Progressive Strengthening and Stretching Exercises and Ultrasound for Chronic Lateral Epicondylitis

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RESEARCH REPORT

Progressive Strengthening and Stretching Exercises and Ultrasound for Chronic Lateral Epicondylitis Tuomo T Pienimaki Tuula K Tarvainen Pertti T Siira Heikki Vanharanta Key Words Epicondylitis, physical exercise, ultrasound, pain, muscle strength.

Summary Thirty-nine patients suffering from chronic lateral epicondylitis were randomised into two treatment groups. The first group (n = 20) was treated with progressive slow, repetitive wrist and forearm stretching, muscle conditioning and occupational exercises, which were intensified in four steps. The second group (n = 19) was treated with pulsed ultrasound. The effect of six to eight weeks’ treatment was measured by a pain questionnaire (visual analogue scale), isokinetic muscle performance testing of wrist and forearm, and isometric grip strength measurements. In the follow-up visit after eight weeks’ treatment, pain at rest and under strain had decreased and subjective ability to work increased in the exercise group significantly more than in the ultrasound group (p = 0.004,0.04 and 0.004). Correspondingly, sleep disturbance was alleviated significantly more in the exercise group (p = O.Ol).The isokinetic torque of wrist flexion increased by 45% in the exercise group and declined by 4% in the ultrasound group (p = 0.0002). Maximum isometric grip strength increased 12 % in the exercise group and remained unchanged in the ultrasound group (p = 0.05). During treatment six of eight patients in the exercise group and three of nine patients in the ultrasound group became able to work. All clinical manual provocation tests for tennis elbow improved within the exercise group. The results indicate that progressive exercise therapy is more effective than ultrasound in treating chronic lateral epicondylitis, reducing pain and improving patients’ ability to work.

Introduction The tennis elbow syndrome, o r lateral epicondylitis, is generally a work-related or sportrelated pain disorder of the common extensor origin of the arm, usually caused by excessive quick, repetitive movements of the wrist and forearm. These quick movements may rupture the proximal attachment of the long extensor muscles and cause local inflammation and pain. Cervical root irritation, shoulder problems, local bursitis or radiohumeral synovitis and posterior interosseus nerve entrapment are implicated in epicondylalgia (Goldie, 1964) and adverse neural tension is also said to contribute t o the epicondylar pain (Yaxley and Gwendolen, 1993).

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Acute cases will usually improve when the cause is avoided as well as with anti-inflammatory drugs or local corticosteroid injections. According to several studies of both conservative and operative methods, chronic cases are often difficult to treat. They cause prolonged disability and inability t o work (Binder and Hazleman, 1983). The tennis elbow syndrome is an important, separate, strain injury-related cause of premature retirement from working life. Outcome from conservative treatment methods is variable. Local steroid injections are widely used in chronic cases (Labelle et al, 1992) and have been shown to be more effective than ultrasound and placebo ultrasound therapy in a clinical trial (Binder et al, 1985). Manipulative and electrotherapy methods have been used with limited effect (Wadsworth, 1987; La Freniere, 1979; Mills, 1928). Continuous and pulsed ultrasound treatment has produced conflicting results (Binder and Hazleman, 1983; Binder et al, 1985; Haker and Lundeberg, 1991; Kivi, 1983; Lundeberg et a l , 1988; Reginssen, 1990) and pulsed ultrasound has been reported to be no better than placebo ultrasound (Haker and Lundeberg, 1991). In practice, treatment is usually a combination of therapies which makes the effects of each separate method difficult to assess. In an attempted meta-analysis, Labelle et al (1992) showed the contradictory results of different therapies. Therefore, randomised therapy studies in the treatment of lateral tennis elbow syndrome are needed t o provide more scientific data. There are few publications on the effect of therapeutic exercises as the sole treatment method (La Freniere, 1979; Fillion, 1991). Strengthening the damaged attachment of the wrist extensors so that it can better tolerate repetitive movements might be beneficial. Continuous passive movement improves tissue healing in many connective tissue problems (Akeson et al, 1991) and active rehabilitation programmes have been successful in treating chronic back patients. Therefore, we decided t o test if an active programme would be effective in the treatment of chronic epicondylitis. As pulsed ultrasound is widely used for epicondylitis (Reginssen, 1990; Haker and Lundeberg, 1991), it was selected

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for comparison. Increased protein synthesis in tissues has been demonstrated at low intensities below 0.5 W/cm2 (Dyson and Suckling, 1978). Haker and Lundeberg (1991) used 1 MHz frequency and 1 W/cm2intensity in treating lateral epicondylalgia with pulsed ultrasound. Evaluation of different treatment methods is usually based on pain relief or subjective wellbeing assessed by pain questionnaires. The effects of therapies on arm function are rarely assessed. Isometric grip strength appears to be a suitable method for evaluating treatment outcome in lateral epicondylitis (Thurtle et al, 1984). Isokinetic testing of muscle performance is a newer method that is used more commonly in sports and rehabilitation clinics to test function and outcome from rehabilitation. Although it has several limitations in practical use, it is safe even in painful conditions (Friedlander et al, 1991). Isokinetic wrist flexion, extension, supination and pronation torques may describe the functional limitation in the disorder better than isometric grip strength. Additionally, produced work, which describes arm function better, can be evaluated with isokinetic devices. Therefore we decided t o measure arm function with both the isometric and isokinetic testing methods. The aim of the study was to explore the effects of a progressive stretching and strengthening exercise programme in chronic lateral epicondylitis and to compare the effects of this treatment with the results of local pulsed ultrasound treatment.

Methods Subjects Thirty-nine patients (14 men, 25 women, mean age 42.3 f 5.4 years, range 31-53 years) with clinically diagnosed chronic unilateral epicondylitis took part in this study. They were selected from patients referred to the Oulu University Hospital for clinical evaluation and treatment by their general practitioners because they had not responded t o primary treatment. Thirty of them had had symptoms for over three months, and nine of them for over one year. All had been treated in different ways before entering the study. General data and previous treatments are listed in tables 1and 2. Clinical Examination and Exclusion and Inclusion Criteria All referred patients were examined by a physician who also examined selected patients after the treatment period. The principal exclusion criteria were cubital osteo-arthritis, carpal or radial tunnel syndrome, rheumatoid arthritis, severe cervical spondylosis or cervical radicular

Table 1: Patient data (N = 39) Exercise group

UItrasound group

No of patients 20 Menlwomen 8112 Mean age (years) 43 (33-53) Mean height (cm) 166 (152-182) Mean weight (kg) 73 (50-98) Smokerslnon-smokers 10/10 Strenuous hobby using arms 11 Regular sport activity 6 Duration of symptoms Under 6 months 9 Over 6 months 11 Duration of sick leave (mean, weeks) 6.3 Non-participants* 1

19 6113 41 (31-53) 166 (154-179) 75 (52-108) 10/9 9 5 11 8 7.1 2

*Excluded from results above and from statistical analysis in the study. See text.

Table 2: Previous treatments ~

~ _ _ _ _ _ _ _ _

Number of patients (N = 39) Exercise gp Ultrasound gp Total lmmobilisation Local injections (n = 82) Oral medication Percutaneous medication support Physical therapy

4 20 18 11 11 12

4 15 18

8 7 7

8 35 36 19 18 19

syndrome, painful shoulder or rotator cuff tendinitis, previous fractures of arm causing limitations in arm function, and no clinical signs of tennis elbow syndrome. To be included in the study, all patients had a positive Mill’s test (Wadsworth, 1987) and resisted wrist and/or middle finger extension produced typical pain at the origin on the lateral epicondyle. A third inclusion criterion was local tenderness on palpation over the lateral epicondyle. The results of the three manual provocative tests were recorded for evaluation of treatment outcome. Sick leave was recorded and ability to work assessed.

Test and Measurements Patients completed a pain and disability questionnaire including a visual analogue scale WAS). The questions covered pain at rest, pain under strain, ability to work, ability to lift objects, restrictions on hobbies and sleep disturbance. Patients indicated the intensity of the pain on a 10 cm long non-segmented line. The questions were to determine the extent of pain in the upper limb. Pain under strain was also assessed during testing of muscle strength. Muscle function was measured independently by a third physiotherapist who was ‘blind’ to the patients’ therapy group and who did not treat the patients at all.

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Isometric grip strength was measured with a strain-gauge dynamometer (Newtest Oy, Oulu, Finland) whose repeatability and usefulness has been demonstrated (Malkia, 1983). Three measurements were made of three different grips (1 cm, 2 cm and 3 cm). The mean value of nine repetitions was calculated and the maximum value of repetitions was recorded. The isokinetic muscle performance of the wrist and forearm was measured with a n isokinetic multi-joint active device (Loredan, Davis, California), the Lido Active multi-joint dynamometer which has previously been demonstrated to be both valid and reliable (Patterson and Spivey, 1992). It was used at a velocity of 90"/second in wrist flexion-extension movements and in forearm supination-pronation movements. The muscle work used was concentric. Ten repetitions were made at each position. From the versatile collected data, peak torque and total work results were analysed.

Procedure The physician selected patients for the trial on the basis of his clinical assessment and randomly allocated them to exercise and ultrasound groups by drawing lots. There were three immediate dropouts, one in the exercise group and two in the ultrasound group, for personal reasons which prevented participation. The 20 patients in the exercise group were trained in a four-step home exercise programme. They visited the physiotherapist once every other week for follow-up examination and t o receive a new, more intensive programme. The exercises started with slow fist-clenching, resisted wrist movements, and wrist rotations with a stick (step 11, followed by movements against a band (step 2) and two-way resisted wrist rotations and pressing hands against a wall (step 3 ) . The patients performed the exercise programmes four t o six times daily a t home. Each programme included ten repetitions in two or three series for each exercise. The fourth step was a versatile occupational

Fig 1: Clenching fist strongly

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training programme. Every exercise period ended with stretching for at least 30 seconds in both flexion and extension and each individual exercise movement was done slowly while the patient counted to eight. The steps of the programme are presented in table 3 and figures 1to 10. Table 3: Progressive exercise programme, steps 1 to 4

Exercises

Figures

Step 1 Clenching fist strrongly Resisted wrist extension Resisted wrist flexion Wrist rotation with a stick Towards the little finger Towards the thumb End: stretching at least 30 seconds to flexion and extension Step 2 Exercises against an elastic band for: Wrist extension Wrist flexion Wrist radial deviation Wrist ulnar deviation End: stretching 30 seconds (as in step 1) 10 x 3 series, several repetitions daily Step 3 Combined wrist rotary movements using eg tabie top as a support Upwards, resisted from below Towards the little finger Towards the thumb Donwards, resisted from above Towards the little finger Towards the thumb Pressing hands against a wall End: stretching 30 seconds 10 x 3 series, several repetitions daily Step 4 An occupational training programme, including: Soft ball compressing exercises Transferring buttons from cup into another Twisting a towel into a roll Rotating hand on a table, in both directions, etc

6

7 8

9

10

End: stretching 30 seconds This program can be performed together with one of steps 1-3 Each separate movement and exercise in each step must be done while slowly counting to eight.

Fig 2: Resisted wrist extension exercises

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Fig 3: Resisted wrist flexion exercises

Fig 7: Wrist flexion exercises against an elastic band

Fig 4: Wrist rotation with a stick towards the little finger

Fig 8: Exercises for radial deviation

Fig 5: Stretching to flexion

Fig 9: Pressing hands against a wall

Fig 6: Wrist extension exercises against an elastic band

Fig 10: Twisting a towel into a roll

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The 19 patients in the ultrasound group received local pulsed ultrasound from 0.3 t o 0.7 W/cm2 two t o three times a week from a Diter S 3000 ultrasonic machine (Diter-Elektroniikka Oy, Turku, Finland). The pulse ratio was 1:5, the duration of pulse 2 ms, and frequency 1MHz. The radiated area was 5 cm2 over the common extensor origin. Treatment time was 10 t o 15 minutes. The treatment for each group was continued for six t o eight weeks during which time they had no other treatment. The same physiotherapist carried out the exercise programmes and treated four of the 19 patients in the ultrasound group. The other 15 patients were treated by another physiotherapist with exactly the same treatment protocol. The questionnaire was completed and clinical examination, isometric and isokinetic muscle testing were done with exactly the same protocols before and after the treatment period.

Analysis of Data Changes in sick leave, clinical manual tests, pain scores, grip strength and isokinetic muscle performance of the upper limbs were calculated from the data and compared between the groups. Statistically the results within and between the treatment groups were compared using the Student’s t-test, ANOVA with repeated measures, the Wilcoxon test for matched pairs or the MannWhitney test.

Results The Sample The mean age of the sample (42 years) is typical for tennis elbow patients. Data are summarised in table 1.There were minor differences between the study groups. Patients in the ultrasound group were two years younger than patients is the exercise group (average 41 and 43 years respectively). There were a few more men in the exercise group (40%) than in the ultrasound group (32%)(and the mean initial values of isometric grip strength and isokinetic torques were consequently lower in the ultrasound group). The occupations of the patients were similar i n both groups although more patients in the ultrasound group who had heavy work were unable to work. Patients in the ultrasound group had also a little more pain under strain and were more restricted is pursuing their hobbies at the beginning of treatment. They had had a variety of treatments before being referred by their general practitioners (table 2). Analysed data were from three sources: the pain questionnaire filled in by patients providing

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subjective data, objective tests of muscle function carried out by the physiotherapist and the manual provocative tests and assessment of ability to work carried out by the physician.

Pain (table 4) Pain at rest increased in the ultrasound group 0.2 cm on the VAS and decreased 1.9 cm on the VAS in the exercise group during treatment. The difference between the groups was statistically significant (p = 0.004). Pain under strain diminished 1.4 cm in the ultrasound group and 3.5 cm in the exercise group (p = 0.04). From the pain questionnaire scales, the mean subjective inability to work declined 3.3/10 cm WAS) in the exercise group and 0.5/10 cm in the ultrasound group. The mean final values were 3.7 and 6.7 cm in the groups. The difference between the groups was statistically significant (p = 0.004). Additionally, mean sleeping disturbance decreased 1.9 cm on VAS in the exercise group and increased 0.2 cm in the ultrasound group. The difference between the groups was statistically significant (p = 0.01). Changes in restrictions on hobbies were almost the same in both groups. Isokinetic Tests (table 5) In the exercise group, the mean isokinetic torque of wrist flexion increased by 45% from 10.1 to 14.7 Nm. The torque declined from 9.6 to 9.3 Nm (4%) in the ultrasound group. Both the difference between the groups (p = 0.0002) and the change within the exercise group (p = 0.0001) were statistically significant . The results were quite similar in flexor work production (p = 0.0002 between group difference),which correlated well with peak torque values. The mean values of work produced by wrist flexion increased by 62% from 10.0 to 16.1 joules per repetition. In the ultrasound group, the mean values were 9.7 and 9.2 joules and the work produced decreased 5%. The extent of change was statistically significant between the groups (p = 0.0002). Total work done per repetition in wrist extension improved in the exercise group and the difference between the groups was statistically significant (p = 0.05). No significant differences between the groups were found for wrist extension peak torques, forearm pronation or supination peak torques or produced work. Grip Strength (table 6) Although the maximal isometric grip strength increased 12.2% in the exercise group and remained unchanged in the ultrasound group, the difference between the groups was not statistically significant (p = 0.05). The change in isometric grip strength was similar to the isokinetic muscle performance in wrist flexion.

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Table 4: Mean changes (decreases/increases in cm) on visual analogue scale of different pain qualities in both groups f a i n quality

Exercise group (n = 20) Initial Change value cm (SO)

Pain at rest Pain under strain Working inability Lifting inability Hobby limitations Sleep disturbance

3.7 7.3 7.0 4.2 4.6 3.8

-1.9 -3.5 -3.3 -2.1 -1.5 -1.9

Ultrasound group (n = 19) Initial Change value cm (SO)

(1.8) (3.5) (2.7) (4.8) (2.0) (1.9)

3.7 7.8 7.0 4.9 6.1 4.4

0.2 -1.4 -0.5 -1.3 -1.0 0.2

Difference of changes

-0.7, -9.1, -0.9, 1.7, 1.5, -0.6,

-2.1 -2.1 -2.8 -0.8 -0.5 -2.1

(2.6) (2.9) (2.9) (2.7) (3.8) (3.0)

95% CI of difference between groups -3.6 -4.3 -4.6 -3.3 -2.4 -3.8

P between groups

0.004 0.04 0.004 0.52* 0.06* 0.01

The table contains initial mean values and changes (cm) and standard deviations (SD) of changes. Negative change (-) shows decrease in reported pain. Statistical significance between the groups is tested with Student's unpaired t-test. *Not significant

Table 5: Changes (mean and SD) between initial and final isokinetic peak torque (Nm) and isokinetic work per repetition (joules) values of wrist and forearm muscle performance in both treatment groups at an angular velocity of 90"/second Movement

Exercise group (n = 20) Initial Change value cm (SO)

Ultrasound group ( n = 19) Initial Change value cm (SO)

Difference of changes

95% CI of difference between groups

P between groups

Wrist Flexion Torque (Nm) Work (J)

10.1 10.0

+4.6 (3.9) +6.1 (5.0)

9.6 9.7

-0.4 -0.4

(2.9) (3.5)

5.0 6.5

2.7, 7.4 3.5, 9.6

0.0002 0.0001

Torque (Nm) Work (J)

5.7 6.0

+0.6 (1.7) +0.9 (2.0)

5.4 5.4

-0.1 -0.3

(1.6) (1.3)

0.7 1.2

-0.4, 1.9 0.0, 2.4

NS 0.05

Forearm Supination Torque (Nm) Work (J)

6.4 7.3

+0.9 (2.1) +0.9 (2.6)

6.0 6.7

0.0 (1.5) -0.8 (2.3)

0.9 1.7

-0.5, -0.2,

2.4 3.6

NS NS

6.1 6.7

+0.9 (1.3) +0.6 (1.2)

5.7 6.1

-0.1 -0.4

(1.8) (2.4)

1.o 1.o

-0.2, -0.3,

2.1 2.4

NS NS

Extension

Pronation Torque (Nm) Work (J)

Table 6: Mean and maximal isometric grip strength (newtons) of involved arms before and after treatment in both groups ~~

Before treatment Mean (SD)

After treatment Mean (SO)

Change

~

P within group

Differences between groups

P between groups

Mean isometric grip strength 9 repebtions EG

305

(152)

357

(149)

+52

0 003

UG

244

(100)

255

(103)

+11

0 45*

0 02

41

0 6*

41

0 05

Maximal isometric grip strength EG

361

(159)

404

(164)

+43

UG

301

(114)

303

(122)

+2

0 92*

Values are means (SD) Change within each treatment group is analysed with Student's t-test and statistical difference between the treatment groups using analysis of variance with repeated measures EG = exercise group (n = 20) UG = ultrasound group (n = 19). *Not significant

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Manual Provocative Test (table 7) To meet the inclusion criteria, the three tests were positive for all patients before treatment. Nine patients in the exercise group and 16 in the ultrasound group had positive Mill’s test after treatment. The change was statistically significant within the exercise group. Changes in palpation and in resisted wrist or middle finger extension were significant during the treatment period for the exercise group also. The changes in the provocative tests were not statistically significant for the ultrasound group. Table 7: Positive clinical manual tests in both treatment groups before and after treatment ~

Before treatment

After treatment

Change Zvalue within group

Pvalue within group

Palpa tion, lateral epicondyle EG UG

20 19

13 17

-7 -2

-2.4 -1.3

0.02 0.18*

-8 -1

-2.5 -0.53

0.01 0.59*

Resisted wrist extension EG UG

20 18

12 17

Resisted middle finger extension EG UG

19 17

11 15

-8 -2

-2.2 -1.34

0.02 0.18*

20 19

9 16

-11 -3

-2.9 -1.6

0.003 0.11*

Mill’s test EG UG

Values are number of patients = number of positive tests. Statistical significance within each group is tested with non-parametric Wilcoxon test for matched pairs. EG = exercise group (n = 20). UG = ultrasound group (n = 19) *Not significant

Ability to Work and Sick Leave (table 8) Before treatment, 40% of the exercise group and 47.4% of the ultrasound group were unable t o work. After the therapy, only 10% of the exercise group and 31.6% of the ultrasound group were absent from work. The difference between the groups was not statistically significant (p = 0.07). Table 8: Patients unable to work before and after the treatment in both groups Before treatment No (“A) Exercise group (n = 20) Ultrasound group (n = 19)

8 9

(40.0) (47.4)

After treatment No (“A) 2 6

(10.0) (31.6)

Discussion The study fulfilled the aims of exploring the effects of progressive exercise therapy on chronic lateral epicondylitis and comparing these effects with outcomes from pulsed ultrasound. The progressive strengthening and stretching exercise

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therapy resulted in significantly better subjective and objective short-term outcomes than pulsed ultrasound therapy. It reduced pain at rest and under strain, improved arm function and muscular performance of the wrist and forearm. Results of clinical tests improved in the exercise group showing a good correlation with the healing process. The exercise treatment also had good effects on subjective and objective working ability, which is important in the prevention of prolonged disability.

Changes in Level of Pain, Function and Ability to Work The main purpose of statistical analysis was to identify significant changes in pain, muscle function of the involved upper limbs, working ability and clinical manual testing within and between the treatment groups and t o compare differences between the groups. Therefore the extent of change, not the level of initial values, is the important factor. The wrist flexion torque is reduced in the tennis elbow syndrome. Not only was it improved significantly by the exercise programme but the improvement correlated well with functional improvement in the upper limb and changes in maximum isometric grip strength. Little change was noted in the extension torques of the wrist but improved work production values show that ability to use the extensor muscles improved in the exercise group. Exact measurement analysis was more difficult on the extensor side, because the peak torque values were small (mostly only 3 to 5 Nm), than on the flexor side where torques were much greater. The relatively small effect on extension forces can be explained by the fact that the damage on the extensor side of the wrist is linked to eccentric rather than concentric muscle work, and eccentric muscle work was not tested in this study. The isometric grip strength did not increase as much as wrist isokinetic flexion torque, perhaps because of greater painful strain on the affected muscle tendon region in isometric muscle contraction. Maximal isometric grip strength increased significantly more in the exercise group, reflecting short-term ability to use the hand. The treatment period was not long enough t o provide results about endurance. Pain at rest and under strain also declined significantly more in the exercise group. This shows that active exercises may have an effect on pain experience in patients. Reported pain under strain represents both painful isometric and isokinetic muscle work in patients’ responses in the pain questionnaire. Pain has an important role underlying decreased muscle function

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and cannot be ignored in analysis of results from muscle function tests. Additionally, characteristics of a patient’s occupation affect the ability to work. Different types of work produce different strains on the upper limb in different patients and, therefore, the change in ability to work noted within each treatment is important. In the exercise group, more patients became able t o do their usual work than in the ultrasound group. Finally, while the results are overwhelmingly in favour of exercise therapy, tennis elbow syndrome is reported to be a self-limiting disorder in some cases (Cyriax, 1936). It is impossible t o know whether or not some of the patients in this study had such a self-limiting disorder and, therefore, whether all measured improvements in pain ratings, muscle function o r ability t o work are attributable to treatment.

Therapeutic Considerations The programme of progressive exercise therapy used in this study appears to offer considerable health gain. I t is inexpensive, because the patients take a n active role and require few treatments and only four follow-up visits t o a physiotherapist. It aims to strengthen damaged tissues. Using slow, repetitive exercise movements for strengthening the soft tissues of the upper limb appears to have beneficial effects in treating chronic strain injuries. As the aetiology of strain injuries such as the tennis elbow syndrome may be repeated rapid movements, slow progressive strengthening exercises may allow tissue healing. Early mobilisation is reported t o have good effects on the tensile strength of connective tissue scars in muscle injury in acute cases (Celberman et al, 1988; Kannus et al, 1992). Eccentric exercises seem t o be stressful to the myotendinous unit (Appell, 1990) and a trend from avulsion-type failures in immobilisation, t o insertion and midsubstance-type failures in remobilisation, has been noted in animal knee ligament studies (Larsen et a l , 1987). Therefore, a progressive, stepwise exercise programme can promote healing without traumatisation. The damaged epicondylar attachment area is an osteotendinal region with the properties of inflamed and atrophied tendon and, in prolonged cases, bony atrophy too. Tipton et a1 (1987) say that ‘prescribed exercises which increase the forces being transmitted t o ligaments, tendons and bones will maintain and generally increase the strength and functional capacity of these structures’. The same principle seems to be valid in the treatment of chronic tennis elbow syndrome. The progressive exercise treatment used in this study

started with slow soft tissue-stretching exercises. The whole programme exercised muscles, tendons and ligaments and also the osteotendineal insertion region, and the fourth step was a more intensive occupational programme t o promote patients’ daily living and ability to work. Pulsed ultrasound was not found to be effective as a sole treatment in treating chronic epicondylar pain. Although pulsed ultrasound 1MHd0.5 W cm2 has been found t o have beneficial effects on protein synthesis (Harvey et al, 1975; Dyson and Suckling, 1978),this kind of ultrasound treatment procedure cannot be recommended. Although the intensity applied in this study was lower, the treatment procedure was similar to the procedure used in the study by Haker and Lundeberg (1991) in which they reported no beneficial effect for pulsed ultrasound over placebo ultrasound.

Conclusions and Recommendations The results indicate that progressive strengthening and stretching exercise treatment is more effective than pulsed ultrasound in treating chronic lateral epicondylitis: it reduced chronic pain and improved upper limb function and the ability t o work of patients in the study. I t may correct the ill-effects of prolonged immobilisation, counter patients’ fear of using the forearm and hands, and help them to return to work. Authors T Tuomo Pienimaki MD was head researcher and principal author. He carried out the clinical evaluation and data analysis. K Tuula Tarvainen PT is a physiotherapist. T Siira Pertti P T carried out the muscle function testing. Heikki Vanharanta MD is a professor of physical medicine and rehabilitation in Oulu University and was the study supervisor. This article was received on October 20, 1995, and accepted on May 16, 1996.

Address for Correspondence Dr Tuomo Pienimaki, Department of Physical Medicine and Rehabilitation, Oulu University Hospital, Kajaanintie 50, FIN-90220 Oulu, Finland.

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Malkia, E (1983). Muscular Performance as a Determinant of Physical Ability in Finnish Adulf Population. Publications of the Social Insurance Institution, Finland, AL:23, page 145. Mills, G P (1928). 'Treatment of tennis elbow', British Medical Journal, 12-13. Patterson, L A and Spivey, W E (1992). 'Validity and reliability of the LIDO active lisokinetic system', Journal of Orthopaedic and Sports Physical Therapy, 15, 32-36. Reginssen, T (1990). 'Effekt av ultralydbehandling - En klinisk kontrollert studie', Fysioterapeuten, 57, 5-8. Tipton, C M, Vailas, A C and Matthes, R D (1987). 'Experimental studies on the influences of physical activity on ligaments, tendons and joints: A brief review', Acfa Medica Scandinavica, 711 , 157-68. Wadsworth, T G (1987). 'Tennis elbow: Conservative, surgical and manipulative treatment', British Medical Journal, 294, 621624. Yaxley, G A ,and Gwendolen, A J (1993). 'Adverse tension in the neural system. A preliminary study of tennis elbow', Australian Physiotherapy Journal, 39,1, 15-22.

periodical review This feature outlines the principal contents of journals and newsletters of Specific Interest Groups. To obtain the publications please contact the honorary secretary of the appropriate group, published in the Annual Report (dispatched to members in April).

Association of Chartered Physiotherapists in Sports Medicine

A personal view of Parkinson's disease

Physiotherapy in Sport

1996, vol XIX, no 2, June/July Tennis elbow - And eccentric rehabilitation

The effects of foam, athletic shoes and aircasts upon L Curry, W Harpur the postural sway of healthy females National Vocational Qualifications

U McC Persson

H J Challis

Sporting injuries to the elbow Tennis elbow and raquet design Acupuncture and the treatment of tennis elbow

P Ludgate R J D'Souza

Steroid phonophoresis - An alternative to injections?

R W Watson

AGILE: Association of Chartered

A Kinloch

C Rogerson, M Williamson

Association of Chartered Physiotherapists in Animal Therapy Journal

,gg6, June The quack physio Rehabilitation for dogs - Whyever not?

P Windle-Baker

0 Hanney

Computerise your practice

P Verey

Setting the standards?

T Crook

Physiotherapists with Elderly People Agility

1966, January Integrated medicine: A physiotherapy view Social service contributions to the rehabilitation of older people Falls in the elderly: What can we learn from the FlCSlT trials? Functional reach in clinical practice Solving footwear problems

Physiotherapy, September 1996, vol 82, no 9

A Culot

Organisation of Chartered Physiotherapists in Private Practice In Touch 1996, no 80, Summer

H Mandelstam

Countdown to self-assessment

J Bruce E Wilson

R Smith

The Physiolympics Accreditation Muscle energy technique

J Kelly, C Wigley E Wilson

J Dow

Sleep and its side effects

B Ancell

J Simpson