Elsevier

Physiotherapy

Volume 88, Issue 6, June 2002, Pages 333-341
Physiotherapy

Research report
Effectiveness of a Specific Physiotherapy Regimen on Patients with Tennis Elbow: Clinical study

https://doi.org/10.1016/S0031-9406(05)60746-8Get rights and content

Summary

The effect of a combination of Mulligan mobilisation (a manual therapy approach) and ultrasound therapy is compared with that of ultrasound therapy alone. In both cases, a progressive exercise programme followed ten sessions of therapy to improve strength and facilitate return to work.

Sixty-six patients (male:female ratio 6:5, mean age 41 years) were recruited. Of these patients, 46 were randomised into two treatment groups by a random draw of chits. The remaining 20, who could not be randomised, comprised the control group

The first (MM) group was treated with a combination of ultrasound therapy and Mulligan mobilisation while the second group was treated with ultrasound therapy alone for ten sessions (completed within three weeks). Both groups then followed a progressive exercise regime for a further nine weeks. They were evaluated at weekly intervals from the time of selection until the third week and finally at the 12th week with four outcome measures: visual analogue scale (VAS), isometric grip strength, weight test and patient assessment test.

In the follow-up visit after 12 weeks of therapy, there was improvement in VAS, weight test and grip strength in both the MM (p < 0.01, 0.01, 0.01) and ultrasound groups (p < 0.01, 0.05, 0.05). The MM group showed a greater improvement than both the ultrasound group and the control group on VAS (p < 0.05, 0.05); weight test (p < 0.01, 0.001) and grip strength (NS, p < 0.05). The ultrasound group was superior to the control group on VAS (p < 0.05); weight test (p < 0.01), but the difference from the control group in grip strength was not significant. The MM group showed improvement on most parameters from the first week onwards whereas the ultrasound group improved only from the second week. Also the patient assessment score improved for the MM group (p < 0.05) and for the ultrasound group improvement was significant at three weeks of therapy (p < 0.05), but the difference was not statistically significant at 12 weeks.

Conclusion

The addition of Mulligan mobilisation to a regimen comprising ultrasound therapy and progressive exercises brings about increased and faster recovery in patients with tennis elbow.

Introduction

Tennis elbow is one of the most common lesions affecting the arm. Several concepts have been put forward concerning its aetiology ranging from intrinsic causes such as bursitis, periostitis, etc, to cervical dysfunction (Thurston, 1998). The main factors in the pathogenesis of tennis elbow are over-use, inflammation and degeneration.

Over-use is encountered when the body's physiological capacity to heal lags behind the repetitive micro trauma (Cyriax, 1992). The inflammatory response is an attempt to speed up tissue production to compensate for an increased rate of tissue micro damage (Kesler, 1983), which occurs owing to greater internal strain on tendon fibres over time that might come about from over-use of the tendon in activities such as carpentry, pruning shrubs, playing tennis, etc. It may also come about with normal activity levels if the capacity of the tendon to attenuate tensile loads is reduced (Putnam and Cohen, 1999). This typically occurs with ageing when loss of mucopolysaccharide chondroitin sulphate makes the tendon less extensible. Hence more energy of tensile loading must be absorbed as internal strain on the collagen fibres rather than deformation of the tissue. Therefore most people presenting with this problem are above 35 years of age.

Numerous treatments have been tried for tennis elbow including corticosteroid injection (Assendelft et al, 1996; Price et al, 1999; Solveborn, 1995), hypospray (Clarke and Woodland, 1974; Hughes and Currey, 1969), electrical stimulation (Halle et al, 1986), manipulation (Burton, 1988), laser (Vasseljen, 1992), acu-puncture (Chilton, 1997), counterforce splints (Clements and Chou, 1993), ultrasound (Haker and Lundeberg, 1991a; Lundeberg et al, 1988), phono-phoresis (Klaiman et al, 1998), surgery (Wittenberg and Muhr, 1992), and extra-corporeal shock waves (Rompe, 1996). However no one treatment has proved to be universally efficacious (Wright and Vicenzeno, 1997).

Garret and colleagues (2000) suggested that the comfort modalities of physio-therapy fail specifically to improve the quality of collagen in tendons or bring in new vascularity to promote tissue healing. These measures must therefore be used only as part of a larger treatment plan. Hence the present study aims to compare the effect of a combination of Mulligan mobilisation (a manual therapy approach) and ultrasound treatment with that of ultrasound therapy alone. A progressive exercise programme was instituted after ten sessions in order to enhance strength and facilitate return to work.

Ultrasound therapy has been used traditionally for treatment of tennis elbow. A study by Binder et al (1985) suggested that ultrasound therapy enhanced recovery in 63% of cases compared to 29% who received a placebo. Lundeberg et al (1988) reported improvement in 36% of patients treated with ultrasound therapy versus 30% receiving a placebo. Though ultrasound proved more effective than rest, it was not superior to the placebo condition. Haker and Lundeberg (1991a) reported a similar outcome. Reviews by Labelle (1992) and Wright and Vincenzeno (1997) also suggested that ultrasound provided little benefit beyond that of a placebo.

Progressive exercise therapy was shown to be superior to ultrasound therapy in an eight-week trial by Peinimaki et al (1996). A subsequent study (Peinimaki et al 1998) reported beneficial long-term effects over three years of a graduated exercise programme over ultrasound. Rehab-ilitative exercises are thought to improve the quality of the injured tissues, allowing them to absorb safely the forces imposed by the lifestyle of individual patients (Garret, 2000).

There are limited data on research protocols investigating mobilisation for tennis elbow. Mulligan mobilisation has shown encouraging results in musc-uloskeletal disorders where pain is the predominant symptom. Brien and Vicenzino (1998) and Kavanagh (1999) successfully tried it for ankle sprains. Vicenzino and Wright (1995) also demonstrated improvements in both pain and function following treatment with Mulligan's lateral glide technique for tennis elbow in a single case study.

This study was designed to evaluate whether the addition of this technique to the traditional regime would alter the outcome. Patients with lesions involving the tenoperiosteal junction of extensor carpi radialis brevis were included in the study.

Section snippets

Materials

  • 1.

    Ultrasound therapy equipment (Phi Action 190, Uniphy, Eindhoven).

  • 2.

    Mulligan belt, an adjustable belt about 8 feet long, made from car seat belt material, with easily released clasp.

  • 3.

    Hydraulic hand dynamometer (Chattanooga Group Inc, Hixson, USA).

  • 4.

    Weights.

Sample

Sixty-six patients (male: female ratio 6:5), with an age range of 23-71 (mean 41) years were recruited from the physio-therapy unit in the Department of Orthopaedics at the All India Institute of Medical Sciences. The duration of their

Results

All the groups were similar with respect to age, sex, occupation, involved side and duration of onset (Table 1, Table 2). Also there were no significant differences at baseline in VAS, weight test and grip strength between the groups. Compliance with the exercise therapy was good. Most patients in the MM group showed complete recovery. There were five recurrences in the ultrasound therapy group. The control group failed to show any statistically significant change in any parameter.

Discussion

The baseline characteristics of the three groups were similar in all respects. VAS, grip strength, weight test and patient assessment have been widely used as diagnostic and prognostic tools for research in tennis elbow. The patients' progress in all the above parameters shows close conformity, justifying their use. Grip strength is reported to be a valid test in diagnosing and evaluating progress in tennis elbow (Stratford et al, 1987). Grip strength, the weight test and VAS have been used in

Conclusion

The results of this study suggest that addition of Mulligan mobilisation to a regimen comprising ultrasound therapy and progressive exercises enhances the recovery of patients with tennis elbow.

References (37)

  • SA Chilton

    ‘Tennis elbow: A combined approach using acupuncture and local corticosteroid injection’

    Acupuncture in Medicine

    (1997)
  • A Clarke et al.

    ‘Comparison of two steroid preparations used to treat tennis elbow using hypospray’

    Rheumatology and Rehabilitation

    (1974)
  • LG Clements et al.

    ‘Effectiveness of custom-made below-elbow lateral counterforce splint in treatment of tennis elbow’

    Canadian Journal of Occupational Therapy

    (1993)
  • J Cyriax

    ‘The elbow’

  • CS Enwemeka

    ‘The effects of therapeutic ultrasound on tendon healing: A biomechanical study’

    American Journal of Physical Medicine and Rehabilitation

    (1989)
  • WE Garrett et al.
  • E Haker et al.

    ‘Pulsed ultrasound treatment in lateral epicondylalgia’

    Scandinavian Journal of Rehabilitation Medicine

    (1991)
  • E Haker et al.

    ‘Lateral epicondylalgia: Report of non-effective midlaser treatment’

    Archives of Physical Medicine and Rehabilitation

    (1991)
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    Ms Moneet Kochar BSc(Physiotherapy) MPTh(Osteomyology) and Mr Ankit Dogra BSc (Physiotherapy) work at the All India Institute of Medical Sciences, C1/8, AIIMS Campus, Ansari Nagar, New Delhi 110029, India

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