The Orthopaedic Research Institute–Tennis Elbow Testing System: a modified chair pick-up test—interrater and intrarater reliability testing and validity for monitoring lateral epicondylosis

doi:10.1016/j.jse.2003.09.017

Journal of Shoulder and Elbow Surgery

Volume 13, Issue 1, January–February 2004, Pages 72-77

https://doi.org/10.1016/j.jse.2003.09.017 Get rights and content

Abstract

Lateral epicondylosis is a degenerative overuse tendinopathy involving the extensor tendons of the forearm, predominantly the extensor carpi radialis brevis, in the region of the lateral epicondyle of the elbow. The Orthopaedic Research Institute–Tennis Elbow Testing System (ORI-TETS) is designed to record objective measurements of force generated with a simulated chair pick-up test. Interrater reliability of the ORI-TETS was excellent, with high intraclass correlation coefficients (ICCs) for right arm mean peak force of 0.93, left arm mean peak force of 0.84, right arm mean total force of 0.93, and left arm mean total force of 0.86. The ORI-TETS also demonstrated excellent intrarater reliability, with ICCs ranging from 0.9 to 0.97. The relative technical error of the ORI-TETS for all measurements ranged from 5.8% to 7.2%. Testing patients with lateral epicondylosis (N = 16) and comparing analog pain scores with ORI-TETS testing demonstrated a strong negative relationship between the two parameters (Spearman ρ, −0.87 to −1.0). Thus, the ORI-TETS is a reliable and reproducible testing system for the forearm extensors. The testing system is inexpensive, takes 5 minutes to perform, and demonstrates good predictive value for objectively assessing patients with lateral epicondylosis. This system could be used for routine clinical monitoring of patients with lateral epicondylosis.

Section snippets

Materials and methods

The ORI-TETS is a simulated chair pick-up test and consists of a vertical handboard attached to a horizontal lever arm, which, in turn, is connected to an adjustable vertical tensile cord in series with a 45-N Xtran K4 load cell (RS Components, Sydney, Australia). The load cell is connected to a transducer, and force data are recorded and stored directly onto computer hard drive by use of National Instruments LabView 5.1 system technology (Austin, TX) (Figure 1).

The testing protocol involved

Results

The results of interrater reliability testing with the ORI-TETS demonstrated ICCs ranging from 0.80 to 0.93 (Table I). ICC scores for all measured parameters in these right hand–dominant subjects were consistently higher on the right hand side than on the left.

Intrarater reliability testing with the ORI-TETS demonstrated higher ICC scores as outlined in Table II, with ICCs ranging from 0.9 to 0.97.

The relative technical error of the measurement for the ORI-TETS was very low, with individual

Discussion

The interrater reliability scores (ICCs) for all measured and calculated parameters were of a very high order and indicate that this testing system can be used with great reliability by different examiners. There did not appear to be a significant learning effect with interrater reliability testing, as there was no evidence of consistently increasing scores with any measured parameter. This may be because the test is relatively simple or because subjects were allowed to practice the test before

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Cited by (26)

Counterforce bracing of lateral epicondylitis: a prospective, randomized, double-blinded, placebo-controlled clinical trial
2019, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
The inclusion criteria for the clinical trial required that the patients be 18 years or older, have a clinical diagnosis of lateral epicondylitis (point tenderness over the lateral epicondyle and exacerbation of pain with the chair pick-up test and maximal hand grip), and have a duration of symptoms between 4 weeks and 6 months at presentation. The chair pick-up test, in which the patient attempts to lift a chair by gripping the back rest with the elbow flexed to 90°, hand in palmar flexion, and forearm pronated, was chosen as it loads the extensor tendons of the wrist.20 Patients were excluded if they underwent previous surgery or suffered a dislocation of the affected elbow, if they received a corticosteroid injection in the affected elbow within the past 3 months, or if there was any scarring over the elbow or sensory and/or motor changes distal to the elbow.
Counterforce bracing is one of the common treatment modalities for tennis elbow. The objective of this study was to determine whether counterforce bracing offers any additional benefit over placebo bracing in the treatment of tennis elbow.
This prospective, randomized, double-blinded, placebo-controlled clinical trial investigated the use of counterforce bracing (n = 17) compared with placebo bracing (n = 14) in the management of acute tennis elbow. Outcome measures included patient-rated pain and functional outcomes, epicondyle tenderness, and strength at 6 months and long term. Follow-up occurred at 2, 6, 12, and 26 weeks, as well as long term (mean follow-up, 3 years). The study duration was 5 years.
The 2 groups, counterforce and placebo, were similar in age, sex, hand dominance, and duration of symptoms. Both braces improved patient-rated pain frequency and severity (P < .01), difficulty with picking up objects and twisting motions, and overall elbow function (P < .001) at 6 months and 3 years. Both braces also improved lateral epicondyle tenderness, grip strength (P < .01), and modified ORI-TETS (Orthopaedic Research Institute–Tennis Elbow Testing System) force (P < .05) at 6 months. Significant intergroup differences were detected for frequency of pain at rest at 6 and 12 weeks (P < .05), level of pain at rest at 2 weeks (P < .001), and patient-rated overall elbow function at 26 weeks (P = .041).
The counterforce brace provides significant reduction in the frequency and severity of pain in the short term (2-12 weeks), as well as overall elbow function at 26 weeks, compared with the placebo brace.
The role of nitric oxide in tendon healing
2012, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
Both groups received tendon rehabilitation. The GTN group had reduced elbow pain at 2 weeks (P = .01), reduced elbow pain with activity at 2 weeks (P = .01), reduced epicondylar tenderness at 6 and 12 weeks (P = .02), and an increase in wrist extensor mean peak force and total work at 24 weeks (P = .03).12 In activities of daily living, 81% of patients on GTN patches were asymptomatic compared with 60% of patients with tendon rehabilitation alone (P = .05).16
Nitric oxide (NO) is a small free radical that is generated by a family of enzymes called the nitric oxide synthases (NOS). There are 3 isoforms of NOS: endothelial NOS (eNOS), brain or neuronal NOS (bNOS), and inducible NOS (iNOS). In experiments performed during the last 20 years, we have shown that NO is induced by all 3 isoforms of NOS after tendon injury and that NOS activity is upregulated in tendinopathy. In normal uninjured tendons, there is very little NOS activity. In injured rat and human tendons, NOS activity was found in healing fibroblasts in a temporal fashion. In animal models, competitive inhibition of NOS resulted in reduced tendon healing, whereas the addition of NO resulted in enhanced tendon healing. In cultured human cells, the addition of NO via chemical means and adenovirus transfection resulted in enhanced collagen synthesis. We performed 3 randomized, double-blinded clinical trials that demonstrated a significant positive beneficial effect of NO treatment on clinical symptoms and function in patients with Achilles tendinopathy, tennis elbow, and supraspinatus tendonitis. NO was delivered via glyceryl trinitrate (GTN) patches. We also conducted a 3-year prospective follow-up that demonstrated significant long-term efficacy of GTN patches in treating noninsertional Achilles tendinopathy. In a 5-year prospective comparison treating lateral epicondylitis, we found no additional benefits of GTN vs placebo at 5 years. The use of a new GTN patch, OrthoDerm, demonstrated no evidence for efficacy in treating chronic lateral epicondylitis.
Combined Multimodal Therapies for Chronic Tennis Elbow: Pilot Study to Test Protocols for a Randomized Clinical Trial
2009, Journal of Manipulative and Physiological Therapeutics
The objective of this project was to develop and test protocols for a randomized clinical trial (RCT) of 2 multimodal package therapies for chronic lateral epicondylitis.
Six participants were enrolled after case review and randomized to 1 of 2 groups (4 in group A and 2 in group B). Group A had high-velocity low-amplitude manipulation, high-voltage pulse galvanic stimulation, counterforce bracing, ice, and exercises, whereas group B had ultrasound, counterforce bracing, and exercise. Both groups had 12 weeks of active care and instructed to restrict usage of the affected elbow. Participants filled out a visual analog scale and the Patient Rated Tennis Elbow Evaluation every week. The pain-free grip strength test was measured at baseline, and at the end of the third, sixth, ninth, and twelfth visits.
One participant in group A dropped out before the end of care. Both groups demonstrated changes in all of the outcome variables from the baseline to the end point (12 weeks) of treatment. Sample size for a larger future randomized clinical trial was calculated as n = 246 participants.
The pilot study demonstrated that the study design is feasible and that patients could be recruited for a 12-week trial of multimodal treatment. A larger trial is warranted in a multicenter setting to detect differences in the effects of these treatment strategies.
What are the Best Diagnostic Criteria for Lateral Epicondylitis?
2009, Evidence-Based Orthopaedics: The Best Answers to Clinical Questions
What are the best diagnostic criteria for lateral epicondylitis?
2008, Evidence-Based Orthopaedics: The Best Answers to Clinical Questions
Oxygen free radicals and tendon healing
2007, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
In other words, NO was applied in addition to “best practice.” The NO group had reduced elbow pain with activity at 2 weeks (P = .01), reduced epicondylar tenderness at 6 and 12 weeks (P = .02), and an increase in wrist extensor mean peak force and total work at 24 weeks26 (P = .03). At 6 months, 81% of patients with GTN patches were asymptomatic in activities of daily living compared with 60% of patients with tendon rehabilitation alone (P = .005 with χ2 analysis) (Figure 5).
Nitric oxide is a small free radical generated by a family of enzymes, the nitric oxide synthases (NOSs). In a series of experiments performed over the last 15 years, we showed that nitric oxide is induced by all 3 isoforms of NOS during tendon healing and that it plays a crucial beneficial role in restoring tendon function. In normal tendons, very little NOS activity was found, whereas in injured rat and human tendons, NOS activity was expressed in healing fibroblasts in a temporal fashion. In healing rat Achilles tendon fibroblasts, the first isoform to be expressed was endothelial NOS, followed by inducible NOS and then brain or neuronal NOS. Systemic inhibition of NOS activity decreased the cross-sectional area and mechanical properties of the healing rodent Achilles tendons. The addition of nitric oxide via nitric oxide–flurbiprofen enhanced rat Achilles tendon healing. The addition of nitric oxide to cultured human tendon cells via chemical means and via adenoviral transfection enhanced collagen synthesis, suggesting that one mechanism for the beneficial effect of nitric oxide on tendon healing might be via matrix synthesis. Most recently, 3 randomized, double-blind clinical trials evaluated the efficacy of nitric oxide donation via a patch in the management of the tendinopathy. In all 3 clinical trials, there was a significant positive beneficial effect of nitric oxide donation to the clinical symptoms and function of patients with Achilles tendinopathy, tennis elbow, and supraspinatus tendinitis.

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^☆: This research was supported in by the St George Hospital–South Eastern Sydney Area Health Service.

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Original articleThe Orthopaedic Research Institute–Tennis Elbow Testing System: a modified chair pick-up test—interrater and intrarater reliability testing and validity for monitoring lateral epicondylosis☆

Abstract

Section snippets

Materials and methods

Results

Discussion

Corticosteroid injections for lateral epicondylitisa systematic review

Br J Gen Pract

Lateral epicondylitisa review of structures associated with tennis elbow

Anat Clin

Tennis elbowdiagnosis, pathology and treatment: nine cases treated by a new reconstructive operation

Clin Orthop

Original article
The Orthopaedic Research Institute–Tennis Elbow Testing System: a modified chair pick-up test—interrater and intrarater reliability testing and validity for monitoring lateral epicondylosis☆