w ere painful previously. This was reflect ed in m axim al isom et ric grip st rengt h as w ell. Kochar and Dogra(2002) st udied t he effect iveness of M ulligan m obilizat ion in pat ient s receiving ult rasound and progressive exercise program for 12 w eeks. It was found t hat addit ion of M ulligan m obilizat ion t o t his regim en brought increased and fast er recovery in pat ient s w it h t ennis elbow.22
Bisset L et al (2006) show ed t hat physiot herapy involving M WM + exercise had a superior benefit t o wait and see approach in t he first 6 w eeks and t o st eroid inject ions aft er 6 w eeks providing a reasonable alt ernat ive t o inject ions in t he m id t o long t erm .23
This was in support t o t he result s of present st udy w here M ulligan mobilizat ion had given addit ional effect on VAS and PRTEE quest ionnaire score.
The result show s im provem ent in VAS, m axim al isom et ric grip st rengt h and PRTEE score in w rist m anipulat ion group. B Vicenzino(2003) show ed clinical eff icacy of m anipulat ive t herapy in random ized clinical t rials w hich report benefit s in t erms of pain relief and more rapid rest orat ion o f f u n ct i o n. The m ech an ism by w hi ch m an ipul at io n w or ks i s po or ly underst o od. M anual t herapy is used quit e oft en for t he spine and peripheral joint s, despit e of t he inabilit y of clinicians t o accurat ely diagnose t he pat hway at w hich a m anipulat ion is t argeted. In people w it h low back pain and neck pain, spinal m anipulat ion is t hought t o free m ot ion segm ent s t hat have undergone disproport ionat e displacement s and t o relax m uscles by sudden st ret ching.24
Convent ional group show ed im provem ent in VAS, m axim al isom et ric grip st rengt h and PRTEE score. Convent ional group received ult rasound, st ret ching and st rengt hening. According t o Speed CA (2001) pain relief by ult rasound occurs by direct ly influencing t he t ransm ission of painful im pulses by elicit ing changes w it hin t he nerve fibers and elevat ing pain t hreshold.25
Whereas indirect pain reduct ion occurs as a result of increased blood flow and increased capillary perm eabilit y t o t he affect ed area.
Th e r esu l t s o f t h e p r esen t st u d y sh ow ed im provem ent in VAS, m axim al isom et ric grip st rengt h and PRTEE score in all t hree groups. But t he m o bi l izat i on w i t h m o v em en t t h er ap y r esu lt ed i n sign if i can t l y b et t er sub j ect iv e o ut co m es t h an w r i st m an i p ul at io n an d convent ional t herapy group in chronic lat eral epicondylit is.
Pain declined significant ly in M WM group. A Paungm ali (2004) show ed t hat M WM produces sensory input sufficient t o recruit and act ivat e descending pain inhibit ory syst em s t hat result in som e or all of t he pain relieving effect s. It p r od u ces hyp o algesic ef fect s d u r i n g an d f ol l o w i n g i t s ap p li cat i o n , as w el l as sym pat hoexcit at or y ef fect .20
Bi ll V icenzino (2006) hypot hesized t hat m alposit ioning of t he ulna and radius occurs in relat ion t o hum erus in t ennis elbow, t he reduct ion of pain could be due t o reposit ioning of t he ulna and radius w it h respect t o hum erus achieved by lat eral glide t o elbow joint .21
Ackn o w led ge m e nt : Aut h o r t h ank f u l t o M rs. M anm it gill, M rs. M rudulla lala and her colleagues & friends.
According t o Byl NN (1992) cycloam inoglycan and hydroxyproline w hich w ere t he essent ial com p onent s for collagen produ ct ion w ere increased follow ing low dose pulsed ult rasound. Cavit at ion and acoust ic st ream ing faci lit at e col lagen sy nt hesi s. Thi s in cr eased rat e o f collagen synt hesis in t endon result s in healing and increased t ensile st rengt h of t endon.25
Binder A et al (1985), st udied t he effect iveness of ult rasound in lat eral epicondylit is pat ient s. This st udy com pares ult rasound w it h placebo. It show ed im provem ent in pain score, w eight lift ing t est and grip st rengt h.26
In co n t r ast , Rob er t so n an d Baker (2001) review ed st udies of effect iveness of ult rasound in lat eral epicondylit is pat ient s from peer-review ed jour nals bet w een 1975 and 1999. Because of sm all sam ple size or ot her problem s, t hey w ere forced t o discard 25 of t he st udies and t herefore report ed findings based on 10 art icles report ing clinical out com es. Of t hese 10 art icles, only 2 report ed t hat ult rasound is m ore effect ive t han placebo. Robert son and Baker concluded t hat t he lit erat ure show s t hat ult rasound is no m ore effect ive t han placebo.27
Acco r di n g t o Pi en em ak i et al (1996), St rengt hening t he dam aged at t achm ent of w rist ext ensors result ed in bet t er repet it ive w rist m ov em en t s p er f or m ed b y t he su b j ect s.1 2
St ret ching m inim izes excessive int ernal st rain t o t he t endon by opt im izing t issue ext ensibilit y during st ressful act ivit ies. Lit erat ures suggest t hat st rengt hening and st ret ching bot h are m ain com ponent s of exercise program , because t en d o ns m ust hav e f l exi b i li t y al o ng w it h st rengt h. Posit ive effect s of exercise program for t end o n i n j ur i es m ay b e at t r i b u t ab l e t o lengt hening of m uscle t endon unit by st ret ching and st rengt hening exercise w hich could achieve loading effect w it hin m uscle t endon unit along w it h hypert rophy and increased t ensile st rengt h of t he t endon.7
The result of present st udy show s no st at ist ically significant im provem ent in w rist m anipulat ion group compared t o mobilizat ion wit h movem ent gr ou p in VAS and PRTEE sco r e. Geet u M anch n ad a et al (2008) f o u nd t hat bo t h m anipulat ive t echniques are equally effect ive t h an con ser vat iv e t r eat m en t . Th at st u d y included subject s w it h lat eral epicondylit is
dur-at ion of 1-3 m ont hs.28 In t he present st udy
subject s w ere t aken w it h durat ion of com plain m ore t han 3 m ont hs. The effect iveness of w rist m anipulat ion m ay even be underest im at ed due t o difference in durat ion of com plain.
The result of present st udy show s no st at ist ically significant difference in m axim al isom et ric grip st rengt h bet w een t hree groups. It m ay be due t o t hat m obilizat ion w it h m ovem ent and w rist m anipulat ion w orks on pain com ponent rat her t han st rengt h direct ly.20, 24
LIM ITATIONS
The sam ple size was sm all so t he result s could not be generalized t o populat ion; long t erm follow up w as not carr ied out ; Short st udy durat ion and only chronic cases w ere t aken.
CONCLUSION
The st udy concluded t hat t here is significant im provem ent in pain and funct ional st at us in m obilizat ion w it h m ovem ent group t han w rist m anipulat ion. The advant age of M WM of elbow is t hat it is effect ive w it hin short period. It also im proves t he abilit y of pat ient s t o m aint ain t heir daily act ivit ies w it hout rest rict ion. It m ight be m ore costeffect ive due t o a reduct ion in num -ber of t reat m ent sessions needed.
Conflict of interest: None
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